Necrotic Eruption of an Inflammatory Melanoma.

This case report describes a vitreous eruption of a choroidal melanoma in a patient aged 64 years who presented with blurry vision.

Diagnostic Confirmation of Choroidal Lymphoma by Anterior Chamber Paracentesis and Aqueous Fluid Flow Cytometry.

PURPOSE: To report the clinical course of patients with diagnostic confirmation of choroidal lymphoma by anterior chamber paracentesis and aqueous fluid flow cytometry. METHODS: Single-center case series. RESULTS: Two patients with choroidal thickening were suspected to have choroidal lymphoma based on clinical findings and ultrasonographic evidence of extrascleral extension. In each case, anterior chamber paracentesis was performed due to the observation of the associated anterior chamber reaction. Flow cytometry detected the presence of a clonal B-cell population consistent with non-Hodgkin's lymphoma. In one case, external beam radiation therapy resulted in a complete therapeutic response. More invasive methods of ocular tissue biopsy were avoided. CONCLUSIONS: Definitive diagnosis in suspected cases of choroidal lymphoma remains challenging. Ocular fluid sampling may be a low morbidity and convenient alternative for confirming a suspected diagnosis in cases associated with cellular infiltration of the intraocular fluids.

Thermal therapy for Sporothrix endogenous endophthalmitis of the anterior segment.

PURPOSE: To report a case of Sporothrix shenkii endophthalmitis successfully treated with local thermal therapy after failure of conventional systemic and local antifungal therapy. OBSERVATIONS: A 44-year-old female on long-term immunosuppressive therapy for extrapulmonary sarcoidosis presented with bilateral Sporothrix shenkii endophthalmitis. Despite prolonged systemic antifungal therapy, numerous intraocular antifungal injections, and surgical intervention with vitrectomy and lensectomy, her condition worsened with progressively increased fungal burden in the anterior chamber. At the patients request, interventional ocular procedures including intraocular injections were withdrawn and enucleation was considered secondary to pain and severe scleral thinning. Local thermal therapy was initiated as a palliative measure, supported by evidence for Sporothrix growth inhibition above 38.5 °C and efficacy with cutaneous Sporothrix. Initiation of ocular thermal therapy with a commercially available electronic heat mask was followed by a dramatic and durable improvement in pain and fungal burden. CONCLUSIONS AND IMPORTANCE: Thermal therapy may be an effective alternative for Sporothrix endophthalmitis affecting the anterior segment with lower risk for toxicity than intraocular injection of antimicrobial therapy.

Anti-adalimumab Antibodies in Patients with Non-infectious Ocular Inflammatory Disease: A Case Series.

PURPOSE: To report the clinical course of patients with ocular inflammatory disease treated with adalimumab in whom anti-adalimumab antibodies (AAA) were detected. METHODS: Single center case series. RESULTS: Eight patients with initial response to adalimumab developed a disease flare associated with positive AAA testing after 5 to 76 months of therapy. Six patients were receiving no concurrent antimetabolite therapy at the time of AAA diagnosis and four had a temporary lapse in adalimumab therapy prior to AAA discovery. AAA resulted in undetectable drug levels in five of the seven patients for whom data were available, and adalimumab was discontinued in six of the eight patients. Of two patients continued on adalimumab, one maintained detectable serum adalimumab despite AAA and one had a low AAA titer. CONCLUSIONS: For patients receiving adalimumab for ocular inflammatory disease, a disease flare in the setting of previously well-controlled disease should prompt consideration of AAA testing.

Bilateral Ampiginous Choroiditis following Presumed SARS-CoV-2 Infection.

