Posterior Retinal Breaks Secondary to Closed-Globe Blunt Ocular Trauma.

Purpose: To describe 2 cases of posterior pole retinal tears resulting from closed-globe trauma. Methods: Two cases of retinal breaks in the posterior pole after blunt ocular trauma were evaluated, and the relevant literature was reviewed. Results: Two eyes of 2 patients with posterior pole retinal tears secondary to closed-globe trauma were included. One patient had a pars plana vitrectomy with laser retinopexy and gas tamponade; the final Snellen visual acuity (VA) was 20/200. The second patient was treated with indirect laser retinopexy; the final Snellen VA was counting fingers. Conclusions: The rapid deformation of the globe in response to blunt ocular trauma may create significant tangential stress on the retina, leading to stretch breaks in the posterior pole. Clinicians should follow patients with a closed-globe injury to watch for retinal breaks in the posterior pole, in particular when a hemorrhage or other pathology obscures the view.

Physician-Patient Face Masking's Influence on Post-Intravitreal Injection Endophthalmitis Rates.

PURPOSE: We sought to determine if universal face mask guidelines implemented during the COVID-19 pandemic significantly influenced the incidence of endophthalmitis following intravitreal injections (IVI). METHODS: This retrospective cohort study reviewed the electronic health records from a retina-only practice located in Michigan. The study evaluated patients receiving IVIs over two distinct time periods of April 2019-March 2020, and April 2020-March 2021, which made up our unmasked and masked groups, respectively. We then calculated the incidence of endophthalmitis following IVI and evaluated cases of post-injection endophthalmitis for both time periods. RESULTS: There were a total of 121,384 intravitreal injections performed over the two year period of interest. Of these, there were 63,114 unmasked and 58,270 masked patient encounters. A total of 46 post-injection endophthalmitis cases were identified. Of these, 29 cases were from the unmasked period and 17 were from the masked period. This resulted in an incidence of endophthalmitis of 0.046% and 0.038% in the masked and unmasked groups, respectively. This difference did not rise to the level of statistical significance (p=0.1336). CONCLUSION: This study suggests that the incidence of post-injections endophthalmitis was not influenced by the implementation of ophthalmologist-patient face masking after intravitreal injection during the COVID-19 pandemic.

Long-Term Use of a Temporary Keratoprosthesis and Perfluorocarbon in Traumatic Retinal Detachment Repair.

Purpose: To present a technique for optimizing repair of traumatic retinal detachments (RDs). Methods: A patient was followed in an outpatient setting with clinical examinations, optical coherence tomography, widefield fundus photography, and anterior segment imaging. Results: The patient presented with a total RD after ruptured globe repair. The patient had combined corneal and retinal surgery with placement of a temporary keratoprosthesis (TKP) and vitrectomy with perfluorocarbon liquid (PFCL) to reattach the retina. The TKP and PFCL were left in the eye for 2 weeks before a planned silicone oil exchange and penetrating keratoplasty were performed. Four months postoperatively, the patient presented with a partially attached retina and improved vision. Conclusions: In this case, a ruptured globe decompensated several months after primary repair. The prolonged use of the TKP allowed for optimal surgical visualization, enhanced office-based assessment, and limited endothelial cell loss of the donor corneal tissue.

Eye Dynamics and Engineering Network Consortium: Baseline Characteristics of a Randomized Trial in Healthy Adults.

