Systemic and Intraocular Methotrexate for the Prevention and Treatment of Proliferative Vitreoretinopathy in Children With Rhegmatogenous Retinal Detachment and Underlying Inflammatory Disease.

Purpose: This index study highlights the efficacy and safety of a combined surgical and medical therapy (with intraocular and systemic methotrexate) of pediatric rhegmatogenous retinal detachments (RRD) complicated by proliferative vitreoretinopathy (PVR). Methods: Three pediatric patients with RRD complicated by PVR in the setting of underlying atopic dermatitis and/or uveitis who were treated with a combination of vitreoretinal surgery and intraoperative intravitreal methotrexate (MTX) (40mg) infusion, followed by at least one injection of 200 µg of MTX into the silicone oil-filled vitreous cavity, are reported. In addition, the patients received short-term systemic immunosuppression with systemic (oral or subcutaneous 20 mg weekly MTX for 12 weeks) and/or steroids. Results: Retinal reattachment with improvement in visual acuity was achieved in all eyes following a single surgery and remained to the final follow-up examination after oil removal. There were no observed side effects of intraocular or systemic MTX. Conclusions: The safety and efficacy of this combination therapy suggests that it could be a successful strategy for treating pediatric patients with RRD with or without PVR in the presence or absence of underlying inflammatory diseases.

Effect of corneal epithelial remodeling on visual outcomes of topography-guided femtosecond LASIK.

PURPOSE: To assess the effect of epithelial remodeling on visual outcomes over a 9 mm diameter corneal surface after topography-guided laser in situ keratomileusis (LASIK) for myopia correction using spectral-domain anterior segment optical coherence tomography (AS-OCT). SETTING: Outpatient clinical practice at the Stanford University Byers Eye Institute in Palo Alto, California. DESIGN: Prospective nonrandomized observational study. METHODS: Visual acuity, including uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), 5% and 25% contrast sensitivity CDVA, manifest refraction, and corneal epithelial thickness after topography-guided femtosecond LASIK were analyzed. Corneal epithelial thickness was mapped across 13 sections and 3 concentric zones using AS-OCT preoperatively and at 1 month, 3 months, 6 months, and 12 months postoperatively. RESULTS: 60 eyes of 30 patients with a mean age of 32.8 years (range 23 to 52 ± 7.03 years) undergoing myopic LASIK correction were assessed. In eyes with complete follow-up data (n = 30), mean preoperative UDVA was logMAR 1.48 ± 0.45 and logMAR -0.11 ± 0.08 at postoperative 12 months. Mean preoperative CDVA was logMAR -0.08 ± 0.11 and logMAR -0.13 ± 0.07 at 12 months. Linear mixed modeling demonstrated a significant correlation between improvement in UDVA and decreased superior and nasal corneal epithelial thickness and between improvement in CDVA and increased central epithelial thickness 12 months postoperatively. CONCLUSIONS: Improvement in UDVA and CDVA at 12 months after topography-guided femtosecond LASIK was correlated with nonuniform epithelial remodeling, including epithelial thickening in the central zone and thinning in the superior and nasal sections as measured by AS-OCT.

Outcomes After Corneal Crosslinking for Keratoconus in Children and Young Adults.

PURPOSE: The aim of this study was to assess the effect of corneal crosslinking on vision and keratometry in children and young adults with progressive keratoconus. METHODS: A retrospective medical records review of patients aged 22 years or younger with keratoconus who underwent corneal crosslinking between January 2013 and November 2019 at Byers Eye Institute at Stanford University was conducted. Outcome measures included logarithm of the Minimum Angle of Resolution corrected distance visual acuity (CDVA); keratometry, including maximum keratometry (Kmax); pachymetry; and total wavefront aberration. Measurements were taken at baseline and at 12 and 24 months postoperatively. RESULTS: Fifty-seven eyes of 49 patients aged 12 to 22 years were assessed. The mean preoperative CDVA was logarithm of the Minimum Angle of Resolution 0.38 ± 0.32 (20/48), with a mean postoperative CDVA of 0.29 ± 0.31 (20/39) and 0.31 ± 0.31 (20/41) at 12 and 24 months postoperatively, respectively. Compared with preoperative mean Kmax, there was an improvement of -0.8 diopters (D) to a mean postoperative Kmax of 59.1 ± 9.1 D at 12 months and -1.3 D to 59.7 ± 8.8 D at 24 months. Subanalysis excluding the second eye of patients who underwent bilateral crosslinking showed similar results. Linear mixed modeling showed significant improvement in Kmax at both 12 and 24 months postoperatively. Minimum central corneal thickness initially decreased but stabilized at 24 months after crosslinking. Total wavefront aberration remained stable. CONCLUSIONS: Corneal crosslinking stabilizes, and in some cases improves, visual and corneal parameters in pediatric and young adult patients with keratoconus. The procedure is safe and well-tolerated and may prevent keratoconus progression in young patients.

