Pharmacologic Anisocoria With Azelastine: The Importance of a Good Anamnesis.

Unilateral pharmacologic mydriasis is one of the differential diagnoses of anisocoria. This is a clinical case of a 37-year-old male patient admitted to the ophthalmology emergency department with unilateral mydriasis, an infrequent side effect of the antihistaminic drug azelastine. A comprehensive medical history including ocular medication was essential to avoid the need for additional tests and to exclude life-threatening conditions responsible for a similar presentation.

Tocilizumab as a Useful Tool for Thyroid Eye Disease in Pediatric Population: A Case Report.

Thyroid eye disease (TED) characterizes by inflammation and remodeling of orbital tissues. Although the majority of pediatric TED is mild, some children present progressive and severe disease. The approach to severe disease in this group of patients, especially when noncortico-responsive, is challenging. The purpose of this work was to describe the effective use of tocilizumab as second-line therapy in steroid-resistant pediatric TED. A 13-year-old female with a history of Graves' disease presented with right eye proptosis for at least 8 months associated with mild pain on eye movements and ocular surface complaints. The ophthalmologic evaluation revealed Hertel exophthalmometry readings of 22 mm on the right eye (OD) and 19 mm on the left (OS). The remaining ophthalmic examination was unremarkable. Intravenous methylprednisolone pulses of 500 mg were initiated without any improvement after 4 treatments. Following multidisciplinary team discussion, therapy was switched to monthly tocilizumab injections at 4 mg/kg. Significant reduction of proptosis and resolution of pain and ocular surface complaints were noted immediately after the treatment switch. Exophthalmometry readings after the end of treatment that included 4 tocilizumab injections were 20 mm on OD and 19 mm on OS. No side effects were reported during the entire follow-up. Six months after treatment cessation, the patient remains stable, without any signs of orbitopathy relapse and no ophthalmologic complaints. This is the second case report showing the effectiveness of tocilizumab in pediatric TED and the first one showing its efficacy when steroids fail. Our results support the potential safety and efficacy of this immunosuppressor in children with TED.

Rhino-Orbital Mucormycosis After COVID-19 Recovery: A Case Report.

The pandemic caused by SARS-CoV-2 remains a health care concern, despite vaccination programs. Mucormycosis, especially rhino-orbital-mucormycosis, has been described as a severe complication of COVID-19. Although it has been described mostly in India and other developing countries, few cases in the western world have also been described. We present a case of rhino-orbito-mucormycosis after recovery from severe COVID-19 in Portugal. A 75-year-old diabetic and obese man presented with right proptosis associated with right eye pain and low vision one month after recovery from severe COVID-19. Considering the most probable etiology for this clinical picture, anti-fungal therapy with liposomal amphotericin B was promptly initiated, followed by endoscopic sinus debridement. However, due to persistent and progressive infection, and after a multidisciplinary revision of the case, orbital exenteration was performed. One year after surgery, the patient is stable, without clinical or imagological signs of relapse of the disease. Although the evolution of the pandemic, along with vaccination programs, led to a lower incidence of severe COVID-19 disease, there are still patients presenting with severe COVID-19, requiring intensive care and at risk for serious complications. This case illustrates the importance of being aware of the development of post-COVID-19 mucormycosis and the need for close surveillance of patients recovering from severe COVID-19. COVID-19 prompt diagnosis and multidisciplinary approach are essential for a timely intervention achieving better survival while minimizing morbidity.

Bilateral Episcleral Corkscrew Vessels: Expedition into the Unknown - Case Report.

We aim to report a case of a middle-aged woman with bilateral idiopathic elevated episcleral venous pressure (IEEVP) and its difficulties in the diagnostic approach. Particularly in this case, the atypical feature of ocular hypertension without glaucomatous optic nerve damage may be misleading. We present a 66-year-old woman with longstanding bilateral "red eyes." Clinical findings included bilateral episcleral vessel engorgement and tortuosity and raised intraocular pressure with open iridocorneal angles. Despite ocular hypertension, glaucomatous neuropathy was absent and confirmed by normal structural (optical coherence tomography) and functional (standard automated perimetry) tests. The systemic workup was unremarkable. Magnetic resonance angiography showed bilateral dilated superior ophthalmic veins. Cerebral digital subtraction angiography was requested, and no carotid-cavernous fistula (or other significant vascular findings) was identified. The diagnosis of IEEVP was assumed. In conclusion, our case highlights the systematic investigation necessary in cases of bilateral episcleral vessel engorgement and tortuosity and the possible differential diagnosis to be considered to rule out life-threatening causes of elevated episcleral venous pressure. It is important for clinicians to be aware of IEEVP even in patients with atypical features that despite significative ocular hypertension had no glaucomatous damage.

