Aspergillus Endophthalmitis Resulting in Development of Retinal Aspergilloma.

A 78-year-old immunocompetent man presented with a 3-month history of painless decreased vision and panuveitis with a macular lesion presumed to be due to endogenous endophthalmitis. He had been treated with systemic, intravenous, and intravitreal antibiotics and antifungal agents as well as intravitreal steroids. A culture from a prior vitrectomy had grown a single colony of Aspergillus thought to be a contaminant. The macular lesion enlarged and caused a tractional retinal detachment. The patient underwent surgery including resection of what appeared to be an invasive retinal aspergilloma, from which polymerase chain reaction and histopathology confirmed Aspergillus fumigatus. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:680-683.].

INFECTIOUS KERATITIS-ASSOCIATED ENDOPHTHALMITIS: A 14-Year Study.

PURPOSE: To describe the demographics, characteristics, management, and outcomes of eyes with endophthalmitis related to infectious keratitis. METHODS: Retrospective chart review of all patients treated for infectious keratitis-associated infectious endophthalmitis between 2001 and 2014 at University Hospital, Rutgers New Jersey Medical School. RESULTS: Thirty-eight cases with infectious keratitis-associated infectious endophthalmitis were identified (21 men [55%], mean age: 66.2 ± 20.7 years), with average time from the beginning of ulcer symptoms to endophthalmitis of 11.0 days. Associated systemic conditions (diabetes, HIV, immunosuppressive therapy, cirrhosis, or dementia) were present in 57.9%; 60.5% had previous intraocular surgery. Etiology showed gram-positive bacteria in 14 cases (36.9%), gram-negative bacteria in 7 (18.4%), fungi in 4 (10.5%), and no growth/unknown in 12 (31.6%). Nineteen cases (50%) presented with no light perception and were primarily enucleated. The remaining 19 eyes each received intravitreal antibiotics (mean: 1.5 injections); 8 (42.0%) underwent pars plans vitrectomy with vitreous biopsy, whereas 5 (26.3%) received emergency corneal transplantation. Final visual acuity was no light perception in 6 eyes (3 secondarily enucleated), light perception in 2, hand motion in 7, counting fingers in 2, and ≥20/50 in 2. CONCLUSION: Our study of 38 eyes with infectious keratitis-associated infectious endophthalmitis revealed generally poor visual outcomes and a high rate of systemic conditions and previous intraocular surgery.

Optical coherence tomographic angiography of choroidal neovascularization ill-defined with fluorescein angiography.

PURPOSE: To evaluate the morphological structure of ill-defined choroidal neovascularisation (CNV) with traditional fluorescein angiography (FA) compared with optical coherence tomographic angiography (OCTA). METHODS: A retrospective case series study of 11 eyes with ill-defined CNV on FA was performed. Eyes were scanned with commercially available spectral-domain optical coherence tomography (OCT) (70 000 A-scans/s). The split-spectrum amplitude-decorrelation angiography (SSADA) algorithm was used to distinguish blood flow from static tissue. En face OCT angiograms were compared with FA. RESULTS: Eleven cases of ill-defined CNV on FA were identified from 10 study participants. Mean age of the participants was 74.5±6.8 years. Six cases had late leakage from undetermined source (LLUS) and five had fibrovascular pigment epithelial detachment (FVPED). Combining cross-sectional structural OCT with OCT angiograms, all cases were found to have type 1 CNV that corresponded to occult CNV with FA. In all cases of occult CNV on FA, distinct vascular structures were visible with OCTA in the outer retinal/retinal pigment epithelium slab. The mean CNV vessel area was 2.61±3.65 mm2. The mean CNV vessel area in cases with FVPED was larger than that in cases with LLUS (4.69±4.72 mm2 compared with 0.85±0.90 mm2, Mann-Whitney p value=0.04). CONCLUSIONS: Although the sample size is small to draw conclusions and the nature of work is retrospective and descriptive, OCTA has the potential to improve visualisation of ill-defined CNV with dye-based angiography, including occult CNV.