Gender of Award Recipients in Major Ophthalmology Societies.

PURPOSE: To assess the gender distribution of major ophthalmology society award recipients DESIGN: Retrospective, observational study METHODS: The study population included award recipients from 9 ophthalmologic societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Glaucoma Society, American Society of Cataract and Refractive Surgery (ASCRS), American Society of Ophthalmic Plastic and Reconstructive Surgery, American Society of Retina Specialists, American Uveitis Society, Cornea Society, and North American Neuro-Ophthalmology Society. A gender-specific pronoun and a photograph of each award recipient were extracted from professional websites to assign their gender. Main outcome measures were gender distribution by award society, year (1970-2020), type (lectureship or not), category (achievement, education, research contribution, research item, international member achievement, public service-global health, service to society), and training level. RESULTS: Out of 2,150 recipients for 78 awards, 1,606 (74.7%) were men and 544 (25.3%) were women. The proportion of women recipients increased from 0% in 1970 to 33.2% in 2020 (P < .001). Women representation varied within each society (P < .01), with ASCRS having the highest percentage (40.8%). Women received 11.0% of awards accompanied by a lecture. Women received a significantly greater proportion of research-related awards than achievement or service awards. Awards for trainees and early-career ophthalmologists had a greater proportion of women (39.8%) than the rest of the awards (21.5%) (P < .001). CONCLUSIONS: Overall, women received awards (25.3%) at a higher rate than the average 1970-2020 American gender distributions of ophthalmologists. However, women are still under-represented in many award categories and subspecialties.

Subjective intermittent colour vision loss as the initial presentation of chronic myeloid leukemia.

PURPOSE: To report a case of subjective intermittent loss of bilateral colour vision and episodic white-out vision in a patient with undiagnosed chronic myeloid leukemia (CML). OBSERVATIONS: A patient initially diagnosed with diabetic retinopathy presented with a chief complaint of subjective intermittent loss of colour vision in both eyes, as well as intermittent bilateral white-out vision. These symptoms previously went uninvestigated until a thorough history revealed concurrent constitutional symptoms including recent night sweats and fevers. Closer fundus examination revealed that the lesions previously thought to be diabetic retinal hemorrhages were Roth spots. CONCLUSIONS AND IMPORTANCE: An unusual chief complaint of colour vision loss and multiple Roth spots in the context of chronic night sweats and fevers prompted further workup. A CBC with differential revealed a markedly increased WBC count and the patient was diagnosed with CML. Cytoreduction therapy led to complete resolution of the patient's visual symptoms and a return to normal WBC count at the most recent follow up appointment. We report, to our knowledge, the only case of colour vision loss as the initial presenting symptom of CML in the current literature, and reiterate the importance of a thorough history, neuro-ophthalmic examination and relevant investigations in patients with unusual visual symptoms, including intermittent loss of colour vision. In this case, we speculate that hyperviscosity syndrome secondary to CML was the cause of this patient's peculiar visual disturbance.

Immunohistochemical analysis of benign and malignant melanocytic lesions of the conjunctiva using double-staining.

