Analysis of the pachychoroid phenotype in an Asian population: methodology and baseline study population characteristics.

AIM: To describe the clinical characteristics in a cohort of patients with the pachychoroid phenotype and to evaluate the association of ocular and systemic factors with type of complications observed. METHODS: We report baseline findings from a prospective observational study which recruited subjects with subfoveal choroidal thickness (SFCT) of ≥300 µm on spectral-domain optical coherence tomography (OCT). Multimodal imaging was used to classify eyes as uncomplicated pachychoroid (UP) or pachychoroid disease with pachychoroid pigment epitheliopathy (PPE), central serous chorioretinopathy (CSC) or pachychoroid neovasculopathy (PNV) subtypes. RESULTS: Among 181 eyes of 109 participants (mean age 60.6 years, 33 (30.3%) female, 95 (7.2%) Chinese), 38 eyes (21.0%) had UP. Of 143 eyes (79.0%) with pachychoroid disease, 82 (45.3%), 41 (22.7%) and 20 (11.0%) had PPE, CSC and PNV, respectively. Addition of autofluorescence and OCT angiography to structural OCT led to reclassification of 31 eyes to a more severe category. Systemic and ocular factors evaluated, including SFCT, were not associated with disease severity. Comparison of PPE, CSC and PNV eyes showed no significant difference in OCT features of retinal pigment epithelial (RPE) dysfunction, but disruption of the ellipsoid zone (PPE 30.5% vs CSC 70.7% vs PNV 60%, p<0.001) and thinning of inner nuclear/inner plexiform layers (PPE 7.3% vs CSC 36.6% vs PNV 35%, p<0.001) were more frequent in CSC and PNV eyes. CONCLUSIONS: These cross-sectional associations suggest pachychoroid disease manifestations may reflect progressive decompensation from the choroid to the RPE then retinal layers. Planned follow-up of this cohort will be beneficial in clarifying the natural history of the pachychoroid phenotype.

Novel Technique for 27-Gauge Forceps-Assisted Transscleral Refixation of the Dislocated CZ70BD Intraocular Lens.

PURPOSE: To report a novel technique for refixation of the dislocated CZ70BD intraocular lens. METHODS: Posterior vitrectomy is performed with a 23-gauge or 25-gauge pars plana vitrectomy system with chandelier illumination. One needle of a double-arm 9-0 prolene needle is passed through the sclera 1.5 mm postlimbus. The needle is retrieved through the corneal paracentesis using a 27-G needle, and the suture is then cut. The suture end is passed through the eyelet of the dislocated CZ70BD intraocular lens inside the vitreous cavity. This is aided with a pair of 27-G MaxGrip forceps, which is inserted through a 27-G sclerostomy site at the intended scleral outlet. After passing the suture through the eyelet, the suture is pulled out at the 27-G sclerostomy site and a knot is tied and rotated. Similar procedure is performed for the second haptic if necessary. RESULTS: Seven eyes were successfully operated on using this technique with a mean follow-up of 12.4 months. There was significant improvement in the best-corrected visual acuity after the operation ( P = 0.016). Postoperative intraocular lens centration and alignment were satisfactory. One patient developed macula-on retinal detachment 1 month after the operation, which was successfully repaired without loss in the best-corrected visual acuity. CONCLUSION: The described novel technique is effective for refixation of dislocated CZ70BD intraocular lens.

Case Report: Retinal Vasculitis in Two Adolescents After COVID-19 Vaccination.

PURPOSE: To report two cases of bilateral retinal vasculitis in adolescents following COVID-19 vaccination. STUDY DESIGN: Case report. RESULTS:  We report the first two cases of retinal vasculitis in adolescents following COVID-19 vaccinations. Both patients received recent second-dose COVID-19 vaccinations (7 weeks and 4 weeks respectively), and presented with bilateral retinal vasculitis and vitritis. Investigations did not reveal other causes of retinal vasculitis. Both patients' retinal vasculitis settled with a short course of oral prednisolone. CONCLUSION: Although rare, the temporal association between vaccination, bilateral eye involvement, and the absence of alternative infective or inflammatory causes, makes this a plausible etiology. mRNA vaccinations may cause an autoimmune reaction via host antigenic mimicry, and systemic vasculitis has previously been described. We believe that a short interval between COVID-19 vaccination doses might be a risk factor for the development of retinal vasculitis in adolescents, and clinicians should be aware to elicit vaccination history.

Author Correction: Determinants of Quantitative Optical Coherence Tomography Angiography Metrics in Patients with Diabetes.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has been fixed in the paper.

Determinants of Quantitative Optical Coherence Tomography Angiography Metrics in Patients with Diabetes.

