Phthisical eye and orbital ischemia after cosmetic platelet-rich plasma injection to the forehead.

Purpose: To report a case of retrograde embolism of cosmetic injection of platelet-rich plasma (PRP) to the ophthalmic artery, resulting in orbital ischemia, blindness, and eventual phthisis bulbi. Observations: A 37-year-old woman presented with two days of vision loss OS beginning seconds after undergoing cosmetic PRP filler injections to the face at an outside clinic. Immediately after injection to the left medial forehead, the patient reported bleeding, transient loss of consciousness, and complete vision loss OS. Two days later, vision remained no light perception OS and she exhibited manifestations of both anterior and posterior segment ischemia in the left eye. These findings were ultimately attributed to retrograde embolism to the ophthalmic artery via inadvertent injection of PRP into the supratrochlear or supraorbital arteries. She ultimately did not regain her vision in the left eye and the eye became enophthalmic and phthisical. Conclusions: After conducting a literature review on August 18, 2023, utilizing PubMed and Google Scholar, and searching for the key words "platelet-rich plasma" and "vision loss" or "vision impairment," we did not find any prior reports of anterior segment ischemia or pan-orbital ischemia resulting in phthisis bulbi. In the setting of vision changes after cosmetic platelet-rich plasma filler injection. Additionally, there is no validated therapy for ophthalmic artery occlusion from any cosmetic filler embolism. Further research should prioritize developing therapeutic guidelines for managing such complications. Injectors should also be educated to emergently refer patients to hospitals with ophthalmology consults available and stroke protocols in place.

Patterns and Disparities in Recorded Gonioscopy During Initial Glaucoma Evaluations in the United States.

PURPOSE: To assess patterns in gonioscopy during initial glaucoma evaluations in the United States. DESIGN: Retrospective, case-control study. METHODS: Patients undergoing initial glaucoma evaluation between 2009-2020 were identified in the Optum Clinformatics DataMart. Initial evaluation was defined as follows: (1) glaucoma suspect, anatomical narrow angle (ANA), or primary/secondary glaucoma diagnosed by an ophthalmologist; (2) continuously observable during a 36-month lookback period; (3) no history of glaucoma medications, laser, or surgical procedures; and (4) optical coherence tomography (OCT) or visual field performed within 6 months of initial diagnosis. Logistic regression models were developed to identify factors associated with no record of gonioscopy based on Current Procedural Terminology (CPT) codes. RESULTS: Among 198,995 patients, 20.4% and 29.5% had recorded gonioscopy on the day of diagnosis or within 6 months, respectively. On multivariable analysis, odds of recorded gonioscopy within 6 months of initial evaluation was lower (P < .001) among non-Hispanic Whites (OR=0.84) but similar for Blacks (OR=1.02) and Hispanics (OR=0.96) compared with Asians. Age ≥60 years (OR<0.82), pseudophakia/aphakia (OR=0.58), or residence outside of the Northeast region (OR=0.66-0.84) conferred lower odds of recorded gonioscopy (P < .001). Angle closure glaucoma (OR=0.85), secondary glaucoma (OR=0.31), or open angle glaucoma/suspect (OR=0.12/0.24, respectively) patients were less likely to have recorded gonioscopy compared to ANA patients (P < .01). CONCLUSIONS: More than 70% patients undergoing initial glaucoma evaluation in the United States do not have a record of gonioscopy, especially elderly, non-Hispanic White, and pseudophakic patients in non-Northeast regions. This pattern does not conform to current practice guidelines and could contribute to misdiagnosed disease and suboptimal outcomes.

Psychological stress induces moderate pathology in the ganglion cell layer in mice.