OBJECTIVE: To implement a double-staining technique to identify the most sensitive and specific combinations of melanoma antigen recognized by T cells (Melan-A), microphthalmia-associated transcription factor (MITF), human melanoma black 45 (HMB45), and Ki67 aiming to assist in the diagnosis of atypical melanocytic conjunctival lesions that are more prone to malignant progression. METHODS: Eight specimens of conjunctival melanoma and of primary acquired melanosis with moderate to severe atypia were double-immunostained with a combination of a cytoplasmic marker (anti-Melan-A or anti-HMB45), and a nuclear marker (anti-MITF or anti-Ki67). Eight specimens of normal conjunctiva and of conjunctival nevi served as controls. The specimens were processed using 3,3-diaminobenzidine substrate for nuclear stains and the fast-red substrate for cytoplasmic stains. Each slide was analyzed by light microscopy and provided a percent scale and a 0 to 4+ score for each nuclear and cytoplasmic component. RESULTS: Melan-A and MITF were strongly positive markers for all melanocytic cells, whereas Ki67 and HMB45 provided a variable response for identifying potentially proliferative or aggressive cells. HMB45 and MITF proved to be the best combination for differentiating between atypical and benign lesions on a percent scale and a 0 to 4+ scale (p = 0.0004), with the 3 other combinations providing mainly confirmatory diagnostic information (p < 0.05). CONCLUSIONS: Our study used an immunohistochemical double-staining approach to differentiate between atypical and benign melanocytic lesions of the conjunctiva. Our findings should aid in a more complete immunohistopathological diagnosis of conjunctival melanocytic lesions, particularly in diagnostically difficult cases.

Regression of Sebaceous Carcinoma of the Eyelid after a Small Incisional Biopsy: Report of Two Cases.

PURPOSE: To report 2 cases of regression of sebaceous carcinoma of the eyelid after a small incisional biopsy. METHODS: Clinical, imaging, and histopathological findings are presented, with a literature review on regressing ocular tumors. RESULTS: Our first patient was a 79-year-old man who presented with a 10-month history of progressive left upper eyelid ptosis caused by an eyelid tumor with orbital involvement and confirmed on magnetic resonance imaging. Our second patient was a 70-year-old woman who presented with ptosis with a left upper eyelid mass. Both patients underwent a small incisional biopsy of their lesion. The histopathological diagnoses in both cases were consistent with sebaceous carcinoma. Both patients refused exenteration. Follow-up clinical examination and imaging disclosed total regression of the ptosis and of the neoplasm with no sign of recurrence in both patients over a 4-year period for Case 1 and a 7-year period for Case 2. CONCLUSION: Regression following incisional biopsy of basal cell, squamous cell, and Merkel cell carcinoma, including of the eyelid, is well documented. To the best of our knowledge, our 2 cases of sebaceous carcinoma are the first to be reported with total involution clinically and on imaging of the tumor following partial incisional biopsy.

Unsuspected and misdiagnosed posterior uveal melanoma following enucleation and evisceration in Ottawa-Gatineau.

OBJECTIVE: There is a gap in the recent literature on the topic of clinically misdiagnosed and unsuspected posterior uveal melanomas (PUM) with a calculation of the frequency of these events for a specific geographical area. As the only ophthalmic pathology laboratory in our region, we determined the rate of these outcomes over a 16-year period. METHODS: We retrospectively reviewed 2558 consecutive ophthalmic pathologic specimens in the Ottawa-Gatineau region, of which 334 were eviscerations and 227 were enucleations. We calculated the frequency of clinically misdiagnosed PUM and of clinically unsuspected PUM. We also determined the rate of uveal melanoma undergoing enucleation. RESULTS: From 100 diagnoses of PUM, 2 (2.0%) cases were clinically unsuspected and 2 (2.0%) cases were clinically misdiagnosed. The rate of uveal melanoma undergoing enucleation was 5.6 cases per 1 000 000 of population per annum. From 2009 to 2012, the incidence of this event was 3.8 cases per 1 000 000 per annum, which was lower than the previous three 4-year increments. CONCLUSIONS: We present the first and only single-centred, population-based data on the rates of unsuspected PUM and of clinical misdiagnosis of PUM in the era of modern diagnostic imaging. Our rate of clinical misdiagnosis is within the range of recent reports of this event. Unsuspected PUM occurred at a rate substantially lower than previously published. The incidence of uveal melanoma undergoing enucleation has decreased despite an increase in population, which reflects a shift in management from enucleation to radiation therapy.

Reactivation of Herpes Zoster Keratitis With Corneal Perforation After Zoster Vaccination.