Giant Orbital Hydrocystoma in Children: Case Series and Review of the Literature.

OBJECTIVE: To describe the clinical features, ancillary diagnostic studies, and treatment outcomes in a cohort of pediatric patients with giant orbital hydrocystomas. DESIGN: Retrospective case series. PARTICIPANTS: Pediatric patients with giant orbital hydrocystomas treated in the practice of one surgeon (PDL). METHODS: A retrospective review of the clinical charts of pediatric patients with orbital hydrocystoma was performed and diagnostic information collected. Results were reviewed and compared with reported clinical data in the literature. MAIN OUTCOME MEASURES: Clinical presentation and histopathological findings of pediatric orbital hydrocystomas. RESULTS: Three pediatric cases of giant orbital hydrocystoma were encountered, each with an unusual feature, including deep orbital location, occurrence following trauma, and eccrine pathology. CONCLUSION: Giant orbital hydrocystomas may present in the pediatric population. Ophthalmologists should be cognizant of this entity when evaluating a child with a large, cystic orbital mass.

Effect of topical anesthesia on episcleral venous pressure in normal human subjects.

PURPOSE: Topical anesthetics can reduce episcleral venous pressure (EVP) and IOP in rabbits. In this study, we investigated the effect of topical anesthesia on EVP in normal human subjects. METHODS: We included in this study 30 eyes of 15 healthy volunteers who were habitual soft contact lens wearers. The EVP was measured before and at 5 and 10 minutes after instillation of topical proparacaine 0.5% in one eye. The EVP was measured by using a custom objective venomanometer. We compared EVP at 5 and 10 minutes after proparacaine to EVP before instilling proparacaine. RESULTS: There was no significant difference between EVP in eyes receiving topical anesthetic at 5 or 10 minutes (7.2 ± 2.2 and 7.6 ± 2.7 mm Hg, respectively; mean ± SD) compared to contralateral eyes (6.9 ± 2.5 and 7.3 ± 2.6 mm Hg, respectively; P > 0.10). As well, EVP was not significantly different 5 or 10 minutes after topical anesthesia compared to baseline in either the eyes receiving anesthetic or the contralateral eyes (all P > 0.10; minimum detectable difference, 1.4-1.9 mm Hg, α = 0.05, ß = 0.20, n = 30 eyes). CONCLUSIONS: The EVP in human eyes is not affected significantly by topical anesthetics.

Saturday Night Retinopathy with Ophthalmoplegia: A Case Series.

The purpose of this study was to present three cases of Saturday night retinopathy. The study design was observational case series. We described three cases who presented to our centre with acute visual loss following intravenous drug abuse and stupor leading to continuous pressure on the orbit while asleep. All cases presented with acute vision loss and had funduscopic evidence of ophthalmic or central retinal artery occlusion. Two of the cases presented with ophthalmoplegia and proptosis. One of the cases had significantly increased intraocular pressure with corneal oedema. All cases had fixed and non-reactive pupils with significant relative afferent pupillary defect. One case also had accompanying peroneal nerve damage. All three cases had poor visual outcomes. Saturday night retinopathy is a blinding condition with either central retinal or ophthalmic artery occlusion, which may present with transient orbital congestion and ophthalmoplegia. It may be accompanied by other nerve damage from compression in other parts of the body and is caused by prolonged positional pressure on the orbit.

Long-term trends in glaucoma-related blindness in Olmsted County, Minnesota.