Purpose: Primary open-angle glaucoma (POAG) is a condition with unclear pathogenesis. Researchers have observed an increased incidence of young Chinese POAG patients who manifest significant psychological stress while their intraocular pressure (IOP) is normal or close to normal; we hypothesize that psychological stress may play a causal role in initiating POAG. Methods: Twenty-four male C57BL/6 mice were included and divided randomly into two groups. A chronic unpredictable mild stress (CUMS) mouse model was established to evaluate the effect of psychological stress on glaucoma-related retinal pathologies. Body weight and IOP were recorded weekly. At 5 weeks after the CUMS procedure, a behavior test, serum corticosterone level, retinal nerve fiber layer (RNFL) thickness, retinal ganglion cell (RGC) number and neurotrophic factor expression were evaluated and compared between the CUMS group and the control group. Results: CUMS exposure induced depression-like behaviors, lighter body weight, and increased serum corticosterone levels in mice. RNFL thinning and neural cell loss in the ganglion cell layer (GCL) were observed in CUMS mice without significant IOP elevation. Decreased mRNA expression and protein levels of neurotropic factors in retinas of CUMS mice were observed, especially brain-derived neurotrophic factor (BDNF). Conclusions: The CUMS mouse model demonstrated that psychological stress induced glaucoma-like changes in the retinas of CUMS mice. The mechanism by which psychological stress induces retina defects may be due to a reduced expression of retinal neurotropic factors. Thus, we conclude that psychological stress is causally associated with POAG.

Impact of iStent Micro-Bypass Shunt on Medicare Part B Glaucoma Surgical Expenditure.

PURPOSE: To examine the impact of the iStent (Glaukos) on the recent glaucoma surgical expenditure for Medicare Part B beneficiaries. DESIGN: Retrospective, observational, population-based analysis. PARTICIPANTS: All applicable cases in the Centers for Medicare and Medicaid Services Part B Summary Data Files. METHODS: The Part B National Summary Data Files from 2007 to 2017 were obtained through the Centers for Medicare and Medicaid Services. Glaucoma surgical procedures, including trabeculectomy, glaucoma drainage implants (GDIs), and select minimally invasive glaucoma surgeries (MIGS) including the iStent, were queried from the database using Current Procedural Terminology (CPT) codes. We used Chow's test to confirm significant changes in expenditure trajectories. We built a mixed-effects regression model to examine the effect of demographic factors on each state's iStent adoption speed. MAIN OUTCOME MEASURES: Proportion of iStent in total glaucoma surgical spending for individual states for each year. RESULTS: Total Medicare part B payment for the selected glaucoma procedures increased from $52.0 million in 2007 to $179.9 million in 2017. The percentage for trabeculectomy and GDIs decreased from 92.3% to 21.2%. Conversely, the iStent, approved by the Food and Drug Administration in 2012, increased to represent 57.9% of total payment by 2017. There were significant changes in the slope of glaucoma surgical Medicare payment (P < 0.00001) and iStent payment (P < 0.0001) trajectories in 2012. Mixed-effect regression analysis showed a wide range among the states' rates of increase in iStent proportion between 2012 and 2017 (range, 5.12%-14.54% per year). Higher male proportion in the population was associated with faster increases in iStent proportions (12.4% per 5% increase in male proportion, 95% confidence interval [CI], 4.3-20.5, P = 0.003). Higher median age of the population was associated with slower increases (-3.6% per 1-year increase in median age, 95% CI, -0.4 to -6.8, P = 0.026). CONCLUSIONS: Increasing payment for the iStent represents the majority of the increase in glaucoma surgical spending in the recent decade. Male gender and age significantly affect the state-wise speed of adoption for the iStent. The impact of the iStent on the comprehensive glaucoma Medicare expenditure in the same time period warrants further study.

GlaucoMap - Distribution of Glaucoma Surgical Procedures in the United States.