Early microvascular damage in diabetes (e.g. capillary nonperfusion and ischemia) can now be assessed and quantified with optical coherence tomography-angiography (OCT-A). The morphology of vascular tissue is indeed affected by different factors; however, there is a paucity of data examining whether OCT-A metrics are influenced by ocular, systemic and demographic variables in subjects with diabetes. We conducted an observational cross-sectional study and included 434 eyes from 286 patients with diabetes. Foveal avascular zone (FAZ) area, FAZ circularity, total and parafoveal vessel density (VD), fractal dimension (FD), and vessel diameter index (VDI) from the superficial capillary plexus OCT-angiogram were measured by a customized automated image analysis program. We found that diabetic retinopathy (DR) severity was associated with increased FAZ area, decreased FAZ circularity, lower VD, lower FD, and increased VDI. Enlarged FAZ area was correlated with shorter axial length and thinner central subfield macular thickness. Decreased FAZ circularity was correlated with a reduction in visual function. Decreased VD was correlated with thinner macular ganglion-cell inner plexiform layer. Increased VDI was correlated with higher fasting glucose level. We concluded that the effects of ocular and systemic factors in diabetics should be taken into consideration when assessing microvascular alterations via OCT-A.

Presumed Sterile Endophthalmitis Afer Intravitreal Triamcinolone (Kenalog)-More Common and Less Benign Than We Thought?

PURPOSE: This study aimed to review the incidence and clinical outcome of presumed sterile endophthalmitis after the off-label use of intravitreal Kenalog injections (triamcinolone acetonide with 1.5% benzyl alcohol) and to compare it with the presumed sterile endophthalmitis incidence after intravitreal Kenacort-A (0.99% benzyl alcohol) at our center. DESIGN: This was a single-center, retrospective, consecutive, interventional case series of all patients who underwent intravitreal Kenalog injections at Hong Kong Eye Hospital from November 1, 2009, to July 31, 2012. METHODS: This was a retrospective medical records review. RESULTS: A total of 81 intravitreal Kenalog injections were performed. Ten eyes (12.3%) developed presumed sterile endophthalmitis, presenting clinically with dense anterior chamber cells, fibrin, hypopyon, and vitritis. All cases were treated with topical steroids and antibiotics. Although the inflammation resolved eventually in all cases, 2 eyes developed complications, resulting in eventual loss of best corrected visual acuity: one developed rhegmatogenous retinal detachment with choroidal detachment, and another developed vitreous hemorrhage. CONCLUSIONS: The rate of presumed sterile endophthalmitis after Kenalog injection is much higher than our previous experience with Kenacort-A. To the best of our knowledge, this is the first study reporting the incidence of presumed sterile endophthalmitis using intravitreal Kenalog and Kenacort in the same center using the same injection technique. We believe that it may be due to a difference in the concentration of the preservative. Although sterile endophthalmitis is generally thought to run a benign course, this study has shown that serious complications may occur.

Surgical treatment for diabetic vitreoretinal diseases: a review.

Over the past four decades, advancements in surgical instrumentations and techniques have significantly improved the postoperative anatomical and visual outcomes of patients with various diabetic vitreoretinal diseases. In particular, surgical interventions for previously serious and untreatable blinding proliferative diabetic retinopathy can now be performed, with much better results. The advents of micro incisional vitrectomy system with better visualization system like binocular indirect ophthalmomicroscope and state-of-the-art instrumentation revolutionized the era of diabetic vitrectomy. High-speed vitrectors, finer instruments, chromo-assisted vitrectomy and use of anti-vascular endothelial growth factors not only change the paradigm but also help achieve much better outcome after diabetic vitrectomies. In this review, we will discuss and summarize the indications, surgical considerations, surgical techniques, potential complications and outcomes of vitreoretinal surgery for diabetic eye diseases.

Clinical characteristics and surgical outcomes of phacoemulsification in true exfoliation syndrome.

PURPOSE: To review the clinical characteristics and surgical outcomes of patients with true exfoliation syndrome of the lens capsule having phacoemulsification cataract surgery. SETTING: Hong Kong Eye Hospital, Kowloon, Hong Kong. DESIGN: Case series. METHODS: Eyes of patients with true exfoliation syndrome diagnosed clinically or intraoperatively had standard phacoemulsification and intraocular lens (IOL) implantation. The anterior capsules removed during capsulorhexis were sent for histological confirmation. RESULTS: Twenty-four eyes of 18 patients were included. All eyes were confirmed to have true exfoliation syndrome by histological examination of the anterior lens capsule. Seven eyes (29.2%) had preexisting chronic glaucoma; 5 (20.8%) had laser iridotomy before the diagnosis. During phacoemulsification, all eyes had a continuous curvilinear capsulorhexis without complications. Trypan blue staining was used during capsulorhexis in 11 eyes (45.8%). Posterior capsule rupture occurred during lens chopping in 1 eye (4.2%). No loose zonular fibers or radial extension of capsulorhexis occurred. Capsular bag IOL implantation was successfully performed in all cases except the 1 with a posterior capsule rupture, in which an anterior chamber IOL was implanted. CONCLUSIONS: Phacoemulsification was safely performed in eyes with true exfoliation syndrome. Trypan blue staining can be used to facilitate capsulorhexis creation. Ultrasound biomicroscopy or anterior segment optical coherence tomography may be useful in preoperative assessment of such cases. The disease may be associated with glaucoma and laser iridotomy.

