Visual Recovery with Iloprost Added to Corticosteroids in a Case of Giant Cell Arteritis.

INTRODUCTION: To date, corticosteroids remain the cornerstone treatment of ocular involvement of GCA, and no other treatment has proven to be effective in this setting. We herein report on a unique case of GCA with ocular involvement worsening despite high dose corticosteroids and recovering with intravenous iloprost. CASE REPORT: A 70-year-old man presented with acute vision loss in his left eye related to anterior ischemic optic neuropathy. The diagnosis of giant-cell arteritis was confirmed by a temporal artery biopsy. Despite intravenous pulse methylprednisolone for 3 days then oral prednisone at 60 mg/day, the patient developed from day 5 fluctuating vision loss in the right eye, related to ocular ischemia by occlusion of the ophthalmic artery, and responsive to hyperhydration. Iloprost, an analog of prostacyclin PGI2, was then administered intravenously for 5 days and resulted in a stable improvement in visual acuity in the right eye. CONCLUSION: This case highlights the potential role of vasodilatator agents in giant cell arteritis with ocular involvement.

Study of choroidal thickness variations after ingestion of a taurine and caffeine-containing energy drink.

BACKGROUND & AIMS: Choroidal thickness can undergo considerable variations in response to different substances. The aim of this study was to assess the change in choroidal thickness after the ingestion of taurine and caffeine contained in the Red Bull energy drink. METHODS: Enhanced Depth Imaging - Spectral Domain Optical Coherence Tomography was used to measure subfoveal choroidal thickness (SFCT) variations in healthy volunteers at several time points after drinking a Red Bull can (25 cl). RESULTS: Forty eyes of 20 volunteers were enrolled. A significant reduction in SFCT (-14 µm, p < 0.0001) occurred at 1 h after the Red Bull intake, and was even more important (-20.14 µm, p < 0.0001) in eyes with particularly thick choroids (≥ 395 µm). SFCT measurements at 4 h were comparable to baseline. CONCLUSIONS: A concomitant ingestion of caffeine and taurine can induce a transient choroidal thinning that is more marked in eyes with thick choroids. REGISTRATION NUMBER OF CLINICAL TRIAL: NCT02856256.

Retinal and choroidal blood flow variations after an endurance exercise: A real-life pilot study at the Paris Marathon.

OBJECTIVES: To collect information about the retinal blood flow variations and other choroidal and retinal parameters during a prolonged effort such as marathon running. DESIGN: Non-randomized prospective cohort study. METHODS: Patients were recruited through an information campaign at the Rothschild Foundation Hospital (Paris, France). A first visit (V1) was planned in the month before the marathon. All participants underwent blood pressure measurement, fundus photography, spectral domain-optical coherence tomography (SD-OCT) and OCT-angiography (OCT-A). A second visit (V2) was scheduled within one hour of crossing the finish line. The same tests were repeated, using the same equipment. RESULTS: Of the 31 runners who were included, 29 finished the marathon and attended V2. At baseline, various ophthalmological abnormalities were found in 45.2% of the 58 eyes, among which almost a third concerned the optic nerve and a quarter the pachychoroid spectrum. A significant decrease in retinal vascular plexus density was found between V1 and V2 (p<0.01). While median macular and retinal nerve fiber layer (RNFL) thicknesses significantly increased after the marathon (p<0.01), median choroidal thickness significantly decreased (p<0.01). Both systolic and diastolic blood pressures significantly decreased (p<0.01 and p=0.021 respectively). CONCLUSIONS: Prolonged physical effort impacts the structure and vascularization of the retina and the choroid. Hypoxia and dehydration due to such an effort may induce a low ocular blood flow rate resulting in a choroidal thinning, contrasting with a transient subclinical ischemic edema of the inner retina and optic nerve head. CLINICAL TRIAL REGISTRATION NUMBER: NCT03864380.

Light-induced modifications of the outer retinal hyperreflective layers on spectral-domain optical coherence tomography in humans: an experimental study.