PURPOSE: To improve understanding of intraocular pressure (IOP) and its variance, this project identifies systemic and ocular characteristics of healthy eyes of adult volunteers including IOP variation, ocular biometrics, and aqueous humor dynamics (AHDs). These data serve as baseline controls for further studies from the Eye Dynamics and Engineering Network (EDEN) Consortium. DESIGN: Multicenter open-label clinical trial in healthy adults randomized to 1 week treatment with 2 approved glaucoma drugs in a crossover design. PARTICIPANTS: Among 135 healthy participants, 122 participants (aged 55.2 ± 8.8 years; 92 females, 30 males) completed the protocol. METHODS: Participants from the University of Michigan, Mayo Clinic, and University of Nebraska Medical Center underwent measurements of ocular biometrics, AHD, and IOP using 4 tonometers. Intraocular pressure data during 3 study visits without glaucoma medications were used in the analysis. The PhenX Toolkit survey acquired standardized data on medical history, surgical history, medications, smoking and alcohol exposures, and physical measures. MAIN OUTCOME MEASURES: The variability of IOP measurements within eyes was assessed as visit-to-visit IOP variation, within-visit IOP variation, and within-visit positional IOP variation. The concordance (or correlation) between eyes was also assessed. RESULTS: Average positional change of > 4.7 mmHg was detected with a range of 0.5-11.0 mmHg. Pearson correlation of IOP between eyes within a visit was 0.87 (95% confidence interval [CI], 0.82-0.91) for Goldmann applanation tonometry, 0.91 (95% CI, 0.88-0.94) for Icare rebound tonometry, and 0.91 (95% CI, 0.88-0.94) for pneumatonometry. There was a 4% to 12% asymmetric fluctuation of 3 mmHg or more between eyes between visits using rebound tonometry, 9% with Goldmann applanation tonometry, and 3% to 4% by pneumotonometry. The coefficient of variation between visits for the same eye ranged from 11.2% to 12.9% for pneumatonometry, from 13.6% to 17.4% for rebound tonometry, and 15.8% to 16.2% for Goldmann applanation tonometry. CONCLUSIONS: The current study from the EDEN Consortium describes measurement methods and data analyses with emphasis on IOP variability. Future papers will focus on changes in ocular biometrics and AHD with timolol or latanoprost treatment. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Preventing Iatrogenic Retinal Breaks in Cutter-Associated Traction from Chronic Vitreous Hemorrhage (CATCH).

BACKGROUND AND OBJECTIVE: To describe an under-recognized complication in the surgical management of dense, nonclearing vitreous hemorrhage, specifically, the development of iatrogenic retinal breaks as a result of cutter-associated traction. STUDY DESIGN/PATIENTS AND METHODS: Review of surgical cases with cutter-associated traction from chronic vitreous hemorrhage (CATCH). RESULTS: Cutter-associated traction from chronic vitreous hemorrhage is a commonly encountered surgical entity that may result in complications such as iatrogenic retinal breaks, including giant retinal tears. These complications can be minimized or potentially avoided through the use of open sclerotomies or potentially mixed-gauge vitrectomy. CONCLUSION: Careful surgical planning in cases of dense or chronic vitreous hemorrhage is required to prevent cutter-associated tractional retinal breaks. [Ophthalmic Surg Lasers Imaging Retina 2022;53:584-585.].

Ocular Complications of Acute Worsening of Nephrotic Syndrome.

This report presents the case of a man aged 45 years who came into the emergency department with acutely worsening vision during the course of 1 week. He was found to have acutely worsening nephrotic syndrome secondary to focal segmental glomerulosclerosis despite systemic immunosuppression. His ophthalmic examination revealed large nerve fiber layer hemorrhages in the posterior pole, significant macular edema, and areas of polygonal retinal whitening sparing the blood vessels, consistent with a diagnosis of Purtscher-like retinopathy. The patient was started on intravenous methylprednisolone followed by an oral taper of prednisone with improvement in his visual acuity and clinical findings 2 weeks later. [Ophthalmic Surg Lasers Imaging Retina 2022; 53:393-396.].

Bilateral Exudative Retinal Detachments, Chemosis, and Impaired Ocular Motility in the Setting of Preeclampsia and HELLP Syndrome.

Purpose: We present a complication of preeclampsia and hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome including bilateral exudative retinal detachments, bullous chemosis, and impaired ocular motility. Methods: The patient was followed in the inpatient and outpatient setting with clinical examinations, optical coherence tomography, widefield fundus photography, neuroimaging including magnetic resonance imaging of the brain/orbits, as well as carotid artery ultrasonography. Results: Our patient was admitted with bilateral vision changes in the setting of preeclampsia and HELLP syndrome and was found to have bilateral exudative detachments, retinal exudation, severe bullous chemosis, and impaired motility. She was started on intravenous dexamethasone followed by an extended prednisone taper with resolution of her ocular findings and return of her vision to baseline. Conclusions: There is evidence that HELLP syndrome and preeclampsia are proinflammatory syndromes. Aggressive blood pressure control, corticosteroids, and a multidisciplinary approach might accelerate visual and systemic recovery in these complex cases.