Hawkes Processes Framework With a Gamma Density As Excitation Function: Application to Natural Disasters for Insurance.

Hawkes processes are temporal self-exciting point processes. They are well established in earthquake modelling or finance and their application is spreading to diverse areas. Most models from the literature have two major drawbacks regarding their potential application to insurance. First, they use an exponentially-decaying form of excitation, which does not allow a delay between the occurrence of an event and its excitation effect on the process and does not fit well on insurance data consequently. Second, theoretical results developed from these models are valid only when time of observation tends to infinity, whereas the time horizon for an insurance use case is of several months or years. In this paper, we define a complete framework of Hawkes processes with a Gamma density excitation function (i.e. estimation, simulation, goodness-of-fit) instead of an exponential-decaying function and we demonstrate some mathematical properties (i.e. expectation, variance) about the transient regime of the process. We illustrate our results with real insurance data about natural disasters in Luxembourg.

A Hybrid Model to Classify Patients with Chronic Obstructive Respiratory Diseases.

Over the last decades, an increase in the ageing population and age-related diseases has been observed, with the increase in healthcare costs. As so, new solutions to provide more efficient and affordable support to this group of patients are needed. Such solutions should never discard the user and instead should focus on promoting more healthy lifestyles and provide tools for patients' active participation in the treatment and management of their diseases. In this concern, the Personal Health Empowerment (PHE) project presented in this paper aims to empower patients to monitor and improve their health, using personal data and technology assisted coaching. The work described in this paper focuses on defining an approach for user modelling on patients with chronic obstructive respiratory diseases using a hybrid modelling approach to identify different groups of users. A classification model with 90.4% prediction accuracy was generated combining agglomerative hierarchical clustering and decision tree classification techniques. Furthermore, this model identified 5 clusters which describe characteristics of 5 different types of users according to 7 generated rules. With the modelling approach defined in this study, a personalized coaching solution will be built considering patients with different necessities and capabilities and adapting the support provided, enabling the recognition of early signs of exacerbations and objective self-monitoring and treatment of the disease. The novel factor of this approach resides in the possibility to integrate personalized coaching technologies adapted to each kind of user within a smartphone-based application resulting in a reliable and affordable alternative for patients to manage their disease.

Immediate Reactions to Fluorescein and Indocyanine Green in Retinal Angiography: Review of Literature and Proposal for Patient's Evaluation.

INTRODUCTION: Contrast rapid sequence angiography with fluorescein or indocyanine green (ICG) is a diagnostic procedure commonly used in ophthalmology. Adverse reactions to fluorescein and ICG are rare and may be classified as toxic, of hypersensitivity and non-specific. The evaluation and management of a patient with an adverse reaction is a challenge for the majority of ophthalmologists, as is the assessment of risk factors that may contraindicate the procedure. PURPOSE: We aim to review the concepts underlying adverse reactions to fluorescein and ICG, especially those of hypersensitivity, and present a proposal or the evaluation of the patients in need to perform retinal angiography and for the treatment of immediate reactions to fluorescein and ICG. METHODS: The available literature was examined using PubMed-Medline, and using the MeSH terms "fluorescein", "Indocyanine green", "ophthalmic dyes", "retinal angiography", "adverse reactions", and "allergic reaction". CONCLUSION: This review may help ophthalmologists to identify patients with higher risk of a hypersensitivity reaction and give them tools to recognize patients with suspected hypersensitivity that may benefit from an allergy study.

Sustained Control from Recurring Non-Infectious Uveitic Macular Edema with 0.19 mg Fluocinolone Acetonide Intravitreal Implant - A Case Report.

In January 2013, a 54-year-old pseudophakic woman was referred to the ocular inflammation clinic with a diagnosis of panuveitis, already on oral cyclosporine (100 mg/day) since 2010. She was a monocular patient, with the left eye eviscerated due to trauma and secondary endophthalmitis in 1995. She had experienced similar recurring episodes between 2010 and 2013. Examination revealed best-corrected visual acuity (BCVA) of 20/200. The anterior segment revealed the presence of flare and absence of cells. Intraocular pressure (IOP) was 11 mmHg. Fundus examination revealed the presence of anterior vitreous organization, exuberant cystoid macular edema (CME) and peripheral Dalen-Fuchs nodules with no activity. Systemic workup showed no changes, and a presumptive diagnosis of sympathetic ophthalmia was made. Initial therapy included topical and systemic corticosteroids. Cyclosporine was replaced with methotrexate (20 mg/week) due to nephrotoxicity. There was marked improvement in anterior inflammation and vitreous organization, but the ME remained exuberant (central ring thickness of 0.7 mm). Over the subsequent 4 years of follow-up, the patient received two intravitreous injections of a dexamethasone extended-release implant (Ozurdex®), with normalization of macular thickness and improvement in visual acuity (VA), but ME recurred around 6 months post-injection. During this period, the patient also underwent three sub-tenon injections of triamcinolone, with marked improvement of ME, but ME recurred between 4 and 6 months after treatment. She was thus recommended for treatment with a fluocinolone extended-release implant (ILUVIEN®). Post-implantation (3-year follow-up), she had controlled anterior inflammation without ME (central macular thickness of 248 µm). This case suggests that sustained control of inflammation enables better control of ME, and benefits may persist even after cessation of the direct anti-inflammatory effect of the implant. FUNDING: Alimera Sciences Ltd funded the Rapid Service Fees.

