Reticular Bullous Epithelial Corneal Edema after Netarsudil Use for Elevated Intraocular Pressure with Concurrent Fuchs Endothelial Corneal Dystrophy: A Case Report.

Introduction: We describe a case of reticular bullous corneal epithelial edema associated with the use of netarsudil ophthalmic solution (0.02%) for elevated intraocular pressure. Case Presentation: A 74-year-old man with a complex ocular medical history, including Fuchs dystrophy and primary open-angle glaucoma, developed progressively worsening loss of vision 3 weeks following the initiation of topical netarsudil for increased intraocular pressure. Visual acuity in the left eye was counting fingers at 3 feet and intraocular pressure in the left eye was 7 mm Hg. A characteristic "honeycomb" pattern epitheliopathy was seen on ocular examination. Conclusion: Reticular bullous epithelial corneal edema is an uncommon finding associated with netarsudil use, which can be overlooked in favor of corneal edema associated with Fuchs dystrophy. This is especially relevant given Fuchs dystrophy itself is a predisposing risk factor for netarsudil-induced reticular bullous corneal epithelial edema. Improvement of both the corneal edema and visual acuity should be expected after discontinuing netarsudil and undergoing superficial keratectomy.

The Safety Profile of FDA-Approved Epithelium-Off Corneal Cross-Linking in a US Community-Based Healthcare System.

Purpose: To determine the occurrence of early post-operative complications following FDA-approved epithelium-off corneal cross-linking in the United States. Materials and Methods: This multicenter, retrospective cohort study identified patients who underwent epithelium-off (epi-off) corneal cross-linking (CXL) for keratoconus and post-refractive keratectasia within the Kaiser Permanente Northern California healthcare system between 2016 and 2018. Post-operative complications including delayed epithelial healing, infection, and loss of visual acuity were recorded. Results: The study included 878 eyes of 654 patients. The mean age was 27±9.4 years (range 7-71). Five hundred ninety-nine patients (91.6%) had keratoconus while 55 had post-refractive corneal ectasia (8.4%). Forty-seven eyes had prolonged follow-up because of the occurrence of complications in the early post-operative period. The respective rates of delayed epithelial healing, and keratitis were 3.9% (95% CI 2.7-5.3%), and 1.5% (95% CI 0.8-2.5%). Four approaches for management of delayed epithelial healing were compared; epithelium healing duration was the longest in the repeat bandage contact lens (BCL) group (23.8 days) and the shortest in the antibiotic ointment group (14.3 days), with statistically significant differences (p < 0.05) in the healing time between these 2 groups. Conclusion: The concern for early clinical complications after epi-off CXL often leads to delayed CXL intervention and further keratoconus progression with increased economic burdens. A large retrospective review of 878 eyes found that FDA-approved epi-off CXL protocol appears to be safe with low occurrence rates of early post-operative complications. The recommended management for delayed epithelial healing is using antibiotic ophthalmic ointment.

Peripheral ulcerative keratitis secondary to severe hidradenitis suppurativa.

PURPOSE: To describe a unique case of peripheral ulcerative keratitis secondary to isolated, severe hidradenitis suppurativa (HS). OBSERVATION: A 31-year-old male with HS presented with a red painful right eye with best corrected visual acuity of count fingers at 3 feet with peripheral corneal thinning, inferior descemetocele, and adjacent infiltrate. Work-up revealed negative corneal cultures and positive ANA, ANCA, and rheumatoid factor without other autoimmune or rheumatologic history or symptomatology. He was treated with topical corticosteroids with improvement until he was lost to follow-up before tumor necrosis factor-a inhibitor therapy could be started. Upon re-presentation, he was found to have corneal perforation. CONCLUSIONS AND IMPORTANCE: Coexistence of inflammatory eye disease and HS is known but rare, and most commonly manifests as anterior uveitis. Here we present a unique case of peripheral ulcerative keratitis secondary to HS and demonstrate the importance of ophthalmologists' familiarly with this systemic disease and its variety of ocular manifestations.

Comparison of Microbiome in Stimulated Saliva in Edentulous and Dentate Subjects.