Extensive autoimmune keratolysis with subsequent corneal perforation managed with tectonic endothelial keratoplasty.

PURPOSE: To report a case of corneal perforation secondary to an extensive rheumatologic corneal melt, that was successfully managed via systemic immunosuppression and internal tectonic endothelial keratoplasty (TEK). OBSERVATIONS: A 55-year-old male with undiagnosed rheumatoid arthritis presented with a progressively enlarging area of peripheral ulcerative keratitis with extensive keratolysis which subsequently perforated despite treatment with oral steroids. The structural integrity of the globe was restored via a combination of cyanoacrylate glue and tectonic endothelial keratoplasty (TEK). This technique provided long term structural support and improved visual acuity. CONCLUSIONS AND IMPORTANCE: TEK grafts represent a viable treatment option in a subset of patients with corneal perforation secondary to an extensive corneal melt. The familiarity and relative ease of the surgical technique along with a lack of corneal sutures represents an alternate technique when compared to full thickness or lamellar keratoplasty. Further, through the use of anterior segment spectral domain optical coherence tomography (SD-OCT) we demonstrate that the donor graft integrated within the host cornea. To our knowledge, this represents the first case in the literature of corneal perforation secondary to an inflammatory corneal melt that was successfully managed with internal tectonic endothelial keratoplasty.

Effect of Timolol on Aqueous Humor Outflow Facility in Healthy Human Eyes.

PURPOSE: Hyposecretion of aqueous humor has been postulated to adversely affect the health of the trabecular meshwork and outflow resistance. However, the effect of medications that reduce aqueous humor production on outflow facility in living human eyes is unclear. This study evaluated the effect of timolol, an aqueous humor flow suppressant, on outflow facility in healthy eyes. DESIGN: Prospective, before-and-after study. METHODS: In a multicenter study, 113 healthy participants over 40 years of age were included. Intraocular pressure (IOP) was measured with the participant in the sitting position by using a pneumatonometer. The outflow facility was measured with the participant in the supine position by 2-minute pneumatonography. After participants self-administered drops of timolol 0.5% for 1 week, twice daily in each eye, both measurements were repeated. RESULTS: Mean IOP decreased from 15.1 ± 3.0 mm Hg at baseline to 12.4 ± 2.4 mm Hg (P < 0.001) after 1 week of timolol use. Mean outflow facility decreased from 0.23 ± 0.08 µL/min/mm Hg at baseline to 0.18 ± 0.08 µL/min/mm Hg (P < 0.001) after timolol. The change in outflow facility was negatively correlated with baseline outflow facility (r = -0.51; P < 0.001). CONCLUSIONS: Timolol reduces outflow facility in healthy human eyes, and this effect is greater in eyes with higher baseline outflow facility. This phenomenon may be related to reduced aqueous humor flow, but the precise mechanism remains to be determined.

Lipemia retinalis as the presenting sign of undiagnosed type 1 diabetes mellitus resulting in severe secondary hypertriglyceridemia.

We describe the clinical course of an 11-year-old girl diagnosed with lipemia retinalis as the presenting sign of diabetes mellitus type 1 with severe secondary hypertriglyceridemia. By performing serial multimodal imaging studies, we provide a comprehensive description of the clinical manifestations associated with severe hypertriglyceridemia to promote recognition of this rare clinical diagnosis.

Changing Initial Glaucoma Medical Therapy Increases Healthcare Resource Utilization.

