Central Retinal Artery Occlusion Leading to Diagnosis of Eosinophilic Granulomatous Polyangiitis After Adenovirus Vector COVID-19 Vaccination.

Purpose: To present a case of central retinal artery occlusion (CRAO) leading to the diagnosis of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) within 1 week of an adenovirus vector COVID-19 vaccination. Methods: A case was reviewed. Results: A 50-year-old man with atopic dermatitis and asthma presented with acute painless vision loss in 1 eye. An examination and imaging findings showed CRAO. Further evaluation found eosinophilia and elevated inflammatory markers. A workup for vasculitis showed elevated cytoplasmic-antineutrophil cytoplasmic antibody, perinuclear-antineutrophil cytoplasmic antibody, myeloperoxidase antibody, rheumatoid factor, and total immunoglobulin E. Skin biopsies were consistent with eosinophilic granulomatosis with polyangiitis. Steroids, cyclophosphamide, and mepolizumab were initiated. At 1 year, the patient's systemic symptoms had improved but his vision had not. Conclusions: Few reports exist of CRAO associated with eosinophilic granulomatosis with polyangiitis, with no other instances related to an adenovirus vector COVID-19 vaccination. Treating a systemic vasculitis early can be vision saving in the fellow eye and prevent systemic life-threatening complications.

Quantitative Autofluorescence at AMD's Beginnings Highlights Retinal Topography and Grading System Differences: ALSTAR2 Baseline.

INTRODUCTION: The aims of the study were to describe baseline quantitative (short-wavelength) autofluorescence (qAF) findings in a large pseudophakic cohort at age-related macular degeneration (AMD)'s beginnings and to assess qAF8 as an outcome measure and evaluate Age-Related Eye Disease Study (AREDS) and Beckman grading systems. METHODS: In the ALSTAR2 baseline cohort (NCT04112667), 346 pseudophakic eyes of 188 persons (74.0 ± 5.5 years) were classified as normal (N = 160 by AREDS, 158 by Beckman), early AMD (eAMD) (N = 104, 66), and intermediate AMD (iAMD) (N = 82, 122). Groups were compared via mean qAF intensities in a 6°-8° annulus (qAF8) and maps of differences between observations and the overall mean, divided by standard deviation (Z-score). RESULTS: qAF8 did not differ significantly among diagnostic groups by either stratification (p = 0.0869 AREDS; p = 0.0569 by Beckman). Notably, 45 eyes considered eAMD by AREDS became iAMD by Beckman. For AREDS-stratified eyes, Z-score maps showed higher centrally located qAF for normal, near the mean in eAMD, and lower values for iAMD. Maps deviated from this pattern for Beckman-stratified eyes. CONCLUSIONS: In a large sample of pseudophakic eyes, qAF8 does not differ overall from normal aging to iAMD but also does not capture the earliest AMD activity in the macula lutea. AREDS classification gives results more consistent with a slow decline in histologic autofluorescence than Beckman classification.

Bilateral Spontaneous Retrobulbar Hemorrhage due to Warfarin Misuse After Sinus Lavage.

While warfarin has historically played an important role in anticoagulation, direct oral anticoagulants have largely supplanted warfarin due to their improved safety profile and reduced need for monitoring. Herein, the authors report the case of a 64-year-old male who developed severe, bilateral retrobulbar hemorrhage following aggressive nasal lavage due to a supratherapeutic international normalized ratio from warfarin misuse. Visual acuity on arrival was hand-motion OD and no-light-perception OS. He underwent bilateral canthotomy with upper and lower lid cantholysis before transfer to a trauma center where his international normalized ratio was greater than 12. Reversal with vitamin K and prothrombin complex concentrate was initiated. Over the course of hospitalization, vision and swelling continued to improve and at 2-month follow-up his visual acuity was 20/20 OD and no-light-perception OS. This case outlines the risk of bleeding associated with warfarin misuse and advocates for the transition of patients to direct oral anticoagulants when possible.

Physician Leader, Humble Thyself: Balancing Narcissism and Humility in Healthcare Leadership.

