Superior Ophthalmic Vein Thrombosis Associated With Asymptomatic COVID-19 Infection.

Superior ophthalmic vein thrombosis is a rare condition scarcely described in clinical literature with potentially severe consequences including permanent vision loss. This report details the case of a 70-year-old woman who presented with acute binocular horizontal diplopia, relative proptosis of the OD by 4 mm, and pain OD. On exam, visual acuity was 20/20 OD and 20/30 OS with full extraocular movements. CT revealed proptosis OD with a thrombosed superior ophthalmic varix. Evaluation for etiology of hypercoagulability was unremarkable, although the patient did have an asymptomatic COVID-19 infection 1 month prior. To the authors' knowledge, this is the first reported case of superior ophthalmic vein thrombosis secondary to an asymptomatic COVID-19 infection.

Ophthalmic manifestations and management considerations for emerging chemical threats.

Chemical agents have been utilized for centuries in warfare and pose a health threat to civilians and military personnel during armed conflict. Despite treaties and regulations against their use, chemical agent exposure remains a threat and measures to understand their effects and countermeasures for systemic and organ-specific health are needed. Many of these agents have ocular complications, both acute and chronic. This mini-review focuses on key chemical agents including vesicants (mustards, lewisite), nerve agents (sarin, VX), knockdown gasses (hydrogen cyanide), and caustics (hydrofluoric acid). Their ophthalmic manifestations and appropriate treatment are emphasized. Acute interventions include removal of the source and meticulous decontamination, as well as normalization of pH to 7.2-7.4 if alteration of the ocular pH is observed. Besides vigorous lavage, acute therapies may include topical corticosteroids and non-steroid anti-inflammatory therapies. Appropriate personal protective equipment (PPE) and strict donning and doffing protocols to avoid healthcare provider exposure are also paramount in the acute setting. For more severe disease, corneal transplantation, amniotic membrane graft, and limbal stem cell transplantation may be needed. Orbital surgery may be required in patients in whom cicatricial changes of the ocular surface have developed, leading to eyelid malposition. Multidisciplinary care teams are often required to handle the full spectrum of findings and consequences associated with emerging chemical threats.

Efficacy of the Buried Temporary Suture Tarsorrhaphy: A Novel Technique.

PURPOSE: To describe a buried variation of the temporary suture tarsorrhaphy and determine its efficacy period. METHODS: This retrospective case review includes 11 patients needing corneal protection. Six patients had lagophthalmos from facial nerve palsy, 4 had cicatricial ectropion, and 1 had neurotrophic keratopathy. A total of 14 buried temporary suture tarsorrhaphies (BTSTs) were placed. The duration of the BTST was the main outcome. The corneal status before and throughout the BTST was monitored. The eyelids were examined for any undesired changes from the BTST. RESULTS: The mean duration of the BTST was 97.5 days, with a maximum of 273 days. Aside from one spontaneous dehiscence 5 days after placement, all BTSTs held until intentional removal. Five BTSTs were removed for a more definitive surgical procedure, 6 were removed after resolution of the initial indication, and 2 are still in place as the patient awaits surgery. All cases of keratopathy improved after BTST placement. There were no complications and no undesired eyelid changes. CONCLUSIONS: The BTST is a simple, fast, safe, and effective procedure that can be performed in the clinic or inpatient to immediately improve ocular surface coverage. As a minimally invasive procedure that can easily last several months, the BTST is an excellent option for patients who require more intense intervention than medical management alone. It can also securely bridge patients to a permanent solution such as lateral canthal resuspension.

Recurrent Retrobulbar Hemorrhage Associated With CPAP Use After Orbital Fracture Repair.

We present a patient who underwent orbital fracture repair complicated by retrobulbar hemorrhages twice within the first postoperative week. The suspected cause is continuous positive airway pressure (CPAP) use with inappropriate patient-modified settings. The most likely mechanism of action was venous congestion from the extrinsic positive pressure, similar to Valsalva maneuvers increasing orbital vasculature pressure. In our patient, because his orbital blood vessels had recently been cauterized, they were too fragile to handle the engorgement and bled, leading to a retrobulbar hemorrhage. It is possible that at a lower CPAP setting, the vascular congestion would not have been as severe and caused bleeding. We recommend routinely asking patients about CPAP use before orbital surgeries and instructing patients to stop CPAP usage for 1 week after any orbital surgeries if medically cleared.

Visual Outcomes in Eyes With Neovascular Glaucoma and Anterior Segment Neovascularization Without Glaucoma.

PURPOSE: To find predictive factors of neovascular glaucoma (NVG) development in eyes with anterior segment neovascularization without glaucoma (ASNVWG), and poor visual outcomes in eyes that have already developed NVG. DESIGN: Retrospective, clinical cohort studies. METHODS: A retrospective chart review was performed on 106 eyes of 94 patients with ASNVWG and 245 eyes of 225 patients with NVG. Measured outcomes included the development of NVG at any time point of the disease for the ASNVWG arm, and a visual acuity of ≤20/200 at 6 months after initial presentation for the NVG arm. RESULTS: Overall, 25% of ASNVWG eyes progressed to NVG. Progression was associated with retinal vein occlusion (RVO) (P < .01), lower median presenting BCVA (P < .01), and concurrent traction retinal detachments (TRDs) (P = .025). Sixty-eight percent of NVG eyes had a BCVA of ≤20/200 by 6-month follow-up, which was associated with RVO (P = .005), vitreous hemorrhage on presentation (P = .001), and no panretinal photocoagulation (PRP) treatments (P < .001). BCVA >20/200 at 6 months was associated with ≥1 PRP or intravitreal bevacizumab (IVB) treatment within 1 week of presentation or ≥3 PRP or IVB treatments overall (P < .001). CONCLUSION: RVO, presenting visual acuity, and concurrent TRD are risk factors for NVG in eyes with ASNVWG. In eyes with NVG, RVO and concurrent vitreous hemorrhage are risk factors for ≤20/200 vision at 6 months, whereas treatment with ≥1 PRP or IVB within 1 week of presentation, or ≥3 treatments of PRP or IVB within 6 months are protective.

