FACTORS ASSOCIATED WITH DELAYED DIAGNOSIS IN PATIENTS WITH PRIMARY VITREORETINAL LYMPHOMA.

PURPOSE: To identify demographic and clinical factors associated with delayed diagnosis in patients with primary vitreoretinal lymphoma (VRL). METHODS: Retrospective, tertiary referral center-based cohort study of all patients at Mayo Clinic in Rochester, Minnesota, with a biopsy-proven diagnosis of VRL from January 1, 2000, to October 31, 2022. RESULTS: There were 87 patients included during the 22-year study period with 73 patients (83.9%) diagnosed with VRL upon initial evaluation at the tertiary center, with the other 14 patients (16.1%) diagnosed later. The median referral time was 4.8 months (range: 0-113 months). Patients who received an initial diagnosis of inflammatory uveitis or another incorrect diagnosis elsewhere were referred slower than those initially diagnosed with VRL (P = 0.04). The most common incorrect initial diagnosis from an outside institution was inflammatory uveitis (n = 35, 40.2%). When patients were split into four groups based on referral time, prior use of corticosteroids was associated with a significant delay in referral (P = 0.03). CONCLUSION: Diagnosing VRL continues to be challenging, as months-long delays from initial evaluation to expert referral center evaluation are common. Prior use of corticosteroids was associated with delay in diagnosis and referral time, underscoring the need to increase awareness regarding differences between VRL and uveitis.

Subretinal Phialophora Abscess in Chronic Granulomatous Disease.

PURPOSE: To report a rare case of a subretinal Phialophora richardsiae abscess in a patient with chronic granulomatous disease (CGD). METHODS: A 21-year-old male with CGD and a history of invasive pulmonary aspergillosis presented with progressive loss of vision and pain in his left eye. He was found to have a subretinal abscess with a macula involving serous retinal detachment. A diagnostic and therapeutic pars plana vitrectomy, subretinal biopsy with debridment, inferior retinectomy and silicone oil tamponade was performed. Intraoperative cultures grew Pleurostoma (Phialophora) richardsiae. He was treated with systemic liposomal amphotericin B and high-dose Posaconazole. However, eye eventually required enucleation. RESULTS: Preoperative visual acuity (VA) was light perception on the left eye and improved to count fingers at 4 weeks post-operative. However, VA rapidly declined to light perception, he developed an opaque white cataract, iris neovascularization, posterior synechiae, and corectopia. The retina remained attached under silicone oil. Histopathology revealed granuloma formation and active fungal elements. DISCUSSION/CONCLUSION: The case supports the importance of vitreoretinal surgery to determine a definitive systemic diagnosis. Treatment of Phialophora infection is surgically challenging to manage and has a poor visual prognosis in patients with CGD.

Gore-Tex Suture-Associated Endophthalmitis in a Scleral-Sutured Intraocular Lens.

PURPOSE: To describe a unique case of Gore-Tex (Gore Medical, Arizona, USA), suture-associated delayed-onset endophthalmitis in a patient with a history of scleromalacia, pathologic myopia, multiple prior vitrectomies in the setting of an scleral sutured intraocular lens. METHODS: Retrospective case report. PATIENT: A 69-year-old man complained of blurry vision and eye pain 21 months after implantation of a scleral-sutured intraocular lens and was found to have an exposed Gore-Tex suture with scleromalacia, vision loss to hand motion, a hypopyon and vitritis. He was diagnosed with culture-positive endophthalmitis. He had a previous history of a rhegmatogenous retinal detachment repair and subsequent dislocated intraocular lens in this eye treated with a scleral sutured intraocular lens. A vitreous tap and injection of broad-spectrum antibiotics and suture removal at the slit lamp were performed at the time of presentation. One week later he later underwent pars plana vitrectomy and removal of the intraocular lens. RESULTS: Following the tap and inject and subsequent lens removal, his vision has returned to his pre-operative vision of 20/100 with refraction. DISCUSSION: Gore-Tex suture is a non-absorbable and flexible option with great tensile strength that has emerged as a favored alternative to polypropylene for the use in transscleral fixated intraocular lenses. While endophthalmitis and suture erosion are known complications of this procedure, this report describes one of the first cases of Gore-Tex associated-endophthalmitis.