Data on expert leadership have shown numerous benefits, including enhanced job satisfaction, productivity, and job retention. Similarly, many of the top hospitals in the United States are physician led; however, the training of a successful physician and that of a successful healthcare administrator often are significantly different. Here, we specifically discuss the balance of narcissism and humility in leadership as it pertains to physicians transitioning from clinical careers to healthcare administrative roles.

Acute posterior multifocal placoid pigment epitheliopathy following COVID-19 infection.

Purpose: To report a case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) following COVID-19 infection. Observations: A 17-year-old female developed central scotomas and photopsias two weeks after SARS-CoV-2 diagnosis with polymerase chain reaction studies. She presented with poor visual acuity of 3/60 on the Feinbloom eye chart in the left eye. Dilated examination and multi-modal retinal imaging were consistent with the diagnosis of APMPPE, with noteworthy subretinal fluid. The patient was treated with an oral prednisone taper starting at 60mg with rapid resolution in subretinal fluid and improvement of visual acuity. Five weeks after presentation, visual acuity improved to 20/20 OU with complete resolution of the creamy white choroidal lesions and subretinal fluid. Conclusion: There is a growing body of literature reporting the ocular manifestations of COVID-19. Rarely inflammation of the retina or choroid have been associated with the infection. To the best of our knowledge, there are no prior reports that describe the clinical course or visual outcome in a patient with APMPEE associated with recent COVID-19 infection. Accordingly, we are not aware of any other reports that describe the treatment of APMPEE associated with COVID-19 with corticosteroids. The mechanism linking COVID-19 infection to inflammatory ocular disorders in unclear and likely multi-factorial.

Impact of the Aging Lens and Posterior Capsular Opacification on Quantitative Autofluorescence Imaging in Age-Related Macular Degeneration.

Purpose: The purpose of this study was to investigate quantitative autofluorescence (qAF8) in patients with and without early or intermediate age-related macular degeneration (AMD); to determine the impact of the aged crystalline lens and posterior capsular opacification (PCO). Methods: In phakic and pseudophakic eyes ≥60 years, AMD status was determined by the Beckman system. PCO presence and severity was extracted from clinical records. qAF8 was calculated using custom FIJI plugins. Differences in qAF8, stratified by lens status, PCO severity, and AMD status, were analyzed using generalized estimating equations. Results: In 210 eyes of 115 individuals (mean age = 75.7 ± 6.6 years), qAF8 was lower in intermediate AMD compared to early AMD (P = 0.05). qAF8 did not differ between phakic and pseudophakic eyes (P = 0.8909). In phakic (n = 83) and pseudophakic (n = 127) eyes considered separately, qAF8 did not differ by AMD status (P = 0.0936 and 0.3494, respectively). Qualitative review of qAF images in phakic eyes illustrated high variability. In pseudophakic eyes, qAF8 did not differ with PCO present versus absent (54.5% vs. 45.5%). Review of implanted intraocular lenses (IOLs) revealed that 43.9% were blue-filter IOLs. Conclusions: qAF8 was not associated with AMD status, up to intermediate AMD, considering only pseudophakic eyes to avoid noisy images in phakic eyes. In pseudophakic eyes, qAF8 was not affected by PCO. Because blue-filter IOLs may reduce levels of exciting light for qAF8, future studies investigating qAF in eyes with different IOL types are needed. Translational Relevance: To reduce variability in observational studies and clinical trials requiring qAF8, pseudophakic participants without blue-filter IOLs or advanced PCO should be preferentially enrolled.

Effect of Novel Design Modifications on Fibrotic Encapsulation: An In Vivo Glaucoma Drainage Device Study in a Rabbit Model.