Association of the Pattern of Retinal Capillary Non-Perfusion and Vascular Leakage with Retinal Neovascularization in Proliferative Diabetic Retinopathy.

PURPOSE: To explore the correlation between retinal capillary non-perfusion and the distribution of retinal neovascularization and vascular leakage (VL) in patients with proliferative diabetic retinopathy (PDR). METHODS: Ultra-widefield angiograms of 96 eyes of 69 patients with PDR were reviewed for the proportion of non-perfused area to total gradable area, and for the presence of neovascularization and VL. RESULTS: Retinal neovascularization was distributed as such: neovascularization elsewhere (NVE), 57.3%; neovascularization of the disc (NVD), 11.5%; both neovascularization of the disc and elsewhere (NVED), 31.3%. The proportion of non-perfused retina, so-called ischemic index, was greater in eyes with NVED compared to eyes with NVE only, but not when compared to NVD only. Overall, 83% of eyes had VL. The presence and the extent of VL correlated with the proportion of the ischemic index. While VL and ischemic index were more severe in the mid-periphery and far-periphery, the majority of NVE was located in the posterior pole. CONCLUSIONS: The presence of both NVD and NVE is associated with a greater ischemic index than NVE alone. Although both VL and ischemic index is significantly higher in peripheral zones, the majority of neovascularization occurs at the posterior pole.

Prospective in vivo evaluation of three different hyaluronic acid gels to varying doses of hyaluronidase with long-term follow-up.

PURPOSE: Several injectable hyaluronic acid dermal fillers exist in the market, each with different rheologic and cross-linking properties. Their reversibility is useful for managing complications. We sought to determine the response of three different hyaluronic acid gels to varying doses of hyaluronidase. METHODS: Each of 18 arms of nine subjects were prospectively randomized to receive intradermal injections of hyaluronic acid gel (Restylane-L, Juvéderm Ultra, Juvéderm Voluma). Seven sites on each arm were randomized to receive 0.2 mL of hyaluronic acid gel in anticipation of dissolution 1 week later with varying doses of hyaluronidase (Hylenex), 2.5, 5, 10, or 20 units or to be a control site. The outcome measures of diameter, elevation, and firmness were measured pre-injection and at varying time points to beyond 4 years. Subjects, graders, and injectors were masked. RESULTS: The most dramatic changes for all fillers occurred starting at the 30-min time point through 3 h time point, with continued gradual degradation through week 2. A mild dose response was found for Juvéderm and Restylane; however, a clear dose response was seen from 2.5 to 10 units for Voluma, with 2.5 units showing features more like those of saline only or no hyaluronidase control. One Restylane arm had controls lasting four years. CONCLUSIONS: All fillers had a dose response, with Voluma exhibiting it most clearly. Voluma required higher doses of hyaluronidase for dissolution, i.e., more than 20 units per 0.2 mL of filler. Restylane appeared to respond most readily to hyaluronidase, at the dose of even 2.5 units, but it also was fastest to dissolve on its own.

Response of twelve different hyaluronic acid gels to varying doses of recombinant human hyaluronidase.

PURPOSE: Hyaluronic acid (HA) fillers can be reversed with hyaluronidase, but their dose responses are not well-characterized. We evaluated 12 fillers' in vitro responses to varying doses of recombinant human hyaluronidase (RHH). METHODS: For the 12 HA gels, 0.2 mL aliquots were placed on six slides. Samples received no injection, saline injection, or RHH (2.5, 5, 10, or 20 units). The most resistant gels received 40 units of RHH on a seventh slide. Photos of gels were taken from bird's-eye and lateral views with a ruler at multiple time points. RESULTS: Restylane-L and Restylane Lyft were the most easily dissolvable HA fillers. Both demonstrated a significant response to 2.5 units RHH/0.2 mL. Juvéderm Ultra, Belotero, Restylane Silk, and Restylane Defyne had moderate resistance to RHH. Restylane Refyne, Juvéderm Ultra Plus, Vollure, Versa, and Voluma were most resistant, requiring more than 20 units RHH/0.2 mL for complete dissolution. Volbella was moderately resistant up to 20 units RHH but demonstrated pronounced dissolution with 40 units RHH. CONCLUSIONS: This study visually and objectively demonstrates the in vitro response of HA to dissolution by hyaluronidase. Fillers were categorized into least, moderate, and most resistant to RHH. Interesting findings include markedly different degrees of liquefaction for products used for similar indications (such as Restylane Lyft being more liquefied than Voluma), and Belotero easily flattening but retaining texture. Combined with in vivo data, this may help calculate hyaluronidase doses needed for controlled, partial reversal of commercially available HA gels.