Adequacy of the Fogging Test in the Detection of Clinically Significant Hyperopia in School-Aged Children.

PURPOSE: To evaluate the efficacy of the "fogging test," performed with a +2 diopters (D) lens, in the exclusion of clinically significant hyperopia in school-aged children. METHODS: We studied 54 children between 5 and 11 years of age, with 10/10 best-corrected bilateral visual acuity (VA) without significant degree of correction. VA was assessed in each eye with a "bilateral" +2 D sphere over-refraction followed by cycloplegic retinoscopy. The capacity of the test to detect hyperopia of ≥+2 D and ≥+1.5 D was evaluated by examining the respective receiver operating characteristic (ROC) curves and sensitivity and specificity values for different cutoff values of VA. RESULTS: For the detection of hyperopia ≥+2 D, the area under the ROC curve (AUC) was 0.955 (p ≤ 0.001). The VA cutoff with best discriminative capacity was ≥5/10, with a sensitivity of 100%, specificity of 79%, positive predictive value (PPV) of 57%, and negative predictive value (NPV) of 100%. In respect of ≥+1.5 D hyperopia, the test capacity was lower (AUC = 0.832; p ≤ 0.001). The best VA cutoff was also of ≥5/10, with a PPV of 81% and a NPV of 85%. CONCLUSION: The accuracy of the test was high for the evaluation of ≥+2 D hyperopia but lower for ≥+1.5 D hyperopia. For the detection of ≥+2 D hyperopia, the VA cutoff of <5/10 may permit the exclusion of clinically significant hyperopia in selected children, without the need for cycloplegia. For the same cutoff, the PPV was low, meaning that in children with ≥5/10 VA cycloplegic refraction remains obligatory.

Fundoscopic Changes in Maroteaux-Lamy Syndrome.

PURPOSE: To describe a clinical case of mucopolysaccharidosis type VI (MPS VI), or Maroteaux-Lamy syndrome, with fundoscopic alterations that may correspond to scleral deposits of glycosaminoglycans. MATERIALS AND METHODS: Clinical case report. RESULTS: A 16-year-old girl with MPS VI was examined at the Ophthalmology Department for poor vision due to opacified corneas. Treatment consisted of bilateral penetrating keratoplasty. Retinographies and enhanced depth imaging optical coherence tomography (EDI-OCT) were performed after surgery, suggesting the presence of scleral glycosaminoglycan deposits. The patient evolved with stable corneal and fundoscopic findings. CONCLUSIONS: To our knowledge, this is the first case of MPS VI described in vivo with suspected deposits of glycosaminoglycans in the sclera. Fundoscopic alterations are not usually included in the ocular pathological spectrum of MPS VI. However, with improved control of systemic comorbidities, survival rates of these patients have increased, which in turn has made it possible to observe other changes besides the ones that were classically described. Despite being particularly challenging to manage, efforts should be made to maximizing the visual acuity of these patients, in order to provide them the best possible quality of life.

Switch to Aflibercept in the Treatment of Neovascular AMD: Long-Term Results.

PURPOSE: To report the long-term clinical outcomes after switching from intravitreal bevacizumab or ranibizumab to aflibercept therapy in eyes with AMD. METHODS: Retrospective analysis of changes in BCVA, SD-OCT image, and frequency of injections after 1, 2, and 3 years of follow-up. RESULTS: 164 eyes were analyzed, 101 eyes switched from bevacizumab (group 1) and 63 from ranibizumab (group 2). One year after the switch, there was an overall nonsignificant mean decrease of 2 ETDRS letters in BCVA. Three years after, there was an overall mean decrease of 7 ETDRS letters, which was statistically significant. A significant improvement in the mean CRT was found at 1, 2, and 3 years. There was a significant decrease in the mean number of injections per year (7.8 to 6.5, p < 0.005) between the first and third year. CONCLUSION: Aflibercept can be useful in the management of refractory neovascular AMD, with a good morphological response. However, in the long-term, BCVA stabilization was not achieved.