Trends in the Clinical Presentation of Uveal Melanoma During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVE: The objective was to evaluate factors associated with clinical presentation of uveal melanoma (UM) during the initial two years of the coronavirus disease 2019 pandemic. PATIENTS AND METHODS: This was a multi-site, retrospective cohort study of patients treated for uveal melanoma during the first (early) and second (late) year of the pandemic compared with the year prior (control). RESULTS: A total of 48, 67, and 75 patients were in the control, early, and late cohorts, respectively. The early cohort had a higher frequency of large tumors (control: 29.2%, early: 40.3%, late: 29.3%; P < 0.001) at presentation. Both the early and late cohorts had higher rates of enucleation (control: 8.33%, early: 20.9%, late: 18.67%; P ≤ 0.0338) compared to the control cohort. CONCLUSIONS: While there was an increase in large tumors along with a rise in enucleation during the first year of the pandemic, enucleation rates remained elevated even while tumor sizes normalized. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

BILATERAL EYE PATCHING MAY IMPROVE CLINICAL OUTCOMES FOR ACUTE PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: Evaluate preoperative bilateral eye patching (BEP) on subretinal fluid and vision in acute primary rhegmatogenous retinal detachments (RRDs). METHODS: Retrospective nonrandomized interventional study of 335 patients with RRD undergoing BEP until surgery (BEP cohort) and separated by the percentage of full-time compliance: high (≥90%), medium (>90% but ≥50%), and low (<50%). Those declining BEP were included (control). All underwent surgery and were followed for ≥3 months. Imaging was obtained immediately before surgery. Best-corrected visual acuity was measured at the longest follow-up and immediately before surgery. SRF and foveal status immediately before surgery were analyzed. RESULTS: Two hundred and forty and 95 patients were in BEP and control cohorts, respectively. Thirty patients presented immediately before surgery for analysis. High (64%) and medium (35%) compliance showed significantly greater ( P < 0.01) SRF reduction compared with low (4%) and control (3%). Mac-off RRD showed significantly greater ( P < 0.01) foveal reattachment with high (29%) and medium (8%) compliance compared with low (2%) and control (1%). Mac-on RRD demonstrated no significant differences ( P ≥ 0.51) in final best-corrected visual acuity among high (0 logarithm of the minimum angle of resolution [logMAR] [median], 20/20 Snellen), medium (0.10 logMAR, 20/25 Snellen), low (0.10 logMAR), and control cohorts (0.10 logMAR). Mac-off RRD demonstrated significantly better final best-corrected visual acuity with high compliance (0.30 logMAR, 20/40 Snellen) compared with low (0.40 logMAR, 20/50 Snellen; P = 0.04) and control (0.60 logMAR, 20/80 Snellen; P = 0.02). CONCLUSION: Preoperative BEP can stabilize or improve subretinal fluid in acute primary RRD. Patients with BEP >50% of the time experienced the greatest benefits.

PROPHYLACTIC TREATMENT OF LATTICE DEGENERATION IN FELLOW EYES AFTER REPAIR OF UNCOMPLICATED PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To evaluate prophylactic treatment (PTx) of lattice degeneration (LD) on retinal tear (RT) and rhegmatogenous retinal detachment (RRD) risk in fellow eyes of patients after primary RRD repair in the first eye. METHODS: This was a consecutive case series with cohort control involving patients with RRD repair from January 1, 2013, through December 31, 2017. Patients received PTx (PTx cohort) or no PTx (No-PTx cohort) in fellow eye with 5-year follow-up. Primary outcome measure was proportion with new fellow eye RT/RRD. Secondary outcomes included logarithm of minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) and status of myopia, posterior vitreous detachment, and pseudophakia. RESULTS: Four hundred ninety-eight patients were divided into 146 and 352 in PTx and No-PTx cohorts, respectively. PTx cohort developed significantly ( P < 0.05) fewer RT/RRD (17%) than No-PTx cohort (41%). PTx significantly ( P < 0.05) lowered RT/RRD irrespective of posterior vitreous detachment and myopia status. PTx patients undergoing phacoemulsification demonstrated significantly ( P < 0.05) less RT/RRD (22%) than No-PTx cohort (31%). There was no significant ( P = 0.96) final BCVA difference between PTx (median = 0 logMAR) and No-PTx (median = 0 logMAR) cohorts. CONCLUSION: PTx of asymptomatic fellow eye LD reduced RT/RRD risk.

Peripheral Hemorrhagic Chorioretinopathy: Differentiating Features from Choroidal Melanoma.