PURPOSE: To report a case of bilateral ampiginous choroiditis following presumed SARS-CoV-2 infection. Case Description. A 25-year-old woman presented with metamorphopsia and a paracentral scotoma in her left eye. She endorsed night sweats, headache, and new-onset anosmia beginning 1 week before her visual symptoms. She also had multiple confirmed ill COVID-19 contacts at her workplace before the onset of her symptoms. Funduscopic examination and multimodal imaging revealed placoid lesions in the macula and midperiphery of both eyes consistent with ampiginous choroiditis. COVID-19 antibody testing returned positive for IgG, and an extensive systemic evaluation was otherwise unremarkable. She was treated with oral prednisone and azathioprine with stabilization of the retinal lesions and no progression of her symptoms. CONCLUSIONS: Ampiginous choroiditis is an inflammatory chorioretinopathy with an unknown pathogenic mechanism that often necessitates early immunomodulatory therapy. This report suggests that SARS-CoV-2 infection may trigger chorioretinal inflammation in susceptible hosts.

Assessing the Uniformity of Uveitis Clinical Concepts and Associated ICD-10 Codes Across Health Care Systems Sharing the Same Electronic Health Records System.

IMPORTANCE: Big data studies may allow for the aggregation of patients with rare diseases such as uveitis to answer important clinical questions. Standardization of uveitis-related variables will be necessary, including the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes used to identify patients of interest. There are currently limited data on the uniformity of diagnosis mapping to ICD-10 codes for uveitis diagnoses among different health systems. OBJECTIVE: To assess the degree of uniformity in mapping of uveitis clinical concepts to ICD-10 codes across health care systems using the same electronic health record (EHR) system. DESIGN, SETTING, AND PARTICIPANTS: This multicenter survey study was conducted between September 14 and October 9, 2020, at 5 academic health care systems that use the Epic EHR. Researchers from the University of Washington, Harvard University, Stanford University, Yale University, and the University of California, San Francisco queried 54 uveitis-related diagnostic terms and recorded the associated ICD-10 codes. MAIN OUTCOMES AND MEASURES: The degree of uniformity for uveitis clinical concepts and associated ICD-10 codes. RESULTS: Fifty-four uveitis-related diagnostic terms were queried within the Epic EHR at 5 different health care systems. There was perfect agreement among all 5 centers for 52 of the 54 diagnostic terms. Two diagnostic terms had differences in ICD-10 coding: juvenile idiopathic arthritis associated chronic uveitis and intermediate uveitis. Intermediate uveitis was associated with codes H20.1x (ICD-10 description: chronic iridocyclitis) or H20.9 (ICD-10 description: unspecified iridocyclitis) in 3 centers while being associated with code H30.2x (ICD-10 description: posterior cyclitis) at the 2 remaining centers. The discrepancies appear to be related to a recent update in diagnostic mapping in the Epic EHR. CONCLUSIONS AND RELEVANCE: This study suggests that ICD-10 code mapping to uveitis diagnostic terminology appears to be highly uniform at different centers with the Epic EHR. However, temporal changes in diagnosis mapping to ICD-10 codes and a lack of 1-to-1 mapping of diagnosis to ICD-10 code add additional sources of complexity to the interpretation of big data studies in uveitis.

Automated Quantification of Choriocapillaris Lesion Area in Patients With Posterior Uveitis.

PURPOSE: To validate a custom algorithm for automated identification and quantification of clinically relevant inflammatory choriocapillaris (CC) lesions from en face swept-source optical coherence tomography (SS-OCTA) images. DESIGN: Observational case series. METHODS: Twenty eyes of 14 patients with posterior uveitis were imaged. The machine-generated en face OCTA CC slabs were exported to a computing platform, where a custom algorithm performed unsupervised lesion boundary delineation and area quantification. Lesions identified by the algorithm (AG) were compared to those identified by 2 masked human graders (HG1 and HG2), using the Sørensen-Dice coefficient (DSC) and intraclass correlation coefficient (ICC). Intragrader and intravisit reliability were determined by coefficient of variation (CV) and DSC. RESULTS: The AG demonstrated excellent agreement with both HGs in determination of lesion area (HG1 vs AG ICC 0.92, 95% CI 0.81-0.97, HG2 vs AG ICC 0.91, 95% CI 0.78-0.97). The AG demonstrated good spatial overlap (DSC ≥0.70) with both HGs in 14 of 20 (70%) eyes and at least 1 HG in 16 of 20 (80%) eyes. Poor spatial overlap (DSC between 0.31 and 0.69) was associated with the presence of a choroidal neovascular membrane and low-contrast lesion boundaries. Intravisit repeatability for the AG was superior to both HGs (CV 2.6% vs >5%). CONCLUSION: This custom algorithm demonstrated a high degree of agreement with HGs in identification of inflammatory CC lesions and outperformed HGs in reproducibility. Automated CC lesion delineation will support the development of objective and quantitative biomarker of disease activity in patients with posterior uveitis.