Long-term effectiveness of ranibizumab for age-related macular degeneration and diabetic macular edema.

Neovascular age-related macular degeneration (AMD) and diabetic macular edema (DME) are major causes of visual impairment in the elderly population worldwide. With the aging population, the prevalence of neovascular AMD and DME has increased substantially over the recent years. Vascular endothelial growth factor (VEGF) has been implicated as playing an important role in the pathogenesis of both neovascular AMD and DME. Since its introduction in 2006, ranibizumab, a recombinant, humanized, monoclonal antibody fragment against all isoforms of VEGF-A, has revolutionized the treatment of neovascular AMD and DME. The efficacy and safety of ranibizumab in neovascular AMD has been demonstrated in the ANCHOR and MARINA trials. Further studies including the PIER, PrONTO, and SUSTAIN trials have also evaluated the optimal dosing regimen of ranibizumab in neovascular AMD. The CATT and IVAN trials compared the safety and efficacy of ranibizumab with off-label use of bevacizumab. Studies such as SUSTAIN and HORIZON have shown that ranibizumab has a good safety profile and is well tolerated for over 4 years with very few serious ocular and systemic adverse events. For DME, Phase II RESOLVE study and Phase III RISE and RIDE studies have demonstrated superiority of ranibizumab treatment in improving vision over placebo controls. Phase II READ and Phase III RESOLVE and REVEAL studies have shown that ranibizumab is more effective both as monotherapy and in combination with laser compared with laser monotherapy. The 3-year results from the DRCRnet protocol I study found that ranibizumab with deferred laser resulted in better long-term visual outcome compared with ranibizumab with prompt laser. This review summarizes various important clinical trials on the long-term efficacy and safety of ranibizumab in the treatment of neovascular AMD and DME. The pharmacological properties of ranibizumab, its cost effectiveness, and impact on quality of life will also be discussed.

Prevalence of ocular abnormalities in adults with Down syndrome in Hong Kong.

BACKGROUND/AIMS: This was a cross-sectional survey to find the prevalence of visual impairment and eye diseases among adults with Down syndrome (DS) in Hong Kong. METHODS: 91 DS patients over the age of 30 were recruited through the Hong Kong Down Syndrome Association. Each patient was provided with a complete ophthalmological assessment including best corrected visual acuity, refraction, slit lamp and fundus examination. RESULTS: In our sample, 56.6% had normal vision to mild vision impairment, 33.7% and 7.2% had moderate and severe vision impairment, respectively, and 2.4% were blind. The mean presenting distant LogMAR visual acuity was 0.66 (Snellen equivalent 20/90), and the best corrected LogMAR visual acuity was 0.48 (Snellen equivalent 20/60). Significant refractive errors were found in 86.3% of the eyes, with spherical equivalent corrections ranging from -23.25D to +3.00D. Myopia and astigmatism were prevalent and found in 59.3% and 72.7% of the eyes, respectively. Blepharitis and chalazion were found in 44% of the eyes, while corneal problems were present in 27.5%. There were low incidences of infective keratitis (0.5%), keratoconus (0.5%) and Brushfield spots (1.1%). Cataracts were found in 72.2% of the eyes; 26.1% were congenital and 44.9% were age-related. Fundal abnormalities were present in 49.5% of the eyes. CONCLUSIONS: There is a high prevalence of vision impairment among Chinese DS adults. Uncorrected refractive errors, high myopia and cataracts are the main visually debilitating ophthalmological abnormalities. Vision may be improved through the simple use of glasses and early treatment of age-related cataracts.

Choroidal evaluation using enhanced depth imaging spectral-domain optical coherence tomography in Vogt-Koyanagi-Harada disease.