PURPOSE: Numerous small hyperreflective dots (HRDs) can be seen within the hyporeflective layer between the ellipsoid zone (EZ) and the interdigitation zone (IZ) on C-scan spectral-domain optical coherence tomography (SD-OCT) with a yet unknown variation under light conditions. The aim of this study was to explore light-induced SD-OCT changes in these HRDs. METHODS: The study subjects were randomly assigned to two groups: Group 1 experienced a dark adaptation protocol followed by intense retinal photobleaching, while Group 2, serving as the control group, was exposed to constant ambient light without any variation. The number of HRDs was automatically counted. RESULTS: Twenty healthy volunteers were prospectively included. The number of HRDs differed significantly over time (p = 0.0013). They decreased in Group 1 after dark adaptation and retinal photobleaching before returning to baseline levels 30 min later; conversely, they remained relatively constant in Group 2 throughout the study (p < 0.001). Light-skinned subjects had less HRD than dark-skinned subjects. CONCLUSION: We observed light-induced modifications in the space between the EZ and the IZ. We hypothesize that the HRDs visible in this zone correspond to melanosomes that are mobilized during the light stimulation protocol. Larger studies are recommended to further evaluate and confirm light-induced SD-OCT changes under physiological and pathological conditions.

Corneal flattening following collagen crosslinking for keratoconus: Findings at 5-year follow-up.

PURPOSE: To study the corneal flattening effect of cross-linking (CXL) overtime and to look for a potential association with preoperative topographic variables and the central depth of demarcation line (DDL). METHODS: 201 eyes of 146 patients (mean age of 31.2 ± 7.3 years) with progressive keratoconus who underwent CXL between June 2007 and December 2012 were enrolled in this retrospective study. Follow-up visits were performed at different time intervals for at least 5 years. Preoperative parameters and depth of demarcation line were collected from LaserVision ophthalmology center in Lebanon. Corneal flattening was defined by a change in postoperative Kmax (ΔKmax) greater than 1.00 D. RESULTS: ΔKmax increased from 50.25% to 61.69%, from first to last follow-up visits. The only factor significantly correlated to ΔKmax during all follow-up visits was preoperative maximum keratometry (Kmax) especially when greater than 50.00 D (OR, 1.92; 95% CI, 1.10-3.34). All eyes showed a corneal demarcation line (mean central depth (DDL): 217.11 ± 26.54 µm), with no statistically significant correlation between DDL and ΔKmax. CONCLUSION: CXL effect on cornea can be cumulative overtime and delayed flattening occurs in some cases. ΔKmax is positively correlated with preoperative Kmax and no association was found between ΔKmax and DDL. Therefore, DDL may not be a valid measure for the efficacy of CXL.

Malleostapedotomy for otosclerosis, our experience of nitinol piston on twelve patients.

OBJECTIVE: Malleostapedotomy allows to completely by-pass the incus in otosclerosis surgery. Recently its use has been rivaled by hydroxyapatite cement for cases of mild and moderate necrosis of the incus. However, it remains gold standard for cases of extensive necrosis, incus dislocation, or epitympanic fixation. Modern heat-crimping pistons make surgery easier and safer. This study focuses on our experience with this technique. METHODS: Retrospective analysis of patient's files and pre- and post-operative audiograms, for cases of surgically treated otosclerosis with malleostapedotomy. RESULTS: Twelve patients underwent malleostapedotomy for otosclerosis between 2011 and 2019. Amongst them there were 10 revision surgeries and 2 primary cases. 75% had incus long-process necrosis, 17% had epitympanic fixation and one had a history of incus transposition. Nine patients (75%) had closure of air-bone gap (ABG) of <10 dB (p < 0.001) and 11 (92%) had a threshold of 20 dB (p < 0.001). Mean pre-operative ABG was 31 dB (15 dB-55 dB), and mean post-operative ABG was 7 dB (0 dB-21 dB; p < 0.001). There was no sensorineural hearing loss nor any other post-operative complication. CONCLUSIONS: Malleostapedotomy is a safe and reliable technique, allowing an ABG closure comparable to conventional incus to vestibule prosthesis. It remains the preferred technique whenever the incus cannot be used.

Assessment of Spontaneous Retinal Arterial Pulsations in Acute Central Retinal Vein Occlusions.

Central retinal vein occlusion (CRVO) is a common retinal disease. Recent works mentioned spontaneous retinal arterial pulsations (SRAPs) as a feature of some CRVOs. This is a retrospective study on patients presenting with CRVO who were followed up for at least 6 months. The objective was to identify SRAP in the acute phase of the disease and determine their relationship with patients' characteristics and visual prognosis. A 10-second infrared film centered on the optic disc was recorded within a month of the onset of symptoms, and SRAPs were detected in two-thirds of the cases. Patients with SRAP were significantly younger than those without SRAP. Mean central macular thickness was significantly higher in the absence of SRAP, which was translated into a more severe macular edema; however, this difference faded with time. BCVA tended to be higher in the presence of SRAP at the 6-month follow-up when adjusted to baseline. This study demonstrates that SRAPs are a frequent finding, easily detected by infrared fundus video recording, and associated with a younger age and lesser macular edema.