Rational laboratory testing in uveitis: A Bayesian analysis.

Uveitis encompasses a heterogeneous group of clinical entities with the common feature of intraocular inflammation. In addition to patient history and examination, a focused set of laboratory investigations is frequently necessary to establish a specific diagnosis. There is limited consensus among uveitis specialists regarding appropriate laboratory evaluation for many distinct patient presentations. The appropriateness of a laboratory test for a given case of uveitis will depend on patient-specific as well as epidemiologic factors. Bayesian analysis is a widely used framework for the interpretation of laboratory testing, but is seldom adhered to in clinical practice. Bayes theorem states that the predictive value of a particular laboratory test depends on the sensitivity and specificity of that test, as well as the prevalence of disease in the population being tested. In this review we will summarize the performance of commonly-utilized laboratory tests for uveitis, as well as the prevalence of uveitic diagnoses in different geographic practice settings. We will propose a logical framework for effective laboratory testing in uveitic disease through rigorous application of Bayesian analysis. Finally, we will demonstrate that while many highly sensitive laboratory tests offer an effective means to rule out associated systemic disease, limited test specificity and low pretest probability often preclude the diagnosis of systemic disease association with any high degree of certainty, even in the face of positive testing.

Comparison of Modified Posterior Sub-Tenon's vs. Trans-Septal Triamcinolone Injection for Non-infectious Uveitis.

Purpose: To compare the safety and efficacy of trans-septal vs. modified posterior sub-Tenon's (PST) corticosteroid injections for noninfectious uveitis.Methods: Retrospective comparison of periocular triamcinolone injection by modified PST (n = 36) vs. traditional trans-septal (n = 79) techniques. Safety and efficacy outcomes were analyzed with regression models.Results: There was no significant difference in visual acuity improvement between the groups at 6 months. There were higher rates of vitritis resolution in the modified PST group but this was not statistically significant (85.7% vs 62.9%, p = .07). Intraocular pressure (IOP) elevation rate trended higher with the modified PST injection (21.9% vs 9.0%, p = .06), with no instances of glaucoma surgery in either group. Two modified PST injection patients with refractory IOP rises had IOP normalization after corticosteroid depot removal. One year cataract surgery rates were similar.Conclusion: Modified PST injection offers clinical efficacy but with possibly higher IOP response rate which could be managed with corticosteroid removal.

Retinal Microvasculature Changes After Repair of Macula-off Retinal Detachment Assessed with Optical Coherence Tomography Angiography.

OBJECTIVE: To characterize the microvascular retinal changes after repair of macula-off rhegmatogenous retinal detachment (RRD) using optical coherence tomography angiography (OCT-A). PATIENTS AND METHODS: A retrospective review of patients who underwent repair of macula-off RRD. Fellow unaffected eyes were used as controls. Post-operative OCT-A allowed comparison of vessel density (VD) and foveal avascular zone (FAZ) area in the superficial and deep retinal capillary plexus (DCP) as well as VD in the choriocapillaris layer. RESULTS: Seventeen eyes of 17 RRD patients were included in the final analysis. There was a reduction in VD of the deep retinal capillary plexus in affected eyes compared to fellow eyes (p = 0.046). RRD eyes with reduced VD in DCP compared with their fellow control eyes had worse visual acuity after repair compared to those without (p = 0.032). No significant microvasculature changes were detected in the FAZ area and VD in the superficial capillary plexus and choriocapillaris compared to fellow eyes. CONCLUSION: In macula-off RRD eyes, significant microvascular changes were detected in the DCP using OCT-A even after successful anatomical repair. Decreased VD in the DCP compared to the fellow healthy eyes was correlated with worse visual acuity.