Introduction: Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) is one of the leading mimickers of choroidal melanoma because of overlapping features with choroidal melanoma that make the distinction between these two entities difficult. Methods: To identify nonoverlapping diagnostic features between PEHCR and choroidal melanoma, a retrospective study of 80 patients (80 eyes); 40 patients (40 eyes) with PEHCR; and 40 patients (40 eyes) with choroidal melanoma was conducted. Ophthalmoscopic and imaging features of PEHCR and choroidal melanoma were compared. Sensitivity and specificity for identifying PEHCR and choroidal melanoma were calculated. Youden's J statistic was assessed for each diagnostic feature. Results: The most frequent clinical features of PEHCR were presence of druse (100%), hemorrhagic PED (93%), dome-shaped mass (B-scan) (90%), and subretinal/intraretinal hemorrhage (78%). Statistical analysis confirmed high sensitivity of hemorrhagic PED (0.93; 95% CI 0.80-0.98) and high specificity of clot retraction cleft, presence of lipid exudation, and bilaterality (1.00; 95% CI 0.91-1.00) as diagnostic features of PEHCR. Statistical analysis revealed presence of subretinal fluid 0.80 (95% CI 0.54-0.91) was most sensitive and presence of orange pigment, mushroom shape on B-scan, ciliary body extension, and choroidal excavation were most specific (1.00; 95% CI 0.91-1.00) for choroidal melanoma. Nonoverlapping diagnostic features of PEHCR were hemorrhagic PED, clot retraction cleft, presence of lipid exudation, and bilaterality. All PEHCR patients (100%) had at least one of these nonoverlapping diagnostic features. Nonoverlapping diagnostic features of choroidal melanoma were the presence of orange pigment, choroidal excavation, mushroom-shaped mass, and ciliary body extension (the latter 3 detected on B-scan). Youden's J statistic was highest for hemorrhagic PED and lowest for dome-shape appearance on B-scan (0.075). Conclusion: PEHCR and choroidal melanoma can be differentiated by identifying diagnostic features that are exclusive to each entity. The presence of hemorrhagic PED strongly supports a diagnosis of PEHCR. B-scan ultrasonography is required to detect a mushroom-shaped mass, choroidal excavation, or ciliary body extension to exclude underlying choroidal melanoma.

Spontaneous Improvement of Myopic Retinoschisis Following a Long-term Observational Period: A Case Series.

PURPOSE: To highlight spontaneous resolution or improvement of myopic retinoschisis (MR) in actively surveilled patients. METHODS: Case series of five patients diagnosed with MR who did not undergo pars-plana vitrectomy and were carefully monitored by a single retina specialist. Ocular and medical history were reviewed, and clinical characteristics including visual acuity, and the status of the MR were monitored with spectral domain ocular coherence tomography (SD-OCT) at each clinic visit. RESULTS: Five patients with were identified to have MR without vitreomacular traction, or macular hole formation. Two patients exhibited spontaneous and complete resolution of MR without surgical intervention over an average observation time of 52.5 months. In these cases, a clinical posterior vitreous detachment (PVD) was documented preceding the resolution of MR over an average time of 26.5 months. Snellen best corrected visual acuity (BCVA) in these patients were improved (Case 1 from 20/50 to 20/40, Case 2 from 20/30 to 20/25). The remaining three patients were monitored for an average of 52 months and showed improvement of MR via OCT imaging. Snellen BCVA either remained stable or improved from baseline (Case 3 stable at 20/30, Case 4 improved from 20/40 to 20/30, and Case 5 stable at 20/20). CONCLUSION: These findings suggest that conservative management of MR with observation can be considered especially in patients with challenging co-morbidities (such as monocular status), and with a clinically identified posterior vitreous detachment without vitreomacular traction.

Evolving Treatment Patterns in Diabetic Macular Edema Between 2015 and 2020.

Purpose: To explore the recent evolution of diabetic macular edema (DME) treatment practice patterns over 5 years among retina specialists in the United States. Methods: This retrospective analysis assessed 306 700 eyes with newly diagnosed DME from the Vestrum Health database between January 2015 and October 2020. The year-over-year and cumulative 5-year distributions of eyes treated with antivascular endothelial growth factor (anti-VEGF) agents, steroids, focal laser, or any combination and those of untreated eyes were calculated. Changes from baseline visual acuity were assessed. Results: Yearly treatment patterns changed significantly from 2015 (n = 18056) to 2020 (n = 11042). The proportion of untreated patients declined over time (32.7% vs 27.7%; P < .001), the use of anti-VEGF monotherapy increased (43.5% vs 61.8%; P < .001), the use of focal laser monotherapy declined (9.7% vs 3.0%; P < .001), and the use of steroid monotherapy remained stable (0.9% vs 0.7%; P = 1.000). Of eyes that maintained follow-up for 5 years (from 2015 to 2020), 16.3% were untreated while 77.5% were treated with anti-VEGF agents (as monotherapy or combination therapy). Vision gains in treated patients remained approximately stable from 2015 (3.6 letters) to 2020 (3.5 letters). Conclusions: From 2015 to 2020, treatment patterns for DME evolved toward greater anti-VEGF monotherapy, stable steroid monotherapy, less laser monotherapy, and fewer untreated eyes.