OBJECTIVE: To determine the longitudinal trends in the probability of blindness due to open-angle glaucoma (OAG) in Olmsted County, Minnesota, from 1965 to 2009. DESIGN: Retrospective, population-based cohort study. PARTICIPANTS: All residents of Olmsted County, Minnesota (aged ≥ 40 years) who were diagnosed with OAG between January 1, 1965, and December 31, 2000. METHODS: All available medical records of every incident case of OAG were reviewed until December 31, 2009, to identify progression to blindness, defined as visual acuity ≤ 20/200 or visual field constriction to ≤ 20°. Kaplan-Meier analysis was used to estimate the cumulative probability of glaucoma-related blindness. Population incidence of blindness within 10 years of diagnosis was calculated using US Census data. Rates for subjects diagnosed in the period 1965-1980 were compared with rates for subjects diagnosed in the period 1981-2000 using log-rank tests and Poisson regression models. MAIN OUTCOME MEASURES: Cumulative probability of OAG-related blindness and population incidence of blindness within 10 years of diagnosis. RESULTS: Probability of glaucoma-related blindness in at least 1 eye at 20 years decreased from 25.8% (95% confidence interval [CI], 18.5-32.5) for subjects diagnosed in 1965-1980 to 13.5% (95% CI, 8.8-17.9) for subjects diagnosed in 1981-2000 (P = 0.01). The population incidence of blindness within 10 years of the diagnosis decreased from 8.7 per 100,000 (95% CI, 5.9-11.5) for subjects diagnosed in 1965-1980 to 5.5 per 100,000 (95% CI, 3.9-7.2) for subjects diagnosed in 1981-2000 (P = 0.02). Higher age at diagnosis was associated with increased risk of progression to blindness (P < 0.001). CONCLUSIONS: The 20-year probability and the population incidence of blindness due to OAG in at least 1 eye have decreased over a 45-year period from 1965 to 2009. However, a significant proportion of patients still progress to blindness despite recent diagnostic and therapeutic advancements.

Circadian variation of aqueous humor dynamics in older healthy adults.

PURPOSE: Intraocular pressure in the sitting position changes minimally during sleep, although aqueous humor flow decreases by 50% or more at night. The explanation for this apparent discrepancy has been unclear. This study investigated the roles of outflow facility, episcleral venous pressure (EVP), and uveoscleral outflow in maintaining IOP at night. METHODS: Forty-two eyes of 21 healthy subjects (age 47-76 years, mean 59 years) were studied. Aqueous humor flow rate, IOP in the sitting position, outflow facility, and EVP were measured in each eye during the middiurnal period (2:00-4:00 PM). Uveoscleral flow was calculated from the other variables by using the modified Goldmann equation. These variables were remeasured during the midnocturnal period (2:00-4:00 AM) and compared with those measured during the diurnal period by using generalized estimating equation models. RESULTS: Intraocular pressure did not change from the middiurnal period (13.9 ± 3.0 mm Hg) to the midnocturnal period (13.0 ± 1.8 mm Hg, mean ± SD, P = 0.07), although aqueous humor flow rate decreased from 2.48 ± 0.96 µL/min to 1.27 ± 0.63 µL/min (P < 0.001). Outflow facility decreased from 0.23 ± 0.06 µL/min/mm Hg to 0.20 ± 0.06 µL/min/mm Hg (P = 0.004), and EVP was unchanged from the middiurnal period (7.4 ± 1.8 mm Hg) to the midnocturnal period (7.4 ± 2.2 mm Hg, P = 0.95). Uveoscleral outflow decreased 93%, from 0.94 ± 1.26 µL/min during the middiurnal period to 0.07 ± 0.78 µL/min (P = 0.008) during the midnocturnal period. CONCLUSIONS: The nocturnal decrease in aqueous humor flow rate in older, healthy subjects is compensated by a small decrease in outflow facility and a large decrease in uveoscleral outflow to maintain a stable IOP.

Clinical results of ab interno trabeculotomy using the trabectome for open-angle glaucoma: the Mayo Clinic series in Rochester, Minnesota.