PURPOSE: To determine the frequency and economic impact of changing initial glaucoma therapy for patients with newly diagnosed open-angle glaucoma (OAG) or ocular hypertension (OHT). METHODS: This retrospective longitudinal cohort study identified individuals within a large managed care network in the United States, who were newly diagnosed with OAG or OHT from 2001 to 2012 and were prescribed either a topical beta blocker (BB) or a prostaglandin analog (PGA). Claims data were analyzed over the 12-month period following their index prescription to determine physician prescribing habits, healthcare resource utilization patterns, and sociodemographic factors which may have contributed to changing the initial treatment strategy. RESULTS: A total of 15,019 beneficiaries were identified with newly diagnosed OAG or OHT and whose index therapy was either a topical BB or PGA. Among these enrollees 80.9% were started on PGAs, while 19.1% were started on BBs. Of these beneficiaries, 29.2% of those started on PGAs and 39.5% of those started on BBs underwent a change in therapy within 12 months of their index prescription. Those in the topical BB treatment group had a 38% increased odds of changing glaucoma therapy relative to those started on PGAs (odds ratio [OR] 0.61, 95% CI:0.56-0.68). Patients who changed therapy required more frequent office visits (P < 0.0001) and incurred higher median eye care related charges (P < 0.0001) compared to those who remained on the index therapy unchanged. CONCLUSIONS: Changing initial ocular hypotensive therapy is common. Individuals who undergo a change in therapy required more frequent face-to-face monitoring and incurred higher healthcare related costs. Identifying strategies capable of optimizing the process of initiating ocular hypotensive therapy are appealing and possess the potential to improve patient outcomes and reduce healthcare costs.

Optical Coherence Tomography Angiography of Paracentral Acute Middle Maculopathy Associated With Primary Antiphospholipid Syndrome.

The authors present the first case of paracentral acute middle maculopathy as a manifestation of primary antiphospholipid syndrome (APS) with multimodal imaging, including optical coherence tomography angiography (OCTA). The association between APS and ophthalmic sequela is well-known. Recent advances in multimodal imaging, specifically OCTA, allow for better characterization of the mechanism and extent by which retinal arterial thrombosis can cause vision loss. Using advanced imaging modalities, the authors provide a comprehensive assessment of retinal ischemia, which showed not only localized capillary occlusion, but also ischemia of the deep retinal capillary plexus. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:175-178.].

PERIPHERAL RETINAL VASCULOPATHY IN COCKAYNE SYNDROME.

PURPOSE: To present peripheral retinal vasculopathy and foveal ellipsoid zone abnormalities as novel fundus manifestations of Cockayne syndrome (CS), a rare autosomal recessive condition with well-described ophthalmic associations. METHODS: Clinical examination, wide-field fundus photography, wide-field fundus autofluorescence, wide-field fluorescein angiography, and spectral domain optical coherence tomography (SD-OCT) were used to diagnose and document the patient's clinical presentation. RESULTS: Our patient presented with postnatal growth delay, neurologic dysfunction, premature aging, dental anomalies, sensory neural hearing loss, and pigmentary retinopathy. This constellation of clinical features satisfies the clinical diagnostic criteria of CS Type 1. In addition to these well-known features, we used multimodal retinal imaging to perform an in-depth analysis of the retinal manifestations of CS and report peripheral vasculopathy and ellipsoid zone abnormality as two novel features which have not previously been described in conjunction with CS. CONCLUSION: This case report is intended to assist physicians in making the correct diagnosis of this rare condition by reviewing the clinical diagnostic criteria and providing the most comprehensive fundus imaging of CS available in the literature to date.

Expansion of Severely Constricted Visual Field Using Google Glass.

Google Glass (Google, Mountain View, CA) is a wearable technology with a computer and camera mounted on an eyeglass frame. The camera captures wide-angle video and projects it onto a prism located in the right superior temporal quadrant of the wearer's visual field. The authors present a case of an individual who used Google Glass' video projection feature to expand his severely constricted right visual field. This patient reported improved ambulatory navigation. Using Google Glass, the patient's peripheral vision, measured using Goldmann kinetic perimetry, expanded impressively. Based on these preliminary results, the authors propose further characterization on the potential utility of such head-mount display technology as a tool to improve the lives of patients with severely constricted visual fields. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:486-489.].

Recovery of outer retina in acute idiopathic blind spot enlargement (AIBSE).