Spectralis High Magnification Module imaging in a case of Multiple Evanescent White Dot Syndrome.

PURPOSE: To report the use of Spectralis High Magnification Module (HMM) as part of multimodal imaging in Multiple Evanescent White Dot Syndrome (MEWDS). OBSERVATIONS: HMM imaging showed a blurry mosaic pattern corresponding to MEWDS-related photoreceptors' lesions. These abnormalities remained detectable at later stages of the disease while other imaging modalities were negative. CONCLUSIONS AND IMPORTANCE: HMM can be a useful technique to monitor the structure of the outer retina during the different stages of MEWDS.

Management of cataract in keratoconus: early visual outcomes of different treatment modalities.

A review of 31 eyes with keratoconus who developed cataract and underwent phacoemulsification. Visual acuities were measured 1mo postoperatively. Six eyes with a history of good corrected distance visual acuity (CDVA) and a similar refractive and topographic astigmatic axis were implanted with toric intraocular lenses (IOLs). The mean postoperative uncorrected distance visual acuity (UDVA) was 0.2 logMAR with a spherical equivalent (SE): 0.75D. Eleven eyes with a history of good CDVA and different refractive and topographic axis were implanted with monofocal IOL+/-Toric implantable collamer lenses to treat anisometropia and ametropia; mean UDVA was 0.25 logMAR with a mean SE: -0.51 D postoperatively. Six eyes with poor CDVA were first treated with intra-corneal ring segments, followed by phacoemulsification, the mean postoperative UDVA was 0.82 logMAR with an SE: 0.22 D. Eight eyes had advanced ectesia and received combined phacoemulsification and penetrating keratoplasty. Our approach is efficient in addressing ametropia after cataract surgery in keratoconic eyes.

Ocular and orbital side effects of ALK inhibitors: a review article.

ALK inhibitors are a new group of tyrosine kinase inhibitors, highly efficient in the treatment of non-small-cell lung carcinoma. However, these targeted therapies can induce various adverse effects, including ocular toxicity. To date, few articles reporting ophthalmological side effects of ALK inhibitors have been published. In this review, we aim to describe the different side effects and to collect information regarding the causes behind the discrepancy between the reported rates of visual disorders. Frequent ocular side effects of ALK inhibitors included flashes, post-flashbulb effect, stripes, photopsia, accommodation disorder, presbyopia, reduced visual acuity and blurred vision. Optic neuropathy, vitreous floaters, diplopia, cataract and macular edema were also reported.

Outcomes of Micropulse Transscleral Cyclophotocoagulation in Uncontrolled Glaucoma Patients.

PURPOSE: This study aimed at evaluating the intermediate-term efficacy and safety of micropulse transscleral cyclophotocoagulation (MP-TSCPC) in cases of uncontrolled glaucoma. METHODS: Patients with moderate to advanced glaucoma and uncontrolled intraocular pressure (IOP) despite maximally tolerable antiglaucoma medications were selected to undergo MP-TSCPC using the MP3 handpiece with the Iridex Cyclo G6 (IRIDEX Laser Systems). Follow-up examinations took place on a regular basis until 15 months postoperatively. RESULTS: Seventy-five eyes of 69 patients (53.6% male patients) were included. Mean age was 55.5±22.9 years. Primary open-angle glaucoma was the most common diagnosis. Corrected distance visual acuity at baseline ranged between 0 and 2.1 logMAR. Mean prelaser IOP was 26.0±7.91 mm Hg. This was reduced significantly to 13.8±5.6 mm Hg (44.0% reduction, P<0.001) at week 1, and to 18.0±7.7, 18.4±7.1, 16.7±6.2, 15.1±4.1, 15.7±5.32, and 14.8±5.50 mm Hg at months 1, 3, 6, 9, 12, and 15, respectively. The mean number of antiglaucoma drops decreased significantly up to 12 months of follow-up (P=0.008) and that of oral acetazolamide tablets decreased significantly up to 15 months (P<0.001). The success rate decreased progressively with time, reaching 81.4% at 6 months and 73.3% at 1 year. No major postoperative complications were encountered, and no eye lost vision completely. CONCLUSIONS: MP-TSCPC is an efficient noninvasive glaucoma treatment that achieves sustained IOP reduction and reduced need for ocular antihypertensive medications for up to 15 months. The optimal laser parameters to achieve the best success rate with the least side effects still need to be determined.

Third- and fourth-generation formulas for intraocular lens power calculation before and after phakic intraocular lens insertion in high myopia.