PURPOSE: To understand the distribution of trabeculectomies, glaucoma drainage implants (GDI) and micro-invasive glaucoma surgeries (MIGS) performed in the United States through geospatial mapping. METHODS: We performed an observational cohort study to evaluate glaucoma surgeries in patients age ≥65. The most recently released data from Centers for Medicare Part B Carrier Summary Files were queried to determine the number of glaucoma surgeries performed per state during the year of 2017. We created choropleth maps, titled "GlaucoMap", to characterize the rates of various surgeries performed across the United States, defined as the number of procedures performed per 10,000 individuals. A chi-squared analysis was further used to evaluate differences in surgical preferences across geographic region. Standardized residuals (SR) were calculated to determine regional influences on surgical distribution. RESULTS: There were 174,788 glaucoma surgeries performed: 22,862 trabeculectomies (13.1%), 19,991 GDI (11.4%) and 131,935 (75.5%) MIGS. The Northeast had the highest trabeculectomy rate, GDI was highest in the Southeast and MIGS were highest in the Southwest. There was a statistically significant difference in proportional use of conventional surgeries versus MIGS across various regions in the United States (p < 0.0001). Given the high trabeculectomy and GDI rates and relatively low MIGS adoption in the Southeast, we observed a +7.03 SR for conventional surgeries and -4.01 SR for MIGS. The Southwest and Western states had the highest MIGS rate and contributed +3.29 and +3.24 SR toward disproportional MIGS preference, respectively. The preference for conventional surgeries in the Northeast (SR = +2.93) and MIGS in the Midwest (SR = +0.99) also contribute to the overall differences in glaucoma surgeries across the United States. CONCLUSION: GlaucoMap is useful for visualizing the distribution of glaucoma surgeries in the United States. The heterogeneity in surgical preferences points to regional differences in glaucoma management.

Histologic Changes Following Continuous Wave and Micropulse Transscleral Cyclophotocoagulation: A Randomized Comparative Study.

Purpose: To compare the macroscopic and microscopic histologic changes in eyes treated with micropulse transscleral cyclophotocoagulation (MP-TCP) versus continuous wave transscleral cyclophotocoagulation (CW-TCP). Methods: Twelve halves of globes from three pairs of adult cadaveric eyes were randomly assigned to nontreated control, CW-TCP, single MP-TCP treatment, or double MP-TCP treatments, and then sectioned for histologic analysis. Presence or absence of the following four unique histologic changes was recorded: splitting within the ciliary process epithelium (splitting), separation of the pigmented ciliary process epithelium from the stroma (separation), coagulation of collagen and destruction of ciliary process stroma (coagulation), and full-thickness destruction of ciliary process epithelium (destruction). Results: A total of 498 slides were analyzed, and laser scars in all treated specimens were located in the pars plana. Logistic regression analysis showed that compared with controls, CW-TCP-treated specimens were significantly more likely to experience separation (odds ratio [OR] = 11.1, P = 0.02), coagulation (OR = 24.3, P = 0.002), and destruction (OR = 11.1, P = 0.03). Destruction of the ciliary process epithelium was observed exclusively in CW-TCP-treated sections. No significant differences in histologic features were observed between controls and MP-TCP. Conclusions: MP-TCP does not produce significant histologic changes in cadaveric eyes, whereas CW-TCP treatment does. Translational Relevance: These findings improve understanding of the mechanism of MP-TCP, help explain the increased rates of adverse effects following CW-TCP treatment compared with MP-TCP, and describe effects of MP-TCP at various doses.

Clinical Outcomes of Micropulse Transscleral Cyclophotocoagulation in Patients with a History of Keratoplasty.