BACKGROUND: Current imaging modalities used in the evaluation of Vogt-Koyanagi-Harada (VKH) disease include ultrasound, fluorescein angiogram, indocyanine green angiography, and optical coherence tomography (OCT). However, they all fail to give detailed information on the ultrastructural changes of the choroid. A recent technique using OCT termed "enhanced depth imaging" produces high-resolution cross-sectional images of the whole thickness of the choroid. The purpose of the study was to describe a novel imaging finding in the choroid in cases of VKH uveitis and to assess for interobserver agreement of this new physical sign. METHODS: This is an age-matched, sex-matched, and spherical equivalent-matched, case-control, cross-sectional study. Six VKH patients in acute and convalescent stages underwent choroidal imaging using enhanced depth imaging spectral-domain OCT imaging. A horizontal enhanced depth imaging spectral-domain OCT scan across the fovea was selected for each eye and was compared with a scan from an age-matched, sex-matched, and spherical equivalent-matched control subject. A loss of focal hyperreflectivity, represented by a decrease in the number of hyperreflective dots in the inner choroid, was observed. This finding was assessed for interobserver agreement using five masked observers. Mean observed agreement and multirater kappa statistics (κ) were calculated. The average choroidal thickness was also calculated and compared among acute-phase VKH patients, convalescent-phase VKH patients, and control subjects. RESULTS: There was a significant loss of focal hyperreflectivity in the inner choroid of VKH patients compared with control subjects in both acute and convalescent stages. Analysis revealed substantial interobserver agreement on this finding. The mean observed agreement was 95%, and the overall kappa coefficient (κ) was 0.80 (P < 0.01). The choroid of acute-phase VKH patients was thicker than that of convalescent-phase patients by 151 µm (P = 0.043) and control subjects by 137 µm (P = 0.001). There was no statistically significant difference in thickness between convalescent eyes and controls. CONCLUSION: Enhanced depth imaging spectral-domain OCT highlights a loss of focal hyperreflectivity in the inner choroid of eyes with VKH, a feature that is consistently observed by independent masked observers. The presence of this feature in both acute and convalescent phases could represent permanent structural change to small choroidal vessels caused by VKH uveitis.

First report of Tsukamurella keratitis: association between T. tyrosinosolvens and T. pulmonis and ophthalmologic infections.

We describe the first two cases of Tsukamurella keratitis, presented as eye pain with or without blurring of vision. One case was associated with trichiasis and the other with contact lens wear. The two isolates were identified as T. tyrosinosolvens and T. pulmonis, respectively, by phenotypic characterization and 16S rRNA sequencing.

Clinical isolates of Streptococcus iniae from Asia are more mucoid and beta-hemolytic than those from North America.

Streptococcus iniae, a widely distributed fish pathogen, is known to cause rare cases of human infection. We describe 2 cases of invasive S. iniae infection, one with septic arthritis complicating chronic gout and the other with bacteremic cellulitis. Both patients were Chinese and have been regularly handling fresh fish for cooking. Both isolates were unidentified or misidentified by 3 commercially available identification system and were only identified by 16S rRNA gene sequencing. When compared with a clinical isolate of S. iniae from Canada, their colonies were larger, more beta-hemolytic, and microcoid. Although bacteremic cellulitis has been described as the most common infection associated with S. iniae, the bacterium has not been reported to cause exacerbations of gouty arthritis previously. Clinical laboratories should be aware of the possibility of different colony morphology of S. iniae from Asia. More accurate identification of nongroupable beta-hemolytic streptococci, especially from patients with epidemiologic linkage to fresh fish, may uncover more cases of S. iniae infection. The Asian population and handlers of fresh fish should be informed of the risk of acquiring S. iniae infection.

Cerebral palsy: correlation of risk factors and functional performance using the Functional Independence Measure for Children (WeeFIM).

We studied the risk factors affecting the functional status of cerebral palsy. A cross-sectional study of 73 children with cerebral palsy was conducted with the Functional Independence Measure for Children (WeeFIM), which assesses functional skills in the domains of self-care, mobility, and cognition. The mean total Functional Independence Measure for Children quotient was 67.5%. The mean subquotients for self-care, mobility, and cognition were 68.3%, 62.7%, and 69.4%, respectively. The risk factors related to the degree of functional dependency were (1) mental retardation (P = .030), (2) epilepsy (P = .005), (3) type of cerebral palsy (P < .001), and (4) severity of cerebral palsy using the Gross Motor Function Classification System (P < .001) (using univariate analysis). However, when using multivariate analysis, only epilepsy (P = .02) and severity status according to the Gross Motor Function Classification System (P < .001) were significantly related. When the etiology was analyzed, only prematurity was significantly associated with better Functional Independence Measure for Children scores using both univariate (P = .022) and multivariate (P = .007) analyses. The functional status of children with cerebral palsy depends on the severity and the presence of epilepsy. Despite impairment, we found that most children with cerebral palsy could achieve functional independence.