PURPOSE: To determine outcomes of ab interno trabeculotomy for treatment of open-angle glaucoma (OAG). DESIGN: Retrospective interventional single-surgeon, single-center case series. METHODS: Data were collected from 246 patients undergoing ab interno trabeculotomy between September 1, 2006, and December 1, 2010, with 3 months' follow-up or longer. Kaplan-Meier analysis was performed using Criteria A (postoperative intraocular pressure [IOP] ≤21 mm Hg or ≥20% reduction from preoperative IOP) and Criteria B (IOP ≤18 mm Hg and ≥20% reduction in IOP). Failure included increased glaucoma medications or subsequent surgery. Failure risk factors were identified using Cox proportional hazards ratio (HR). RESULTS: Of 88 cases of ab interno trabeculotomy-only and 158 cases of ab interno trabeculotomy with cataract extraction, the retention rate was 70% for 1 year and 62% for 2 years. Preoperative mean IOP was 21.6 ± 8.6 mm Hg; the number of glaucoma medications was 3.1 ± 1.1. At 24 months postoperatively, mean IOP was reduced 29% to 15.3 ± 4.6 mm Hg (P < 0.001) and the number of glaucoma medications was reduced 38% to 1.9 ± 1.3 (P < 0.001) with a success rate of 62% (95% CI, 56%-68%) using Criteria A and 22% (95% CI, 16%-29%) using Criteria B. Failure risk factors using Criteria A included primary OAG (HR 3.14, P < 0.01, 95% CI, 1.91-5.17) and past argon laser trabeculoplasty (HR 1.81, P < 0.01, 95% CI, 1.18-2.77). Using Criteria B, the HR for pseudoexfoliative glaucoma was 0.43 (P < 0.01, 95% CI 0.27-0.67). Of the cases, 66 (26.8%) required subsequent surgery on an average of 10 months (2 days to 3.2 years) after ab interno trabeculotomy. CONCLUSIONS: For criteria involving IOP ≤18 mm Hg, the 24-month survival of ab interno trabeculotomy is low. This surgery is appropriate for patients requiring a target IOP of 21 mm Hg or above.

Delayed-onset symptomatic hyphema after ab interno trabeculotomy surgery.

PURPOSE: To describe patients who have experienced delayed-onset hyphema after ab interno trabeculotomy surgery with the Trabectome (Neomedix Corp) for open-angle glaucoma. DESIGN: Retrospective case series. METHODS: study population: Patients at Mayo Clinic, Rochester, Minnesota, who underwent Trabectome surgery between September 1, 2006, and December 31, 2010, and who had symptomatic hyphema at least 2 months after surgery. observation procedure: Patients with blurred vision at least 2 months after Trabectome surgery were examined for the presence of hyphema using a slit lamp and gonioscopy. main outcome measures: Proportion of patients experiencing delayed-onset symptomatic hyphema after Trabectome surgery. Associated factors and clinical course for these patients. RESULTS: Of 262 cases of Trabectome surgery, there were 12 cases of delayed-onset symptomatic hyphema (4.6%). The average age was 74.3 years (range, 66 to 82 years). Median time to onset of hyphema was 8.6 months (range, 2 to 31 months) after surgery. Symptom onset commonly occurred on awakening. The most common characteristic was maintaining a sleep position on the surgical side. Most hyphemas resolved within 1 to 2 weeks, except in 1 patient, who required trabeculectomy for a refractory intraocular pressure spike. CONCLUSIONS: This is a series of patients with symptomatic delayed-onset hyphema after Trabectome surgery in the absence of further surgeries or trauma. Likely mechanisms are exertion-related increase in episcleral venous pressure or ocular compression from sleeping on the surgical side, followed by sudden decompression and blood reflux. Symptomatic patients should identify and avoid associated triggers because delayed-onset hyphema may be associated with intermittent intraocular pressure spikes that may require medical or surgical treatment.

Effect of head and body position on intraocular pressure.