PURPOSE: To examine the surgical outcomes and graft conditions in patients receiving micropulse transscleral cyclophotocoagulation (MP-TSCPC) to treat post-keratoplasty ocular hypertension. METHODS: This retrospective observational study included 30 eyes of 28 consecutive glaucoma patients with a history of penetrating keratoplasty (PKP) or Descemet's stripping automated endothelial keratoplasty (DSAEK) who underwent MP-TSCPC at the University of California, San Francisco from 09/2015 to 08/2018. Using the Wilcoxon signed-rank test, we compared preoperative and postoperative intraocular pressure (IOP), number of glaucoma medications, visual acuity, and central corneal thickness at 1, 3, 6, and 12 months. Postoperative complications, additional surgeries, and graft failures were also recorded at these follow-up times. Linear regression model was used to study whether PKP vs. DSAEK affects the effectiveness of MP-TSCPC. RESULTS: Thirty eyes from 28 patients were followed for 12 months. IOP was significantly decreased from preop at all follow-up points (P < 0.001). There was no significant change in the number of glaucoma drops, visual acuity, or CCT. At 12 months, 21 of the 30 eyes met the definition of success, and only one underwent repeat PKP due to graft rejection. The type of corneal transplant was not a significant factor for IOP reduction at the last follow-up. CONCLUSIONS: MP-TSCPC achieved desirable IOP control and success rates for postkeratoplasty patients while resulting in minimal complications and graft failure. It appears to be a safe and effective procedure in patients who received corneal transplant with one-year follow-up.

Clinical and economic burden of neurofibromatosis type 2 in the United States.

OBJECTIVES: We aimed to investigate the prevalence and cost-associated risk factors for hospital stays for Neurofibromatosis Type 2 (NF2) patients in the past decade. PATIENTS AND METHODS: A multi-year cross-sectional study was performed using the National Inpatient Sample. Patients with a diagnosis code of NF2 according to the International Classification of Diseases, 9th Revision, Clinical Modification coding system were queried from 2006-2014. Sampling discharge weights were used to calculate trend estimates for national demographics, hospital characteristics, comorbidities, and surgical interventions. Regression analysis was performed to determine significant independent associations between comorbidities and admission cost. RESULTS: From 2006-2014, there were 5,078 discharges for patients diagnosed with NF2. Patient demographics, comorbidities, and procedures performed were overall consistent over time. The most common admission diagnoses were hearing loss (28.2 %), acoustic schwannoma (14.3 %), cranial meningioma (11.8 %) and epilepsy (10.8 %). The most common procedures performed were craniotomy and meningioma resection (10.2 %) and acoustic neuroma open resection (7.9 %). The median inflation-adjusted cost of admission did not change over time, with an admission cost value of $12,387 [6,042 - 26,051]. On regression analysis, obstructive hydrocephalus, craniotomy and meningioma resection, acoustic neuroma open resection, and spine tumor resection were all independent predictors of increased cost. CONCLUSION: The care for NF2 patients continues to evolve over time. We report the prevalence of patient demographics, comorbidities, and treatments in the NF2 inpatient population. Further studies are warranted to better understand the risk factors for higher costs, so that patients with NF2 may continue to receive life-long quality care in a cost-effective manner.

Tumor Location and Treatment Modality are Associated with Overall Survival in Adult Medulloblastoma.

Introduction Medulloblastoma (MB) is an aggressive brain tumor most commonly found in children. Although prognostic factors are well studied in children, factors affecting survival in adults with medulloblastoma are unclear. Methods We queried the 1973-2015 United States Surveillance, Epidemiology, and End Results (SEER) registry to identify all adult cases of medulloblastoma, and performed multivariate survival analyses to assess the relationships amongst various clinical variables, including age, sex, race, tumor location, treatment modalities, and overall survival. Results A total of 857 patients, 20 years of age and older, with MB were identified in the SEER registry. Adult cases presented most frequently in the cerebellum (91.6%) compared to other less common regions (brain stem 3.2%, brain 2.2%, ventricle 1.8%). The overall median survival for adult MB is 60 months (SD = 94.3) and survival time is related to tumor location and course of treatment (P < 0.001). Multivariate Cox proportional hazard models showed that lesions found outside the cerebellum corresponded to worse median survival times (37 months) than those in the cerebellum (63 months) (hazard ratio 1.69, 95% CI 1.321-2.158, P = 0.001). Patients who were assigned chemotherapy had shorter survival (54 months) than those who were not (67 months) (HR 1.4515, 95% CI 1.26-1.671, P < 0.001), but receiving radiation therapy was associated with better overall survival (66 months) relative to not receiving radiation (25 months) (HR 0.581, 95% CI 0.48-0.70, P < 0.001). Conclusions Tumor location appears to be a significant prognostic factor for survival in adult MB. Recommended treatment regimes, likely reflective of the underlying aggressiveness of the tumor, also seem to impact survival.