CLINICAL OUTCOMES OF ACUTE ENDOPHTHALMITIS AFTER INTRAVITREAL DELIVERY OF VASCULAR ENDOTHELIAL GROWTH FACTOR INHIBITORS VERSUS STEROIDS.

PURPOSE: To compare patients with acute endophthalmitis after intravitreal injection of vascular endothelial growth factor (VEGF) inhibitors vs. steroids. METHODS: Retrospective single-center, nonrandomized interventional study from 2013 to 2021.Patients underwent vitreous biopsy before initiating treatment and were divided into the following cohorts: (1) anti-VEGF managed medically (T&I-anti-VEGF), (2) anti-VEGF managed by immediate pars plana vitrectomy (PPV-anti-VEGF), and (3) steroid therapy and managed medically or by pars plana vitrectomy (steroid). RESULTS: A total of 141 patients were analyzed. The steroid cohort demonstrated significantly worse presenting (median = 2.80 logarithm of the minimum angle of resolution [logMAR]; P ≤ 0.01) and final (median = 2.30 logMAR) best-corrected visual acuity compared with T&I-anti-VEGF (presenting: median = 2.00 logMAR; final: median = 0.40 logMAR) and pars plana vitrectomy-anti-VEGF cohorts (presenting: median = 2.30 logMAR; final: median = 0.48 logMAR). There was no significant ( P = 0.33) difference in the final best-corrected visual acuity between T&I-anti-VEGF and pars plana vitrectomy-anti-VEGF cohorts. There were no significant ( P ≥ 0.63) differences among cohorts in best-corrected visual acuity before acute endophthalmitis diagnosis (T&I-anti-VEGF: median = 0.40 logMAR; pars plana vitrectomy-anti-VEGF: median = 0.40 logMAR; steroid: median = 0.44 logMAR). Microbial cultures revealed similar profiles for all cohorts. CONCLUSION: Acute endophthalmitis after intravitreal injection steroid therapy had worse outcomes compared with anti-VEGF therapy.

Trends in the Clinical Presentation of Primary Rhegmatogenous Retinal Detachments During the First Year of the COVID-19 Pandemic.

PURPOSE: To evaluate the effect of 1 full year of the coronavirus disease 2019 (COVID-19) pandemic on clinical presentation of acute, primary rhegmatogenous retinal detachment (RRD). DESIGN: Single-center, retrospective observational cohort study. METHODS: Patients were divided into 2 cohorts: consecutive patients treated for primary RRD during the COVID-19 pandemic (March 9, 2020, to March 7, 2021; pandemic cohort) and patients treated during the corresponding time in previous year (March 11, 2019, to March 8, 2020; control cohort). MAIN OUTCOME MEASURES: Proportion of patients presenting with macula-involving (mac-off) or macula-sparring (mac-on) RRD. RESULTS: A total of 952 patients in the pandemic cohort and 872 patients in the control cohort were included. Demographic factors were similar. Compared with the control cohort, a significantly greater number of pandemic cohort patients presented with mac-off RRDs ([60.92%] pandemic, [48.17%] control, P = .0001) and primary proliferative vitreoretinopathy ([15.53%] pandemic, [6.9%] control, P = .0001). Pandemic cohort patients (10.81%) had significantly higher rates of lost to follow-up compared with the control cohort (4.43%; P = .0001). Patients new to our clinic demonstrated a significant increase in mac-off RRDs in the pandemic cohort (65.35%) compared with the control cohort (50.40%; P = .0001). Pandemic cohort patients showed worse median final best-corrected visual acuity (0.30 logarithm of the minimum angle of resolution) compared with the control cohort (0.18 logarithm of the minimum angle of resolution; P = .0001). CONCLUSIONS: Patients with primary RRD during the first year of the COVID-19 pandemic were more likely to have mac-off disease, present with primary proliferative vitreoretinopathy, be lost to follow-up, and have worse final best-corrected visual acuity outcomes.

Extensive Cerebral Venous Sinus Thrombosis Due to Medroxyprogesterone Acetate.