Mask-induced Artifact Impacts Intraocular Pressure Measurement Using Goldmann Applanation Tonometry.

PURPOSE: The coronavirus (COVID-19) pandemic has impacted ophthalmology practices significantly. American Academy of Ophthalmology and Center for Disease Control guidelines suggest mandatory masking of patients and physicians during outpatient visits. We have recently become aware of a mask-induced phenomenon, whereby the intraocular pressure (IOP) as measured by Goldmann applanation tonometry (GAT) is artificially elevated due to mechanical interference from the mask. CLINICAL PRESENTATION: A 37-year-old male with a history of primary open-angle glaucoma on triple therapy presented for a routine visit. CLINICAL FINDINGS: When measuring IOP by GAT the right eye measured 16 mm Hg, but the left eye measured 20 mm Hg. The patient's mask was noted to be touching the base of the sensor rod on the tonometer. This patient's IOP was falsely elevated due to the lateral edge of his mask touching the base of the applanation tonometer, changing the relationship between the bi-prism tip and the weighted balance below, and eliminating the weighted balance from the pressure measuring mechanism. The patient's mask was adjusted to ensure there was no touch and repeat measurement showed an IOP of 16 mm Hg in the left eye. CONCLUSION: Recognizing mask-induced alteration in IOP is essential as it could lead to unnecessary escalation of treatment. We recommend flattening the area of mask protrusion during applanation and ensuring that the sensor arm remains clear of the mask while the tonometer tip approaches the cornea, especially at the moment the mires become visible during corneal contact.

Changes in Iridocorneal Angle and Anterior Chamber Structure in Eyes With Anatomically Narrow Angles: Laser Iridotomy Versus Pilocarpine.

PURPOSE: To compare the effects of laser iridotomy (LI) and pilocarpine on iridocorneal angle and anterior chamber structure in anatomically narrow angles (ANAs). MATERIALS AND METHODS: Temporal LI was performed 90 minutes after 2% pilocarpine administration in patients with occludable ANA. Swept-source optical coherence tomography B-scans of the anterior segment were obtained at baseline, 60 minutes after 2% pilocarpine administration, and 1 week after LI. Angle-opening distance (AOD), trabecular-iris surface area (TISA), and angle recess area (ARA) were measured at the temporal, superior, nasal, and inferior quadrants. Anterior chamber depth (ACD) and lens vault (LV) were also measured. AOD, TISA, ARA, ACD, and LV were compared among 3 time points: at baseline, 60 minutes after 2% pilocarpine administration, and 1 week after LI. RESULTS: Twenty-four eyes (24 patients; mean age, 55 y) were included. In all 4 quadrants and globally, AOD, TISA, and ARA increased from baseline after pilocarpine and after LI (all P<0.010). The increase in AOD, TISA, and ARA was greater after LI than after pilocarpine globally and in the temporal and superior quadrants (all P<0.040). ACD decreased and LV increased from baseline after pilocarpine (both P<0.001). Postpilocarpine anterior chambers were shallower with higher LV than post-LI (both P<0.016). CONCLUSION: LI is more effective than pilocarpine in widening the iridocorneal angle without significant shallowing the anterior chamber in eyes with ANA.

Relationship Between Optic Nerve Head Drusen Volume and Structural and Functional Optic Nerve Damage.