Factors affecting height velocity in normal prepubertal children.

PURPOSE: To analyze the effects of clinical and laboratory factors, including insulinlike growth factor (IGF) levels, on the height velocity of normal prepubertal children. METHODS: Ninety-five healthy prepubertal children (33 boys, 62 girls) were enrolled. The mean chronological age was 6.3±1.4 years, with a height standard deviation score (SDS) of -0.88±0.70. IGF-1, IGF binding protein-3 (IGFBP-3), SDS for anthropometric measurements, and changes in SDS for anthropometric measurements were analyzed for 1 year, and their associations with 1-year height velocity were investigated. RESULTS: The group of children with a 1-year height velocity of ≥6 cm were chronologically younger than the group with a 1-year height velocity of <6 cm (5.9±1.3 years vs. 6.7±1.3 years, P=0.004), with a lesser increase of SDS for body mass index (BMI) over 1 year (-0.18±0.68 vs. 0.13±0.53, P=0.014). There were no differences between the 2 groups in IGF-1 SDS and IGFBP-3 SDS. Multiple linear regression showed that baseline chronological age (r=0.243, P=0.026) and height SDS (r=0.236, P=0.030) were positively associated with IGF-1 SDS. Binomial logistic regression showed that an older chronologic age at referral (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.47-0.99) and an increase of BMI SDS over 1 year (OR, 0.41; 95% CI, 0.18-0.89) were associated with a decreased growth possibility of an above-average height velocity (≥6 cm/yr). CONCLUSION: Height velocity of normal prepubertal children is affected by an increase of BMI SDS and chronological age. Prepubertal IGF-1 SDS reflects height SDS at the time of measurement but is not associated with subsequent height velocity.

Correlation of Corneal and Scleral Pneumatonometry in Pediatric Patients.

PURPOSE: To study the correlation between corneal and scleral intraocular pressure (IOP) by pneumatonometry in pediatric patients. DESIGN: Cross-sectional study. PARTICIPANTS: Patients (age range, 0-15 years) undergoing an eye examination under anesthesia or eye surgery were recruited at the University of California, San Francisco, Benioff Children's Hospital between July 2015 and April 2016. METHODS: Intraocular pressure measurements were obtained by pneumatonometry on the central cornea and the inferonasal and inferotemporal sclera in a random order. Spearman correlations between corneal versus inferonasal scleral IOP and corneal versus inferotemporal scleral IOP were calculated. A linear mixed-effect model was used to derive a predictive equation for corneal IOP from scleral IOP and to perform covariate analysis for age, axial length, central corneal thickness, and lens status. The standard deviation of the predicted corneal IOP was determined by bootstrap mixed-effect regression analysis. MAIN OUTCOME MEASURES: The predictive model of corneal IOP from scleral IOP. RESULTS: Seventy-five eyes from 40 patients were included in the study. Spearman correlation coefficient for corneal versus inferotemporal scleral IOP was 0.79 (P < 0.01) and 0.48 for corneal versus inferonasal scleral IOP (P < 0.01). Corneal IOP may be predicted from scleral IOP via the following equations: corneal IOP = 0.73 × inferotemporal scleral IOP + 7.45 and corneal IOP = 0.21 × inferonasal scleral IOP + 17.83. Central corneal thickness (P = 0.07), lens status (P = 0.4), age (P = 0.33), and axial length (P = 0.15) did not affect significantly the relationship between corneal and scleral IOP in the multivariate regression analysis. The standard deviation of predicted corneal IOP was less than 1.2 mmHg within an inferotemporal scleral IOP range of 10 to 35 mmHg. CONCLUSIONS: In children, corneal and scleral IOP are correlated significantly when measured by pneumatonometry. Measurements obtained from the inferotemporal sclera are better predictors of corneal IOP than those obtained from inferonasal sclera. Pneumatonometry on the inferotemporal sclera may be an alternative method to estimate IOP for pediatric patients from whom corneal IOP measurement is difficult to obtain.