OBJECTIVE: To investigate the effect of different head and body positions on intraocular pressure (IOP) in a randomized study. DESIGN: Prospective, comparative case series. PARTICIPANTS: Twenty-four healthy volunteers. METHODS: Subjects had 2 sets of IOP measurements performed, sitting and recumbent, with the order of these sets of measurements randomized. In the sitting position, IOP was measured in neutral neck position, neck extension, and neck flexion, with the order of measurements randomized. In the recumbent positions, IOP was measured in the supine position, and right and left lateral decubitus positions, with the order of measurements also randomized. All IOP measurements were performed with pneumatonometry. RESULTS: Mean IOP of right and left eyes while sitting with the neck in neutral position was 14.8±2.0 mmHg, which was significantly lower than IOP measured with neck flexion or extension or in the recumbent positions. As well, IOP in neck flexion was significantly higher than IOP in neck extension (all P<0.0001). The IOP was higher in the dependent eye when measured in the right lateral decubitus position (18.8±2.9 vs 17.7±3.1 mmHg; P = 0.016), but did not attain significance in the left lateral decubitus position (P = 0.076). CONCLUSIONS: In normal subjects, IOP is lowest when measured while sitting with the neck in the neutral position. All other head and body positions result in an elevation of IOP compared with the position used for typical clinical measurements. Lateral decubitus positions may result in a small increase in the IOP in the lower eye. Further research is required to determine whether similar elevations of IOP occur in glaucoma patients, and elucidate the clinical significance of these elevations.

A novel method for computerized measurement of episcleral venous pressure in humans.

Episcleral venous pressure (EVP) is an important determinant of intraocular pressure (IOP) and can be estimated by the pressure required to compress an episcleral vein. However, the lack of objective measurement endpoints makes EVP measurements in humans uncertain. To address this issue, we developed a new method to measure EVP objectively and reproducibly, and demonstrated its utility on a group of normal subjects. Our system for pressure chamber based venomanometry included a computer-controlled motor drive to increase pressure automatically, a transducer to record pressure, and a high-definition video camera to record vein collapse. Pressure measurements were synchronized with the video stream to determine the pressure required to collapse the vein to a specific pre-determined degree. This system was used to measure EVP in 10 eyes from 5 young healthy volunteers. Episcleral veins were selected in each of 4 quadrants. EVP was calculated to be the pressure in the chamber that compressed the vein by 0% (by back-projection), 10% or 50% as determined by using image analysis of the video stream. For this group of subjects, mean EVP was 6.3 ± 2.8 mmHg (mean ± SD, n = 40 measurements), 7.0 ± 2.6 mmHg, and 9.6 ± 2.6 mmHg using the 0%, 10% and 50% reduction endpoints, respectively. Pressures and standard deviations determined from these endpoints were significantly different from each other (p < 0.001). Coefficients of variation between right and left eyes were 12.7%, 10.2%, and 6.8% using the 0%, 10% and 50% endpoints, respectively. Based on previous research and theoretical considerations, the 0% endpoint is assumed to provide the most accurate estimate of baseline EVP, and can only be estimated by analyzing the brightness profiles of the vessels in the video stream. Objective measurement of EVP is important for understanding normal aqueous humor dynamics and its changes in disease states and with therapies. EVP has typically been assumed to be constant because of the lack of a convenient means of its measurement. This new method provides a precise means to assess EVP based on specific endpoints of vessel collapse, and enables, for the first time, objective and non-invasive measurements of EVP changes.

Prophylactic intravitreal bevacizumab for diabetic macular edema (thickening) after cataract surgery: prospective randomized study.

PURPOSE: To determine the role of intravitreal bevacizumab injected at the time of cataract surgery on postoperative increase of retinal thickness in patients with diabetic retinopathy. METHODS: Patients were randomized to a standardized procedure of phacoemulsification with intraocular lens implantation alone (control group; 30 eyes) or to receive 1.25 mg intravitreal bevacizumab at the end of surgery (IVB group; 31 eyes). Efficacy measures included best-corrected visual acuity (BCVA) testing, optical coherence tomography (OCT), and ophthalmoscopic examination at each postoperative visit during a 6-month follow-up. RESULTS: There were no significant differences in central macular thickness, BCVA, or systemic condition between the control and IVB groups at baseline. One month after surgery, the control group showed a significant increase in central macular thickness, whereas the bevacizumab group did not show an increase. After 6 months, there was no significant difference in macular thickness and postoperative visual acuity between the 2 groups. CONCLUSIONS: Intravitreal administration of 1.25 mg bevacizumab at the time of cataract surgery is effective just for the short term and 6-month results are the same as the control group.