PURPOSE: To determine the effect of Visian Implantable Collamer Lens phakic intraocular lens (pIOL) insertion on biometric parameters and IOL power calculation. SETTING: Beirut Eye and ENT Specialist Hospital, Beirut, Lebanon. DESIGN: Prospective case series. METHODS: The IOLMaster 500 biometer was used to measure axial length (AL), keratometry (K), and anterior chamber depth (ACD) values before and 2 months after pIOL implantation. The IOL power was calculated using third-generation formulas (SRK/T, Holladay 1, Hoffer Q) and fourth-generation formulas (Haigis, Barrett Universal II). RESULTS: The study comprised 24 eyes (12 patients). The preoperative and postoperative AL were comparable (27.35 mm ± 1.51 [SD] versus 27.36 ± 1.6 mm; P = .91), as were the K values. There was a significant difference between the preoperative and postoperative ACD (3.67 ± 0.46 mm versus 3.4 ± 0.56 mm; P = .008). The mean IOL power calculation did not change significantly using the Haigis (10.04 ± 3.42 diopters [D] versus 10.1 ± 3.59 D; P = .69), SRK/T (9.85 ± 3.41 D versus 9.94 ± 3.58 D; P = .44), Holladay 1 (9.70 ± 3.47 D versus 9.80 ± 3.64 D; P = .45), Hoffer Q (9.70 ± 3.40 D versus 9.85 ± 3.59 D; P = .37), or Barrett Universal II (9.29 ± 3.52 D versus 9.35 ± 3.71 D; P = .63) formula. CONCLUSIONS: Phakic IOL insertion did not affect IOL power calculation. If preoperative data are not available, postoperative values can be used in IOL calculation formulas.

Inducing fibrogenesis and new interfibrillary bonds in post-laser in situ keratomileusis keratectasia.

Flap creation weakens the cornea and is a risk factor for keratectasia after laser in situ keratomileusis (LASIK). We describe a new technique to halt the progression of keratectasia by mechanically reintegrating the flap into the residual stroma. Deep stromal vertical puncturing is performed in the 4.0 to 9.0 mm paracentral corneal zone at a depth of 350 to 420 µm. The puncturing is applied in circumferential rows using a 25-gauge needle or a diamond blade, with denser puncturing at the level of the cone. In 5 eyes with worsening post-LASIK keratectasia, improved uncorrected and corrected visual acuities, corneal flattening, and a hyperopic shift were observed. There was no progression of keratectasia on serial topographies. New collagen fibrogenesis was documented by optical coherence tomography. The technique seems to be promising to halt the progression of post-LASIK keratectasia. More clinical data and longer follow-up are needed for validation.

Influence of soft contact lens material on corneal warpage: prevalence and time to resolution.

OBJECTIVE: Corneal warpage represents a reversible distortion of the corneal surface induced by soft contact lens (SCL) wear. The aim of the study is to assess the influence of SCL materials, age, wearing duration, cylindrical refraction, and spherical equivalence on the prevalence and time to resolution of corneal warpage. METHODS: This is an interventional prospective study in which SCL wearers volunteered to remove their SCLs and underwent, on each visit, a corrected distance visual acuity and anterior and posterior segment evaluation, along with keratometry measurement and corneal topography. Visits were scheduled 30 minutes after SCL removal, on day 4, day 7, and then weekly after SCL removal until warpage resolution. RESULTS: A total of 17 volunteers (34 eyes) were included, with 9 (18 eyes) in the hydrogel SCL group and 8 (16 eyes) in the silicone hydrogel SCL group. The difference in warpage prevalence between the hydrogel group (28%, 5 eyes) and silicone hydrogel group (31%, 5 eyes) was not statistically significant (p > 0.90). Duration necessary for warpage resolution ranged from 7 to 21 days with no statistically significant difference between the 2 groups (p = 0.12). CONCLUSIONS: Both types of SCL had similar corneal warpage prevalence and time to resolution, with slightly longer mean time to resolution with silicone hydrogel. All eyes had resolution of warpage by 3 weeks. It seems more cautious to wait longer than the usual 1-week interval before performing refractive surgery, especially in patients wearing SCL for long periods and regardless of the type of material.

Evaluation of allergic sensitization in Lebanese patients with allergic conjunctivitis.