Measurement of saliva microbes is promoted as a way to detect oral and systemic disease, yet there is a multitude of factors that affect the oral microbiome. The salivary microbiome is influenced by biofilm of shedding (epithelial) and non-shedding (tooth) surfaces. Methods for study of the salivary microbiome are by no means standardized, and differences in sample collection, storage, and processing can all affect results to some degree. Here we describe one method of saliva collection that has been validated for reproducibility. Standard 16S rRNA gene analysis is done using the Human Oral Microbiome Database library which results in analysis that is straightforward. Everything about this procedure except the library synthesis and DNA sequencing itself can easily be done in-house. To gauge the ability of salivary microbial analytics to distinguish between edentulous and dentate oral conditions, differences in the saliva microbiome of subjects with and without teeth were examined. Fifty-two dentate and 49 edentulous subjects provided stimulated saliva samples. 16S rRNA gene sequencing, QIIME-based data processing, and statistical analysis were done using several different analytical approaches to detect differences in the salivary microbiome between the two groups. Bacteria diversity was lower in the edentulous group. Remarkably, all 31 of the most significant differences in taxa were deficits that occurred in the edentulous group. As one might expect, many of these taxa are attributed to dental plaque and gingival sulcus-associated bacteria verifying that the measurement of 16S rRNA genes in the bacteria of the saliva can be used to reproducibly measure expected differences in the oral microbiome that occur with edentulism or other conditions and diseases.

Cataract and systemic disease: A review.

We review the current literature regarding the risk factors for cataract and the association between cataract and systemic disease. Numerous epidemiologic studies have found that the risk factors for age-related cataract formation include age, sex, race and myopia. Modifiable risk factors include smoking, socioeconomic status and ultra-violet light exposure. Alcohol intake and nutritional status may play a role in cataract formation. Cataract has been associated with many systemic diseases mainly diabetes mellitus, hypertension, obesity, chronic kidney disease and autoimmune disease. Cataract is also a hallmark of many metabolic disorders and syndromes. These findings are important to help implement risk factor and lifestyle-modification strategies that can hopefully decrease the burden of global cataract blindness.

PARACENTRAL ACUTE MIDDLE MACULOPATHY AFTER EPIRETINAL MEMBRANE REMOVAL.

PURPOSE: To describe a patient with newly developed paracentral acute middle maculopathy after uncomplicated epiretinal membrane removal. METHODS: Retrospective chart review. RESULTS: A 74-year-old white man underwent uncomplicated vitrectomy and epiretinal membrane removal in his left eye. One week later, the patient complained of a small paracentral visual field deficit and decreased visual acuity. Spectral domain optical coherence tomography revealed a characteristic hyperreflective band-like lesion at the level of the inner nuclear layer, consistent with paracentral acute middle maculopathy. The patient was closely followed and endorsed subjective improvement of his paracentral visual deficit at 3 months postoperatively. CONCLUSION: Paracentral acute middle maculopathy, although rare, may be encountered after epiretinal membrane removal.

Rhino-orbital-cerebral mucormycosis (ROCM) and associated cerebritis treated with adjuvant retrobulbar amphotericin B.

PURPOSE: We report a case of rhino-orbital-cerebral mucormycosis (ROCM) with focal anterior cerebritis treated favorably with retrobulbar amphotericin B and systemic antifungals. OBSERVATIONS: A 55-year-old diabetic male presented to the emergency department with left sided proptosis, left temple headache, maxillary sinus pain, and diplopia of 3 days duration. Biopsy results from the left middle turbinate, ethmoid, and maxillary sinus revealed broad and irregular non-septate hyphae consistent with mucormycosis. Despite treatment with intravenous antifungals and endoscopic debridement of the sinuses, his condition did not improve. Disease progression included the development of left ophthalmoplegia and left-sided cerebritis. The patient received retrobulbar injection of deoxycholate amphotericin B with eventual disease resolution, without exenteration. CONCLUSIONS: We present a case of ROCM with associated cerebritis that responded to retrobulbar amphotericin B, without exenteration.

Effect of Unilateral Endothelial Keratoplasty on Vision-Related Quality-of-Life Outcomes in the Descemet Endothelial Thickness Comparison Trial (DETECT): A Secondary Analysis of a Randomized Clinical Trial.