Outcome of Micropulse Laser Transscleral Cyclophotocoagulation on Pediatric Versus Adult Glaucoma Patients.

PURPOSE: To study and compare the outcome of micropulse transscelral cyclophotocoagulation in pediatric glaucoma patients to that in adult glaucoma patients. METHODS: Consecutive pediatric and adult patients who received micropulse transscelral cyclophotocoagulation between July 2015 and December 2016 at University of California, San Francisco were retrospectively analyzed. All cases had at least 12 months of follow-up. RESULTS: Nine eyes from 9 pediatric patients and 27 eyes from 25 adult patients were included. The sample size in pediatric group is small because MP-TCP was not offered to pediatric patients after unsatisfactory results in initial cases. Preoperatively, the mean intraocular pressure (IOP) was 28.41±8.32 mm Hg in adult patients and 34.28±9.92 mm Hg in pediatric patients. Postoperatively, the mean IOP in adult patients significantly decreased at all follow-up points (P<0.001). In pediatric patients, the mean IOP decreased to 20.44±13.41 mm Hg at 1 month (P=0.021), 23.56±10.10 mm Hg at 3 months (P=0.093), 23.00±8.31 mm Hg (P=0.018) at 6 months, and 27.20±15.68 mm Hg (P=0.15) at 12 months. No significant complications were noted in either group. The success rate in adults was 72.22% versus 22.22% in pediatric patients at 12 months (P=0.02). Seven of 9 pediatric patients required reoperation during the 12 months of follow-up. CONCLUSIONS: Micropulse transscelral cyclophotocoagulation is a safe procedure for pediatric as well as adult glaucoma patients. Its effect seems to be short lived in pediatric patients and the rate of reoperation was high.

Early Reoperation Rate, Complication, and Outcomes in Resident-performed Glaucoma Surgery.

PURPOSE OF THE STUDY: The purpose of the study was to examine reoperation rate and complications of resident-performed glaucoma surgeries within the first 90 postoperative days. MATERIALS AND METHODS: A retrospective study of resident-performed glaucoma filtering surgeries at the San Francisco Veterans Affairs Medical Center between 2002 and 2014 was performed. Patients requiring reoperation within 90 days of the initial surgery were included in our study. Combined surgeries were excluded. Complications and the rates of reoperation within the first 90 days were evaluated. Clinical outcomes for those who needed reoperations were evaluated at the 1-year follow-up. RESULTS: Total of 180 cases were reviewed [34 trabeculectomy, 85 Ex-PRESS shunt, and 61 Ahmed glaucoma valve (AGV)]. One hundred and four eyes developed complications, most commonly choroidal effusion (65.3%), followed by hypotony (45.2%) and wound leak (32.7%). Complications were comparable among the 3 groups, except that filtering surgery had significantly more wound leak than AGV (P<0.001). Seven (3.9%) cases required reoperation within first 90 days. There was no reoperation for trabeculectomy group. Reoperation rate was 4.7% for Ex-PRESS and 4.9% for AGV (P=0.74). Indications for reoperation were persistent wound leak (4 cases) and tube occlusion/revision (3 cases). For the 7 patients who required reoperations, their intraocular pressure at 1-year postreoperation was significantly decreased compared with intraocular pressure before the initial glaucoma surgery (P<0.001) with similar number of glaucoma medications and stable visual acuity. CONCLUSIONS: Glaucoma incisional surgeries performed by third-year ophthalmology residents had acceptable and comparable reoperation rates and complication rates for patients with trabeculectomy, Ex-PRESS, and AGV. Clinical outcomes for the patients requiring reoperation were favorable.