PURPOSE: To describe the profile of patients with allergic conjunctivitis (AC) regarding their demographics, symptomatology and specific allergen sensitization, in a Lebanese tertiary hospital. METHODS: Cross-sectional study conducted at the Hôtel-Dieu de France hospital (Beirut, Lebanon) during a period of 18 months. Patients with seasonal or perennial AC presenting for ophthalmic consultation had measurements of total and specific IgE. A matching group of patients with AC seen at the allergist office during the same period underwent skin prick tests (SPTs). RESULTS: Forty-four patients were enrolled for blood work by their ophthalmologists. Seasonal and perennial forms were almost equivalent. In total, 56.8% had positive specific IgE, with higher prevalence in patients with seasonal AC (p = 0.002), other associated allergies particularly allergic rhinitis (p = 0.002) or a family history of allergy (p = 0.005). Ocular surface severity scales were not shown as predictors. High levels of total IgE were commonly detected in those with positive specific IgE. Thirty-eight patients were assessed with SPT, and all had a positive result for at least one allergen. Dust mites were found to be the most frequent allergens based upon both specific IgE (72%) and SPT (92%), followed by Parietaria and other pollens. CONCLUSION: In our study, dust mites mono- or co-sensitization is present in the majority of patients with AC, with odds of positivity being higher using SPT than specific IgE. The latter are found more readily in seasonal AC and in the presence of personal and family history of allergy.

Central Macular Thickness Monitoring after a Taxane-Based Therapy in Visually Asymptomatic Patients.

BACKGROUND: Taxanes are drugs used in various chemotherapeutical protocols to treat solid tumors. They have multiple systemic adverse effects, such as bone marrow suppression, alopecia, nausea, and vomiting, and may rarely cause ocular symptoms. In the past decade, a few reported cases have shown the occurrence of a cystoid macular edema with significant visual loss after the use of a taxane-based chemotherapy. The aim of this study was to compare the central macular thickness (CMT) before and after the initiation of a taxane-based therapy in visually asymptomatic patients and to elucidate the possible impact of these drugs on the vision of cancer patients. METHODS: Patients with a confirmed diagnosis of a solid tumor were screened for any ophthalmic disease before inclusion and had a baseline macular spectral domain optical coherence tomography (OCT; RTVue-100; Optovue Inc., Fremont, CA, USA) before the initiation of a taxane-based chemotherapy according to different protocols, such as 4EC-4T, 3FEC/3T, or 4TC. OCT was repeated after 4 cycles (or 3 months) of treatment, and CMT was compared to baseline. Patients presenting diabetic retinopathy, age-related macular degeneration or any condition that causes macular edema confirmed by ophthalmic examination were excluded. RESULTS: Fifty eyes of 25 patients were included; 92% of the subjects were female with a mean age of 48.52 years, 88% were diagnosed with breast cancer, 8% with esophageal cancer, and 4% with ovarian cancer. Docetaxel was the taxane administered to 92% of the patients. The received dose of docetaxel ranged between 110 and 160 mg. The other patients had paclitaxel in their protocols. No significant macular edema or drop in visual acuity were noted in any patient. Nevertheless, the mean CMT was found to be increased, particularly in the parafoveal and perifoveal areas (mean difference of +2.22 µm; p = 0.001). CONCLUSION: Taxane-based chemotherapy regimens seem to increase macular thickness, with a relative sparing of the fovea, in patients without significant macular edema. Further research is required to better explain the pathophysiology and possible impact of this phenomenon.

Choroidal tuberculoma as a presenting sign of tuberculosis.

Choroidal tuberculoma is a rare ocular form of tuberculosis (TB) that raises both a diagnostic and a therapeutical challenge, especially when occurring without other manifestations of the disease. This study reports the case of a 27-year-old woman who had a unilateral drop of vision (20/100) with ocular pain. Her fundus examination revealed an elevated juxtapapillary choroidal mass measuring 892 µm in diameter, as calculated by optical coherence tomography (OCT), and associated with a serous retinal detachment involving the macula. The diagnosis of choroidal tuberculoma was established by positive QuantiFERON-TB and tuberculin skin test. Laboratory and imaging workup ruled out pulmonary and systemic TB as well as other possible etiologies. Antituberculosis therapy was started and led to an improved visual acuity (20/30) and a shrinkage of the tuberculoma to a diameter of 499 µm at 3 months. This is one of the few reported cases of solitary choroidal tuberculoma in a patient with no other sign of TB. It sheds light on the place of OCT in the diagnosis and follow-up of the choroidal mass, in terms of measuring the size of the mass and revealing the associated serous retinal detachment and the distinctive "contact sign" between the neurosensory retina and the retinal pigment epithelium (RPE)-choriocapillaris layer surmounting the tuberculoma.