Effects of Smoking on Outcomes of Thyroid Eye Disease Treated with Teprotumumab: A Retrospective Cohort Study.

Introduction: Smoking has been demonstrated to worsen the disease process and conventional treatment outcomes of thyroid eye disease. However, the effects of smoking on outcomes of thyroid eye disease treated with the novel therapeutic teprotumumab are currently unknown. Our study compares response to teprotumumab treatment between smokers and non-smokers with thyroid eye disease. Methods: A single-center, retrospective cohort study was conducted. Inclusion criteria were patients diagnosed with thyroid eye disease who had started or completed therapy with teprotumumab at the time of our data collection. Main outcome measures included reduction in clinical activity score, diplopia, and proptosis. Results: All smokers had type 2 thyroid eye disease prior to treatment and demonstrated less improvement in diplopia, proptosis, and overall clinical activity score compared to non-smokers with thyroid eye disease. There was no significant difference between smokers and non-smokers in baseline variables (sex, thyroid stimulating hormone (TSH), thyroxine (T4), triiodothyronine (T3), number of infusions completed). Data analysis revealed a statistically significant difference in proptosis reduction between non-smokers and smokers. Conclusions: Smoking is a modifiable risk factor which portends a worse response to treatment of thyroid eye disease with teprotumumab.

Nocardia keratitis mimicking superior limbic keratoconjunctivitis and herpes simplex virus.

PURPOSE: Nocardia keratitis is a rare type of infectious keratitis and may mimic other corneal diseases and lead to delay in diagnosis. This case illustrates how Nocardia often escapes accurate diagnosis due to its insidious onset, variable clinical manifestations, and unusual characteristics on cultures. OBSERVATION: The patient presented with an epithelial defect and superior pannus and scarring, which was misdiagnosed as superior limbic keratoconjunctivitis (SLK) and herpes simplex virus (HSV) keratitis. Repeat corneal scraping cultures, smears, and conjunctival biopsy were necessary to elucidate the diagnosis. It can be effectively treated with the intravenous preparation of trimethoprim-sulfamethoxazole 80 mg/mL (brand name SEPTRA) used topically as eye drops. CONCLUSION: The diagnosis of Nocardia keratitis relies on a high clinical suspicion and a prompt corneal scraping with culture. Due to its potential for rapid resolution with early therapy, it is important to isolate Nocardia early in its disease course. IMPORTANCE: Topical amikacin had been the standard of care for Nocardia keratitis for many years. However, recently there is increasing resistance of Nocardia to amikacin. SEPTRA offers an alternative therapy. Nocardia keratitis mimics other infectious and inflammatory etiologies so rapid diagnosis and treatment is critical in the prevention of long-term complications.

Focal Choroidal Elevations: Localized Pigment Epithelial Contour Alterations due to Isolated Choroidal Vessels.

PURPOSE: The objective of this case series was to describe the clinical and imaging features of focal choroidal elevations (FCE), which are chorioretinal contour changes induced by individual choroidal vessels within an overall thin-appearing choroid. METHODS: A total of 787 enhanced depth imaging (EDI) spectral domain optical coherence tomography (SD-OCT) patient images were initially screened for the presence of FCE. Prospective imaging analysis of 38 patients with FCE was done. Mean central macular choroidal thickness (CMCT), FCE location, FCE vessel lumen diameter, patient demographics, cycloplegic autorefraction, ophthalmoscopic findings, and presence of choroidal neovascularization (CNV) in the fellow eye were recorded. RESULTS: FCE were observed in 25 patients with age-related macular degeneration (ARMD), in 5 patients with high myopia, and in 8 patients with age-related choroidal atrophy (ARCA). Mean patient age was 80 ± 9.4 years. Mean CMCT was 86 ± 40 µm. Mean lumen diameter of the vessels inducing FCE was 131 ± 33 µm. CONCLUSIONS: FCE are relatively frequently encountered morphologic features of elderly patients with ARMD, high myopia, and ARCA, and have a distinct clinical and imaging morphology which differs from classically described chorioretinal folds. The lesions may commonly be mistaken for pigment epithelial detachments on ophthalmoscopy, may be associated with CNV in fellow eyes, and have a characteristic SD-OCT appearance.