This retrospective patient report describes a unique case of cerebral venous sinus thrombosis arising from hormonal contraceptive use, and the management of said thrombosis and its secondary ophthalmic manifestations. The patient initially presented with significant visual decline, headaches, florid disc oedema, and vessel tortuosity, due to extensive sinus thromboses that were causing increased intracranial pressure. It was determined that the root cause of the thrombosis was the use of injectable medroxyprogesterone acetate, leading to a hypercoagulable state. Optic nerve sheath fenestration was performed for this patient as an early intervention. The patient, though ultimately experiencing some vision loss, was able to recover and retain limited unilateral central vision, despite a protracted hospital course. We hope to propose that optic nerve sheath fenestration, in conjunction with anti-coagulation therapy, may be a consideration for patients with similar presentations on an individualised basis, in order to prevent vision loss from cerebral venous sinus thrombosis. Though studies are limited, we believe early intervention may be what allowed our patient to retain some central vision, and suggest more studies be done into the utility of this procedure for patients with this clinical vignette.

Successful Clinical Outcome of Vancomycin-induced Hemorrhagic Occlusive Retinal Vasculitis.

We present a case of a patient that experienced severe hemorrhagic occlusive retinal vasculitis secondary to injection of 1.0 mg/0.1 ml of intracameral vancomycin for endophthalmitis prophylaxis after an uneventful cataract surgery. The case is especially unique in that our patient ended up maintaining 20/25 vision with an ocular disease that is typically visually threatening. This may be due to the aggressive administration of periocular and oral steroids combined with scheduled anti-VEGF injections that were later transitioned into a treat and extend regimen.

Bilateral Proptosis in a Case of Recurring Multiple Myeloma: Uncommon Orbital Presentation of Plasmacytoma.

Multiple myeloma is a malignant plasma cell dyscrasia that may invade the orbits in extramedullary presentations. Common manifestations of orbital involvement include unilateral proptosis, injection, chemosis, diplopia, and occasionally pain. Additionally, the soft-tissue tumors associated with multiple myeloma typically cause bony destruction of adjacent structures. However, in certain patients, bilateral proptosis and a lack of bony destruction may occur. In these instances, it is important for physicians to consider patient history, presentation, and progression in order to ensure that a potentially fatal diagnosis is not missed. The reason this case is important is two-fold: 1) we describe a case of an individual with relapsing multiple myeloma presenting as bilateral proptosis and lacking bony destruction, highlighting the importance of understanding the disease process and 2) we discuss why patients with multiple myeloma may be more prone to developing tumors of the orbit in recurrent cases.

Do Prior Intra-Articular Corticosteroid Injections or Time of Administration Increase the Risks of Subsequent Periprosthetic Joint Infections after Total Knee Arthroplasty?

Intra-articular injections of corticosteroids have been used as a treatment option for degenerative arthritis of the knee for short- to mid-term symptomatic pain relief for many decades. Recently, there have been studies that have reported increased risks of periprosthetic joint infections in patients who have received these injections. In this study, we evaluated the risk of superficial, deep, and overall rate of infections in 302 patients who had received intra-articular corticosteroid infiltration within 12 months before undergoing total knee arthroplasty (TKA) and compared them with a 1:1 matched cohort who had undergone TKA, but who did not have any prior corticosteroid knee injections. At a mean follow-up of approximately 3.5 years after TKA, there were no significant differences in the rate of superficial incisional infections (7 vs. 6 out of 302 patients), deep periprosthetic infections (3 vs. 6 out of 302 patients), and overall infections (10 vs. 12 out of 302 patients) in the two groups. In addition, no significant differences were found in the rate of deep infections when intra-articular corticosteroids were administered 10 weeks to 2 months, 2-4 months, 4-6 months, 6-12 months, and beyond 12 months before surgery. We concluded that intra-articular corticosteroid injections are safe and do not increase the rate of postoperative infections.

Nonsurgical intra-operative blood management strategies for total hip arthroplasty.

The substantial blood loss that can occur during total hip arthroplasty frequently requires allogeneic transfusions. Both allogeneic transfusions and post-operative anemia are causes of increased morbidity, cardiovascular risks, and length of stay. This anemia can also lead to decreased vigor, suboptimal rehabilitation, and lowered quality of life in patients undergoing total hip arthroplasty. The aim of this review was to analyze recent evidence on nonsurgical intra-operative blood management strategies utilized for total hip arthroplasty. Specifically, we evaluated the use of fibrin sealants, desmopressin, acute normovolemic hemodilution, hypotensive anesthesia, blood salvage, and peri-operative normothermia. No single strategy has been shown to provide superior results over another in reducing the need for allogeneic transfusions. However, a combination of the above blood management strategies may further result in reduced blood loss over one strategy. Larger prospective randomized studies comparing the individual strategies, as well as their combination, are needed to develop the best algorithm that can be the most effective and safe for intra-operative blood management in total hip arthroplasty.