PURPOSE: To quantify the effects of modified Ahmed glaucoma valves® (AGV) with anti-fibrotic plate coatings or a plate surface micro-pattern on outflow resistance and tissue response. METHODS: Twelve New Zealand rabbits were divided into four groups: commercially available AGV implants (n = 3), AGV with hydrophilic coating (n = 3), AGV with heparin coating (n = 3), and AGV with a plate surface micro-pattern (n = 3). After 6 weeks, the anterior chamber silicone tube was cannulated in situ and perfused with 2.5 µL/min of saline. The pressures were recorded with a perfusion system to measure outflow resistance. The rabbits were then euthanized followed by enucleation of all eyes for bleb histological analyses. RESULTS: Hydrostatic pressures were significantly lower in AGVs with the hydrophilic plate coating (mean difference -9.6 mm Hg; p < 0.001), heparin-coated plates (mean difference -4.4 mm Hg; p < 0.001), and micro-patterned plates (mean difference -18.6 mm Hg, p < 0.001), indicating lower outflow resistance compared to control AGV models. Fibrotic encapsulation was lower in hydrophilic plate coating (84.2 µm; mean difference -6.2 µm, p = 0.425), micro-patterned surface (63.7 µm; mean difference -26.7 µm, p = 0.003), and heparin plate coating (49.3 µm; mean difference -41.1 µm, p = 0.006) when compared to control AGV models. CONCLUSIONS: Modified AGVs with plate coatings and AGVs with micro-patterned plates both appear to reduce postoperative fibrotic encapsulation and aqueous outflow resistance by altering the tissue response to implanted materials. Further studies are needed to characterize the safety and role of plate surface modifications on glaucoma drainage devices.

Frequency of pediatric traumatic cataract and simultaneous retinal detachment.

PURPOSE: Traumatic cataract in children is a treatable cause of vision loss. In cases of simultaneous retinal detachment, the prognosis for visual recovery is often poor. The purpose of this study was to investigate risk factors for concurrent retinal detachment in patients with traumatic cataract. METHODS: A retrospective review of patients diagnosed with traumatic cataract at Children's Hospital Colorado between 2005 and 2014 was conducted. Demographics, mechanism of injury, and incidence of retinal detachment were recorded. Logistic modeling with generalized estimating equations to account for correlation of eyes within patients was used to analyze associations between potential risk factors and retinal detachment. RESULTS: A total of 62 total eyes with traumatic cataract were included: 52 patients presented with unilateral cataract; 5 presented with bilateral cataracts. Mean patient age was 8.4 ± 4.1 years (range, 0-16 years), and 83% of patients were male. A total of 9 eyes (14.5%) had comorbid retinal detachment. Traumatic cataracts caused by self-injurious hitting were more likely to present with simultaneous retinal detachment than those caused by other mechanisms of injury (OR = 24.0; 95% CI, 3.8-153.3; P = 0.0010). CONCLUSIONS: Patients with traumatic cataract who display self-injurious behavior are at higher risk for concurrent retinal detachment. These patients can often only be examined under sedation. Ophthalmologists should counsel families of high-risk patients and consider involving retinal specialists in surgical planning.

A Survey of Patient Perceptions and Preferences for Glaucoma Treatment with Intravitreal Injections.

PURPOSE: To investigate patient perceptions and preferences regarding the use of intravitreal injection (IVI) for the treatment of glaucoma. DESIGN: Cross-sectional study of patients seen at the University of Colorado Health Eye Center. PARTICIPANTS: Patients with a diagnosis of glaucoma who were receiving or previously had received topical medication drops and previously had received an IVI for a different eye condition. METHODS: In this pilot study, participants were surveyed by telephone using a 10-item questionnaire. Preferences regarding glaucoma treatment methods, specifically a theoretical choice between topical and IVI treatment options, were recorded. MAIN OUTCOME MEASURES: Preferences regarding IVI compared with topical drops in 2 different hypothetical scenarios, one in which both are equally effective and another in which IVI is more effective. Secondary outcomes included preferred interval between injections. RESULTS: Fifty patients completed the survey. The mean age was 65 years (range, 16-95 years). Patients were using an average of 1.6 glaucoma medications per day (range, 1-4). Seventy-four percent of patients (n = 37) said they would prefer topical medication if equal in efficacy to monthly IVI. In a hypothetical scenario in which a monthly IVI was more effective than topical medication, 76% (n = 38) said they would then prefer injection. Additionally, injection became more preferable as the hypothetical dosing interval changed. Assuming equivalent efficacy, 46% of patients preferred injection if required every 2 months, 62% if required every 3 months, and 82% if injection was required every 6 months. The main reasons cited for preferring topical medications were fear of pain, fear of the procedure, and the inconvenience of more frequent clinic appointments to undergo treatment. CONCLUSIONS: Patients are open to alternative methods of drug delivery, and their willingness to undergo more invasive treatments, like IVI, for glaucoma rises with a longer theoretical duration between treatments.