Homonymous hemianopia detected by short wavelength automated perimetry in a patient with normal standard perimetry and MRI.

PURPOSE: To report a case of homonymous hemianopia detected by short wavelength automated perimetry (SWAP) in a patient with normal standard automated perimetry (SAP) and magnetic resonance imaging (MRI) of the brain and orbits. METHODS: A 61-year-old woman with a history of motor vehicle accident with head injury nearly 50 years before presentation was referred for further evaluation as a glaucoma suspect. Complete ophthalmic examination, corneal pachymetry, SAP, SWAP, retinal nerve fiber layer analysis by ocular coherence tomography, and brain and orbital MRI were done. RESULTS: The patient had intraocular pressure (IOP) of 18-mm Hg and vertical cup-to-disc ratios of 0.8 in each eye. Superior neuroretinal rim pallor was detected in both optic discs on dilated optic nerve examination, and corresponding retinal nerve fiber layer thinning was detected with ocular coherence tomography. SAP indicated minimal nonspecific changes in the right eye, whereas the left eye had a normal visual field. SWAP revealed a left homonymous hemianopia. Neurologic examinations and MRI of the brain and orbits were found to be normal. CONCLUSIONS: SWAP can detect subtle hemianopic field defects in patients with normal standard perimetry.

Enucleation with hydroxyapatite implantation versus evisceration plus scleral quadrisection and alloplastic implantation.

PURPOSE: To compare the motility and complications of enucleation with evisceration plus scleral quadrisection. METHODS: In a prospective study between January 2006 and June 2007, 50 patients underwent evisceration with scleral quadrisection and alloplastic implantation (group 1) and 50 patients underwent enucleation and hydroxyapatite implantation (group 2). Horizontal and vertical excursions of implants and complications such as exposure or extrusion and deep superior sulcus deformity were evaluated postoperatively. RESULTS: After a mean follow-up interval of 11.5 months for group 1 and 13.2 months for group 2, vertical measurements were approximately 20% less than horizontal measurements in both groups. The mean horizontal and vertical movements in group 2 were significantly less than in group 1 (p < 0.001). There was 1 case of small hydroxyapatite exposure in group 2 (1 in 50; 2%) and 2 cases of implant extrusion in group 1 (4%) (p = 0.50). Deep superior sulcus deformity was noted in 10 patients in group 1 (20%) and 7 patients in group 2 (14%) (p = 0.43). Analysis of covariance in both groups showed that age, gender, and follow-up interval were not predictors of movement in either direction (all p-values >0.05). CONCLUSIONS: Evisceration with scleral quadrisection and alloplatic sphere implantation can effectively substitute for a more extensive procedure such as enucleation in patients with painful blind eyes, cosmetically unacceptable blind eyes, and medically uncontrolled endophthalmitis. It provides rapidity, ease, and better implant excursion and lower cost of the implants compared with their porous counterparts.

Use of sealant (HFG) in corneal perforations.

PURPOSE: To repair corneal perforation using human fibrin glue and determine its efficacy. METHODS: A case series study was performed on corneal perforations up to 3 mm in diameter who were admitted in Farabi Eye Hospital. Age, visual acuity, presence and size of corneal thinning, corneal epithelial defect, size and depth of corneal infiltration, site and size of corneal perforation, corneal vascularization, anterior chamber depth, and reaction and the etiology of corneal perforation were recorded. Then, corneal perforation was sealed using FG and soft contact lens, and the patients were followed up for at least 3 months. Healing of the corneal perforation with adhesive was considered as a success (the primary outcome) and reported. RESULTS: Of 18 patients, 8 were women and 10 men. The mean age of the patients was 52 +/- 25.7 years. The size of corneal perforations was 0.6-3 mm (mean = 1.88 mm). The etiologies of corneal perforation were postinfectious in 11 and noninfectious in 7. Fifteen (83.3%) eyes had successful healing of corneal perforation after 3 months. All the patients who were failed had corneal perforation larger than 2 mm in diameter. The success rate was higher in corneal perforation