PURPOSE: The purpose of this study is to assess the relationships between optic nerve head drusen (ONHD) volume, retinal nerve fiber layer (RNFL) thickness and visual field (VF) loss. METHODS: Patients with ONHD and no other ocular or systemic conditions that can affect RNFL or VF were enrolled. Serial enhanced depth imaging (EDI) optical coherence tomography (OCT) B-scans of the optic nerve head (interval between scans, ~30 µm) were obtained from each participant. ONHD volume was calculated for each eye by delineating the ONHD masses in each OCT B-scan using 3-dimensional reconstruction software. RESULTS: A total of 47 eyes (28 patients) with ONHD were included (mean age, 57±16 y). ONHD volume varied considerably [0.265±0.227 (range, 0.005 to 0.855)] mm. Linear and quadratic regression analyses demonstrated that ONHD volume is significantly associated with both global average RNFL thickness (linear R=0.531, quadratic R=0.557; P<0.001) and VF mean deviation (linear R=0.519, quadratic R=0.522; P<0.001). ONHD were most prevalent in the nasal quadrant (46 eyes, 98%), followed by superior, inferior and temporal quadrants [35 (74%), 30 (64%), and 16 (34%) eyes respectively]. The proportion of eyes with OCT RNFL defects (81%; 38/47 eyes) was significantly greater than that with VF defects (60%; 28/47 eyes) (P<0.001). RNFL defects were detected in 10 of the 19 eyes with no VF defects. RNFL defects were detected in all 28 eyes with VF defects. CONCLUSIONS: ONHD volume generally correlates with structural and functional optic nerve damage.

Glaucoma Patient-Reported Concerns and Associated Factors.

PURPOSE: To assess the character and degree of concerns of glaucoma patients and identify demographic/clinical factors affecting the concerns. DESIGN: Prospective cross-sectional study. METHODS: A questionnaire that addressed patients' concerns was administered to consecutive glaucoma patients. Severity of concern was scored with a scale of 0-5 in order of increasing severity. Age, sex, intraocular pressure, visual field (VF) mean deviation (MD), number of antiglaucoma medications, history of glaucoma surgery, and employment status were recorded. RESULTS: Questionnaire results of 152 patients (mean VF MD, -8.03 ± 7.86 dB [better eye] and -16.06 ± 10.22 dB [worse eye]; mean age, 69 ± 14 years) were analyzed. Severity of concern was greatest for general eyesight (2.92/5.00) and visual symptoms (2.78/5.00), followed by activities (2.20/5.00) and socioeconomic factors (2.13/5.00), and then ocular symptoms (1.69/5.00) (P < .001). The most common concerns within each domain were blurry vision (32%), reading small print (34%), medical costs (26%), and dryness (32%). Concern about visual symptoms correlated with VF MD of the better eye (r = -0.258; P = .001) and worse eye (r = -0.233; P = .004). Concern about activities correlated with history of glaucoma surgery (r = 0.148; P = .023) and VF MD of the better eye (r = -0.284; P < .001) and worse eye (r = -0.295; P < .001). Concern about socioeconomic factors correlated with VF MD of the better eye (r = -0.245; P = .003) and age (r = -0.260; P = .001). CONCLUSIONS: Glaucoma patients reported varied degrees of concern regarding items associated with quality of life. Certain items may be more concerning than others. Severity of some concerns increased with more severe VF loss, prior glaucoma surgery, or younger age.

Iridocorneal Endothelial Syndrome Presenting With Large Diurnal Intraocular Pressure Fluctuation.