Importance: Vision-related quality of life can be a valuable outcome for some interventions in ophthalmology. In the primary Descemet Endothelial Thickness Comparison Trial (DETECT), Descemet membrane endothelial keratoplasty (DMEK) had superior postoperative visual acuity compared with ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK). It is of interest to determine whether this trend extends to quality of life. Objective: To determine the effect of UT-DSAEK and DMEK on vision-related quality of life. Design, Setting, and Participants: A prespecified secondary analysis of a 2-surgeon patient- and outcome-masked randomized clinical trial was conducted at the Casey Eye Institute in Portland, Oregon, and Byers Eye Institute in Palo Alto, California. The study was conducted between January 20, 2015, and April 26, 2017. DETECT enrolled 38 individuals and included 50 eyes with isolated endothelial dysfunction; for this analysis, the second eye from a single participant was excluded along with any questionnaires in the first eye after second eye surgery for evaluation of 38 eyes at baseline and 3 months and 26 eyes at 12 months. Mean (SD) baseline visual acuity was 0.35 (0.31) logMAR in the DMEK arm and 0.28 (0.22) logMAR in the UT-DSAEK arm. Each arm consisted of 19 participants: 18 individuals with Fuchs dystrophy and 1 participant with pseudophakic bullous keratopathy. Interventions: Study eyes were randomized to receive either UT-DSAEK or DMEK. Main Outcomes and Measures: Responses to the National Eye Institute (NEI) Visual Function Questionnaire-39 (VFQ-39) administered at baseline and 3 and 12 months postoperatively were analyzed using the NEI-defined traditional subscales and composite score on a 100-point scale and with a Rasch-refined analysis. Results: There were more women in both arms of the study (UT-DSAEK, 12 [63%]; DMEK, 11 [58%]); mean (SD) age was 68 (11) years in the UT-DSAEK arm and 68 (4) years in the DMEK arm. Overall, study participants experienced a 9.1-point improvement in NEI VFQ-39 composite score at 3 months compared with baseline (N = 38; 95% CI, 4.9-13.3; P < .001), and an 11.6-point improvement at 12 months compared with baseline (n = 26; 95% CI, 6.8-16.4; P < .001). Eyes randomized to DMEK had 0.9 points more improvement in NEI VFQ-39 composite score at 3 months compared with UT-DSAEK after controlling for baseline NEI VFQ-39 (95% CI, -6.2 to 8.0; P = .80). Conclusions and Relevance: Improvement in vision-related quality of life was not shown to be greater with DMEK compared with UT-DSAEK. Trial Registration: ClinicalTrials.gov identifier: NCT02373137.

Topical Plasminogen as Adjunctive Treatment in Recurrent Ligneous Conjunctivitis.

Ligneous conjunctivitis is a rare, autosomal recessive, membranous conjunctivitis characterized by a deficiency in type 1 plasminogen. The absence of normal plasmin activity results in the formation of fibrin-rich, membranous material that typically manifests on the palpebral conjunctiva. Surgical treatment often causes irritation of the conjunctiva and accelerated recurrence of pseudomembranes. In this interventional case report, the authors document the results of treatment with topical plasminogen following conjunctival pseudomembrane excision in a 32-year-old woman. The patient underwent pseudomembrane excision in the OS followed immediately by hourly topical application of plasminogen eye drops. The plasminogen was prepared from pooled human plasma purchased under Food and Drug Administration approval from DiaPharma. Follow-up evaluation at 1 week, 1 month, and 5 months showed no evidence of recurrent pseudomembranous change. Adjunctive topical plasminogen application appears to be an effective and safe method of controlling pseudomembrane recurrence in patients with ligneous conjunctivitis.

Thyroid-associated periorbitopathy: eyebrow fat and soft tissue expansion in patients with thyroid-associated orbitopathy.

OBJECTIVE: To compare soft tissue and fat volumes in the supraorbital area of healthy patients and patients with thyroid-associated orbitopathy (TAO) using 3-dimensional reconstruction software. METHODS: The superiolateral orbital area was delineated on a bony framework. Three-dimensional reconstruction and volumetric calculation of the retro-orbicularis oculi fat (brow fat), galeal fat (including the retro-orbicularis oculi fat), and soft-tissue muscle were performed. RESULTS: We analyzed 100 computed tomographic scans from 48 patients with TAO and 52 control subjects. All patients showed an age-related increase of fat volumes. The mean total eyebrow volume was greater in patients with TAO vs healthy control subjects (P < .001). Galeal fat (P = .02) and retro-orbicularis oculi fat (P = .01) volumes were significantly higher in patients with TAO vs control subjects. Soft-tissue muscle volume decreased with age in healthy females but remained constant in the aging female group with TAO. Both total volume and brow thickness did not appear to change with age in healthy patients but exhibited an increase in the female population with TAO. CONCLUSIONS: This study brings into focus the clinicopathologic entity of thyroid-associated periorbitopathy. Three-dimensional evaluation of computed tomographic scans can provide information on volumetric changes in the eyebrow profile of patients with TAO. Further investigation of the biologic and morphologic changes of eyebrow fat and soft tissue in patients with TAO may help better characterize, classify, and guide their treatment.