Clinical factors affecting operating room utilization in cataract surgery: Results from the PCIOL study.

PURPOSE: To identify preoperative clinical characteristics affecting cataract surgery operative time. SETTING: Academic center. DESIGN: Large-scale retrospective cohort study. METHODS: All cases of cataract extraction by phacoemulsification and intraocular lens insertion performed by Comprehensive Ophthalmology at Massachusetts Eye and Ear between January 1, 2014, and December 31, 2014, were reviewed. Clinically relevant predictors of operative time were identified a priori, and a multivariate analysis was used to identify which predictors were associated with operative time. To quantify the surgeon effect, 2 regression models were built, one inclusive of surgeon identity and the other with years of experience and the training level of the supervised resident instead of identity. RESULTS: Overall, 1349 cataract surgeries in 1072 patients were included. The mean operative time was 22.1 ± 7.8 minutes. Multiple clinical factors were significantly associated with operative time, with attending surgeon identity being the most important. In the multivariate model with surgeon identity, longer operative time was associated with male sex, increased body mass index, first-eye surgery, left operative eye, advanced cataract, use of iris hooks, use of Malyugin ring, use of trypan blue, history of diabetic retinopathy, short axial length, and shallow anterior chamber depth. The R value for the model inclusive of attending identity was 0.42, significantly higher than the R value of 0.23 for the model exclusive of identity. CONCLUSION: Preoperative clinical characteristics, such as patient demographics, biometry data, and cataract severity, significantly correlate with operative time. Surgeon identity is highly correlated with operative time. Incorporating these results into predictive algorithms may allow for more predictable surgical scheduling and more efficient use of operative resources.

Outcomes in resident-performed cataract surgeries with iris challenges: Results from the Perioperative Care for Intraocular Lens study.

PURPOSE: To assess the outcomes of resident-performed cataract surgeries with iris challenges and to compare these outcomes with similar surgeries performed by attending surgeons. SETTING: Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA. DESIGN: Retrospective chart review. METHODS: All cases of cataract extraction by phacoemulsification with intraocular lens implantation, performed by comprehensive ophthalmologists between January 1 and December 31, 2014, were reviewed. Cases with preoperative or intraoperative miosis, iris prolapse, and intraoperative floppy iris syndrome, were included for analysis. Visual outcomes and the rate of perioperative adverse events were compared between resident and attending surgeon cases. Factors predicting adverse events were also assessed. RESULTS: In total, 1931 eye cases of 1434 patients were reviewed, and 65 resident cases and 168 attending surgeon cases were included. The mean logarithm of the minimum angle of resolution corrected distance visual acuity was better in the resident group 1 month after surgery (0.051 ± 0.10 [SD] versus 0.132 ± 0.30, P = .03); however, the difference was eliminated when controlling for macular disease. The mean operative time was 43.8 ± 26.5 minutes and 30.9 ± 12.6 minutes for cases performed by resident surgeons and attending surgeons, respectively (P  .0001). Residents utilized supplemental pharmacologic dilation or retraction more frequently than attending surgeons (98% versus 87% of cases, P = .008). The overall rate of adverse events was no different between residents and attending surgeons (P = 0.16). Dense nuclear sclerosis predicted adverse events in cataract cases with iris challenges (adjusted odds ratio, 1.86; 95% confidence interval, 1.17-2.94; P = .001). CONCLUSION: Although requiring longer operative times and more surgical manipulation, residents who performed cataract surgeries with iris challenges achieved outcomes comparable to those performed by attending surgeons, and residents should be given the opportunity to operate on these eyes.