Inner Nuclear Layer Cystic Changes in Phakic Fellow Eyes of Patients With Acute Pseudophakic Cystoid Macular Edema.

Improvements in retinal imaging have recently elucidated structural patterns in the development of macular edema, particularly involving the inner nuclear layer. Here, the authors describe two cases of isolated inner nuclear layer cystic changes in the phakic fellow eye of patients with pseudophakic cystoid macular edema. Both cases improved with treatment of their fellow eye and resolution of contralateral macular edema. The authors hypothesize potential pathomechanisms for this likely common but under-recognized phenomenon. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:522-524.].

Morphology of Peripheral Vitreoretinal Interface Abnormalities Imaged with Spectral Domain Optical Coherence Tomography.

The objective of this study is to describe the clinical utility and morphologic characteristics of peripheral vitreoretinal interface abnormalities with spectral domain optical coherence tomography (SD-OCT). A prospective imaging analysis of 43 patients with peripheral vitreoretinal interface abnormalities seen on binocular indirect examination with scleral indentation was done. SD-OCT was evaluated for image quality and structural findings. Laser retinopexy was performed to surround all retinal breaks containing a full-thickness component via SD-OCT. Acceptable image quality for inclusion was obtained in 39/43 (91%) patients. Mean age was 41 ± 22 years, and mean follow-up was 14 ± 1.6 months. Decision to treat was altered following SD-OCT in 5% of the patients. Two cases of previously diagnosed operculated holes were found on SD-OCT to be partial-thickness operculated breaks or focal operculated schisis. Peripheral SD-OCT is a reliable and useful technique to examine the structural features of vitreoretinal interface abnormalities in vivo. This imaging modality is useful in the clinical management of suspected retinal breaks identified with indirect ophthalmoscopy.

Visual outcomes, efficacy, and surgical complications associated with intracameral phenylephrine 1.0%/ketorolac 0.3% administered during cataract surgery.

AIM: The purpose of this study was to compare visual outcomes, surgical time, and perioperative surgical complications after intracameral use of either phenylephrine/ketorolac (P/K) or epinephrine (Epi) during cataract surgery. METHODS: This was a single-center, retrospective case review of patients undergoing cataract surgery from August to November 2015. Of the 641 eyes of 389 patients who underwent cataract surgery, 260 eyes were administered phenylephrine 1.0%/ketorolac 0.3% and 381 eyes received Epi in the irrigation solution intraoperatively. All patients received a topical nonsteroidal anti-inflammatory drug regimen (bromfenac 0.07%, nepafenac 0.3%, or ketorolac 0.5%) for 3 days before surgery and topical tropicamide 1.0%, cyclopentolate 1.0%, and phenylephrine 2.5% on the day of surgery. RESULTS: Mean length of surgery (LOS) was 15.4±0.6 minutes. Although a positive correlation was noted between patient age and LOS (p<0.001), P/K was associated with a decrease in the LOS, when controlled for age quartiles. A statistically significant lower incidence of complications (1.1%) was observed with P/K use than Epi (4.5%; p=0.018). Among surgeons who used mydriatic-assist devices more frequently, P/K use was associated with a reduction in the use of these devices (p<0.001). When controlling for age quartile, patients of age groups 69-76 and 76-92 years who received P/K had significantly better uncorrected visual acuity at postoperative day 1 than those receiving Epi (p=0.003). CONCLUSION: Intracameral use of phenylephrine 1.0%/ketorolac 0.3% during cataract surgery may be effective in maintaining mydriasis. It appears to be superior to intracameral Epi at reducing intraoperative and postoperative complications, need for pupillary dilating devices, and surgical time.