PURPOSE: We present a case of reactivated herpes zoster keratouveitis of 6 years duration with corneal perforation requiring penetrating keratoplasty shortly after inoculation with herpes zoster vaccine (Zostavax, Merck, Quebec, Canada). METHODS: Retrospective case report. RESULTS: A 67-year-old woman with a 5-year history of recurrent unilateral herpes zoster keratouveitis in her right eye presented with another recurrence 2 weeks after Zostavax vaccination. Three months later, she developed descemetocele and 2 months afterward, corneal perforation, which was managed by penetrating keratoplasty. Immunohistopathological examination disclosed positive staining for varicella zoster virus in most of the keratocytes adjacent to the descemetocele and perforation, most vividly in the deeper two-thirds of the stroma where the keratocytes were most dense, but not in corneal epithelium or endothelium. Electron microscopic examination showed universally severely degenerated corneal keratocytes in the corneal stroma adjacent to the perforation with variable numbers of herpes virus capsids present in half of these cells. Only a rare normal-appearing keratocyte was identified in the more peripheral corneal stroma. CONCLUSIONS: We present a case of reactivation of herpes keratouveitis shortly after vaccination with Zostavax in a patient with previous herpes zoster ophthalmicus. We demonstrate, for the first time, ultrastructural evidence consistent with inactive virus capsids in diffusely degenerated keratocytes in the extracted corneal tissue.

Greater nondominant hand proficiency is not associated with enhanced simulated surgical performance.

OBJECTIVE: To determine whether greater nondominant hand proficiency, or handedness approaching ambidexterity, is associated with better two-handed anterior segment surgical outcomes. DESIGN: Repeated-measures study. PARTICIPANTS: Our study included 14 resident physicians from various medical specialties, including ophthalmology, from our academic institution. METHODS: The Eyesi surgical simulator was used to measure the surgical proficiency of 14 resident physicians at our institution on a dominant hand, nondominant hand, and separate bimanual task. The Edinburgh Handedness Inventory (EHI) was used to provide a measure of handedness for each participant. RESULTS: The measured parameters were dominant hand, nondominant hand, and bimanual task scores as determined by the Eyesi surgical simulator and gradients of handedness as determined by the Edinburgh Handedness Inventory for each participant. Having greater nondominant hand proficiency did not enhance two-handed surgical outcomes (p = 0.23). Surgical proficiency was greater bimanually compared with use of the nondominant hand alone (median score 74.0 vs 61.0; p = 0.0007), and bimanual and dominant hand surgical performances were not statistically significantly different from each other (median score 74.0 vs 70.5; p = 0.17). CONCLUSIONS: Our study shows that having greater nondominant hand proficiency is not a necessary trait for simulated anterior segment surgical aptitude. Two-handed surgical outcomes are directly related to dominant hand surgical performance but less so to the nondominant hand.

Secondary corneal amyloidosis after perforating corneal trauma: A series of 5 cases and review of the literature.

We retrospectively reviewed the clinical and surgical histories of 5 patients with traumatic secondary corneal amyloidosis, a relatively rare sequela of nonsurgical and surgical perforating corneal trauma. Four had history of nonsurgical trauma, and 1 had surgical trauma to the cornea. Three specimens were obtained by penetrating keratoplasties and 2 by excision of the cornea during evisceration of the ocular contents. All the corneal specimens showed full-thickness scars of a prior perforating wound with congophilic amyloid deposits that exhibited apple-green birefringence under polarized light and dichroism. All cases had variable degrees of predominantly chronic nongranulomatous inflammation. Ultrastructural examination in 1 patient disclosed 8-nm diameter fibrils in disarray, consistent with amyloid. Amyloid P immunostaining was positive in all 3 patients tested for this protein.

Less education predicts anticholinesterase discontinuation in dementia patients.

OBJECTIVE: We investigated patient socio-demographic, clinical and functional factors predicting cholinesterase inhibitor discontinuation by patients presenting to a memory clinic in Saskatoon, Saskatchewan. METHODS: Data collection began in March 2004 at the Rural and Remote Memory Clinic where family physicians referred their non-institutionalized patients. Neurological and neuropsychological assessment, patient and caregiver questionnaires provided the socio-demographic, clinical and functional variables. Univariate logistic regression analysis was used to examine possible associations between each independent variable and the binary outcome variable of treatment discontinuation. Multivariate logistic regression was used to determine predictors of cholinesterase inhibitor discontinuation within six months of drug initiation. RESULTS: Our sample consisted of the first 63 patients (60.3% female) for whom we prescribed a cholinesterase inhibitor. The mean age at clinic day was 74.56 years (SD=7.78). We found that years of formal education was the only variable significantly associated with cholinesterase inhibitor discontinuation by six months. The more years of formal education, the lower the rate of drug discontinuation by six months. CONCLUSIONS: Likelihood of cholinesterase inhibitor discontinuation by six months was predicted by fewer years of formal education.