PURPOSE: To report the anatomic and functional recovery of the ellipsoid zone in a case of acute idiopathic blind spot enlargement (AIBSE), which was documented by serial high-resolution optical coherence tomography imaging. OBSERVATIONS: The patient's clinical presentation and follow up visits were documented via Humphrey's Visual Fields, fundus autofluorescence, and high resolution spectral domain optical coherence tomography (SD-OCT). At presentation, Humphrey's Visual Field testing showed an enlarged blind spot in the right eye. Fundus autofluorescence and optical coherence tomography showed an increased peripapillary autofluorescence and loss of the outer retinal layers, respectively. At 3 months a modest improvement in the visual field was observed. This improvement was stable at both the 7 and the 15 month follow up visits. SD-OCT corresponding to the areas of visual field improvement demonstrated recovery of the outer retina. CONCLUSION AND IMPORTANCE: Serial OCT imaging demonstrated anatomic evidence of ellipsoid zone recovery in isolated AIBSE. Anatomic recovery was consistent with the functional gain detected by visual field improvement.

Vasculitic central retinal vein occlusion: The presenting sign of seronegative rheumatoid arthritis.

PURPOSE: To report the case of a patient who presented with a vasculitic central retinal vein occlusion (CRVO), which was the result of an undiagnosed systemic inflammatory condition, seronegative rheumatoid arthritis (RA). OBSERVATIONS: The patient presented with reduced vision in the left eye and polyarthralgia. Fundoscopic examination revealed a central retinal vein occlusion (CRVO) with concurrent evidence of vasculitis. Work-up for polyarthralgia included comprehensive serologic testing for connective tissue disease, including Vectra® disease activity (DA) testing. Results of these studies confirmed the diagnosis of seronegative rheumatoid arthritis (RA). Systemic steroid therapy was initiated with subsequent anatomic and visual improvement. CONCLUSIONS AND IMPORTANCE: We hypothesize that the systemic inflammation-a hallmark of RA-led to the development of a vasculitic CRVO and, thus, the retinal manifestations served as the disease marker that prompted thorough work-up of the patient's disease, even in the face of initial seronegativity. This case serves as a reminder that, in the setting of CRVO and polyarthralgia, systemic inflammatory conditions must be considered as the underlying etiology. Further, this case report highlights our evolving understanding of the role that serologic markers play in the diagnosis and monitoring of RA.

Advances in Retinal Tissue Engineering.

Retinal degenerations cause permanent visual loss and affect millions world-wide. Current treatment strategies, such as gene therapy and anti-angiogenic drugs, merely delay disease progression. Research is underway which aims to regenerate the diseased retina by transplanting a variety of cell types, including embryonic stem cells, fetal cells, progenitor cells and induced pluripotent stem cells. Initial retinal transplantation studies injected stem and progenitor cells into the vitreous or subretinal space with the hope that these donor cells would migrate to the site of retinal degeneration, integrate within the host retina and restore functional vision. Despite promising outcomes, these studies showed that the bolus injection technique gave rise to poorly localized tissue grafts. Subsequently, retinal tissue engineers have drawn upon the success of bone, cartilage and vasculature tissue engineering by employing a polymeric tissue engineering approach. This review will describe the evolution of retinal tissue engineering to date, with particular emphasis on the types of polymers that have routinely been used in recent investigations. Further, this review will show that the field of retinal tissue engineering will require new types of materials and fabrication techniques that optimize the survival, differentiation and delivery of retinal transplant cells.

Sturge-weber syndrome and cerebral vascular av malformation in an african-american adolescent.

PURPOSE: The purpose of this study was to report the case of a 16-year-old black man who without ocular history or physician-recognized dermatologic signs was found to have Sturge-Weber syndrome. METHODS: Color flow Doppler ultrasound and cerebral vascular imaging showed a child with Sturge-Weber syndrome with a cerebral vascular AV malformation. RESULTS: Color flow Doppler ultrasound and cerebral vascular imaging showed a total retinal detachment, diffuse choroidal hemangioma, and cerebral vascular AV malformation consistent with the diagnosis of Sturge-Weber syndrome. CONCLUSION: This case shows that this child with typical ocular vascular findings of Sturge-Weber syndrome and a cerebral AV malformation did not show recognizable evidence of a port wine stain during several physician examinations because of the child's darkly pigmented skin color.