PURPOSE OF THE STUDY: The purpose of the study was to report a case of iridocorneal endothelial syndrome with an initial presentation of a large diurnal fluctuation of intraocular pressure (IOP) which peaked early in the morning. METHODS: A 31-year-old white man had transient blurry vision oculus sinister (OS) upon awakening in the morning for the past 2 months. The blurry vision improved within 1 to 2 hours. Clinical examination, diurnal IOP measurements, and specular microscopy were performed to investigate the cause of his transient blurry vision. RESULTS: At 6 AM, IOP OS was 38 mm Hg with corneal edema and visual acuity of 20/30. At 8 AM, IOP OS decreased to 25 mm Hg with clear cornea and visual acuity of 20/20. Diurnal IOP measurements revealed a large fluctuation OS (18 mm Hg). Specular microscopy revealed pleomorphism, polymegathism, light peripheral borders and light/dark reversal of the corneal endothelium OS. IOP oculus dexter remained within normal limits with clear cornea and stable visual acuity throughout the diurnal measurements. CONCLUSIONS: In patients with consistent daily episodes of transient blurry vision, clinicians should suspect a large diurnal IOP fluctuation with high peak IOP. If symptoms and signs are unilateral, iridocorneal endothelial syndrome should be included in the differential diagnosis and corneal specular microscopy should be obtained.

Effect of Pilocarpine Hydrochloride on the Schlemm Canal in Healthy Eyes and Eyes With Open-Angle Glaucoma.

IMPORTANCE: The in vivo effect of pilocarpine hydrochloride on the Schlemm canal may help explain its pharmacologic mechanism of action and better indicate its clinical use. OBJECTIVE: To investigate the effect of pilocarpine on the structure of the Schlemm canal in vivo in healthy eyes and eyes with glaucoma. DESIGN, SETTING, AND PARTICIPANTS: In this case-control study, healthy individuals and patients with open-angle glaucoma were prospectively enrolled between September 1, 2013, and June 30, 2014, after a complete ophthalmologic examination at a tertiary glaucoma referral practice. Eighty-one serial, horizontal, enhanced depth imaging optical coherence tomographic B-scans (interval between B-scans, approximately 35 µm) of the nasal corneoscleral limbus were performed before and 1 hour after topical administration of pilocarpine, 1%, in 1 eye of healthy volunteers and pilocarpine, 2%, in 1 eye of patients with glaucoma. Fifty B-scans in the overlapping area (circumferential length, approximately 1.7 mm) between the 2 sets of serial scans (before and after pilocarpine administration) were selected for analysis based on the structures of aqueous and blood vessels as landmarks. The cross-sectional area of the Schlemm canal was measured in each selected B-scan. Volume of the Schlemm canal was calculated using commercially available 3-dimensional reconstruction software. MAIN OUTCOMES AND MEASURES: Mean cross-sectional area of the Schlemm canal. RESULTS: Enhanced depth imaging optical coherence tomographic scans of the Schlemm canal were performed successfully before and after administration of pilocarpine, 1%, in 9 healthy eyes (9 individuals) and pilocarpine, 2%, in 10 eyes with glaucoma (10 patients) (mean [SD] age, 31.9 [7.8] and 68.7 [13.2] years, respectively). Following pilocarpine administration, mean (SD) intraocular pressure decreased from 14.3 (1.3) to 13.7 (1.1) mm Hg in healthy eyes (P = .004) and from 17.5 (6.0) to 16.6 (6.1) mm Hg in eyes with glaucoma (P = .01). The mean (SD) cross-sectional area of the Schlemm canal increased by 21% (4667 [1704] to 5647 [1911] µm2) in healthy eyes (P < .001) and by 24% (3737 [679] to 4619 [692] µm2) in eyes with glaucoma (P < .001) (mean difference in percent increase, 2.2%; 95% CI, -8.5% to 12.9%). The mean (SD) volume of the Schlemm canal in the overlapping area increased from 8 004 000 (2 923 000) to 9 685 000 (3 277 000) µm3 in healthy eyes (P < .001) and from 6 468 000 (1 170 000) to 7 970 000 (1 199 000) µm3 in eyes with glaucoma (P < .001). CONCLUSIONS AND RELEVANCE: These data suggest that pilocarpine expands the Schlemm canal in eyes with and without glaucoma. No differences in the effect were identified between the 2 groups. Enhanced depth imaging optical coherence tomography may be useful in investigating the effect of pharmacologic agents on the Schlemm canal.