Cryoglobulin-Associated Retinal Vasculitis: Retrospective Case Series.

Purpose: To highlight clinical and imaging features of 5 patients diagnosed with retinal vasculitis and cryoglobulins. Methods: This retrospective case series describes clinical and angiographic features of retinal vasculitis and serum cryoglobulins and is the most extensive series to our knowledge. Results: Five female patients were diagnosed with retinal vasculitis and serum cryoglobulins. The average age at time of cryoglobulin identification was 46 years (range, 28-72 years), although retinal vasculitis had been present for various durations. Fluorescein angiograms demonstrated large-vessel and small-vessel segmental leakage in 3 patients, only large-vessel segmental leakage in 1 patient, and only small-vessel segmental leakage in 1 patient. Treatment included topical steroids, intraocular steroid injections, oral corticosteroids, oral antimetabolites, and biologic therapy. At the time of this report, 4 of 5 patients had persistent angiographic leakage; however, none had retinal vascular occlusions. Conclusions: Various treatments were efficacious, although resolution was difficult. No patient experienced retinal vascular occlusions or other types of end-organ compromise.

Sustained Control of Serpiginous Choroiditis with the Fluocinolone Acetonide 0.18 mg Intravitreal Implant.

Purpose: To describe an alternative treatment for a patient with serpiginous choroiditis (SC) who was not tolerant to systemic therapies. Methods: Case report of a patient with serpiginous choroiditis with their clinical course followed with ophthalmic examinations and multimodal imaging overtime. Patients and Results. A 57-year-old female with serpiginous choroiditis was treated for seven years with numerous therapies including systemic steroids, immunosuppressive agents, and repeated dexamethasone intravitreal implants. The patient was intolerant of systemic therapies and would flare if dexamethasone injections were performed less frequently than every 8 weeks, making a viable long-term treatment plan problematic. Following one injection of the fluocinolone acetonide 0.18 mg intravitreal implant, she has experienced sustained control for 20 months. Discussion and Conclusions. Real-world treatment of SC is complex as long-term control is necessary, and associated side effects of the therapies provided may limit sustained use. The fluocinolone acetonide implant lasts 36 months and may be an alternative long-term management option, especially in the setting of systemic medication intolerance for some patients with SC.

Short term visual and structural outcomes of anti-vascular endothelial growth factor (anti-VEGF) treatment delay during the first COVID-19 wave: A pilot study.

Regularly scheduled intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections are essential to maintaining and/or improving many ocular conditions including: neovascular age-related macular degeneration (nAMD), diabetic retinopathy, and retinal vein occlusions with macular edema (RVO). This study aims to assess the effect of unintended delays in anti-VEGF treatment during the first wave of the COVID-19 pandemic. This retrospective case series identified patients receiving regularly scheduled anti-VEGF intravitreal injections based on current procedural terminology (CPT) code at two practices in Minnesota. Diagnoses were limited to nAMD, diabetic macular edema (DME), proliferative diabetic retinopathy, and RVO. Patients were divided into two groups based on whether they maintained or delayed their follow-up visit by more than two weeks beyond the recommended treatment interval during the COVID-19 lockdown. The 'COVID-19 lockdown' was defined as the period after March, 28th, 2020, when a lockdown was declared in Minnesota. We then compared the visual acuity and structural changes to the retina using ocular coherence tomography (OCT) to assess whether delayed treatment resulted in worse visual outcomes. A total of 167 eyes from 117 patients met criteria for inclusion in this study. In the delayed group, the average BCVA at the pre- and post-lockdown visits were 0.614 and 0.715 (logMAR) respectively (p = 0.007). Central subfield thickness (CST) increased from 341 to 447 in the DME delayed group (p = 0.03) while the CST increased from 301 to 314 (p = 0.4) in the nAMD delayed group. The results of this pilot study suggests that treatment delays may have a negative impact on the visual and anatomic outcomes of patients with nAMD and DME. Future studies with larger sample sizes are required for further investigation.

"Glaucomatous fields" after monthly intravitreal injections: Normal tension glaucoma or a mimicker?

PURPOSE: Anti-vascular endothelial growth factor (VEGF) injections, while used to effectively treat numerous retinal vascular conditions, can be associated with transient and prolonged ocular hypertension. There is minimal literature detailing the development of normal-tension glaucoma (NTG) following intravitreal anti-VEGF injections. OBSERVATIONS: A 38-year-old Caucasian male with no medical or ocular history was diagnosed with an inferior HRVO with macular edema in the left eye. The patient received a total of eleven monthly intravitreal aflibercept injections over one year, with maintenance of stable vision and intraocular pressure (IOP) throughout the treatment period and during follow-up. Nine months after the last aflibercept injection, cup-to-disc asymmetry, inferior thinning of retinal nerve fiber layer (RNFL), and reduced superior visual field was evident in the left eye. Clinically, the patient was consistent with normal tension glaucoma and thus, the patient was started on daily timolol drops; however, the role of the glaucomatous findings being secondary to repeated injection-related IOP elevations is possible. CONCLUSIONS AND IMPORTANCE: While the clinical features based on visual fields and RNFL thinning with unmedicated normotensive IOP may suggest NTG in a patient, this clinical presentation may be a masquerader of NTG with the etiology of the glaucoma optic neuropathy caused by cumulative impact of transient IOP elevations secondary to intravitreal injections.

Simultaneous Presentation of Uveitic Disc Edema and Papilledema in an Adult.

PURPOSE: To present a case of simultaneous uveitic disc edema and increased intracranial pressure (IICP) in an adult. METHODS: Retrospective case report. Patients. A 29-year-old woman affected by bilateral optic disc edema from bilateral posterior uveitis complicated by IICP with papilledema. RESULTS: Laboratory workup was negative for infectious and systemic inflammatory causes of uveitis. Computed Tomography scan of the chest was negative for Sarcoidosis. Magnetic Resonance Imaging of the brain and orbits revealed a partially empty sella, bilateral posterior globe flattening without optic nerve sheath enhancement, masses, white matter lesions, or meningeal enhancement. Cerebral Magnetic Resonance Venography showed narrowing of the right and left transverse sinuses without thromboses. Prednisone was initiated for the uveitis which improved the vision but caused weight gain. Neurology evaluation with a lumbar puncture in the lateral decubitus position revealed elevated opening pressure and otherwise normal cerebrospinal fluid. Ocular ultrasonography was considered but not available to measure optic nerve sheath diameter. Oral acetazolamide 1000 mg twice daily was started for papilledema as prednisone was tapered. Periocular steroid and intravitreal bevacizumab injections were used for sight threatening cystoid macular edema and choroidal neovascularization, respectively. Discussion. While previously described in children, we report the first known case of bilateral uveitic disc edema and papilledema in an adult. This report will discuss recommendations for evaluation of these rarely concurrent conditions and therapy for both uveitic disc edema and papilledema.

Eliminating Visual Acuity and Dilated Fundus Examinations Improves Cost Efficiency of Performing Optical Coherence Tomogrpahy-Guided Intravitreal Injections.

PURPOSE: The clinic efficiency and cost savings achieved by eliminating formal visual acuity (VA) and dilated fundus examinations (DFEs) were assessed for established patients receiving optical coherence tomography (OCT)-guided intravitreal injections. DESIGN: Comparative cost analysis. METHODS: Two different treatment models were evaluated. The first model included patients undergoing routine VA assessment, DFEs, OCT imaging, and intravitreal injections. The second model eliminated the routine VA assessment and DFE while using OCT imaging through an undilated pupil followed by the intravitreal injection. The 2 models incorporated both bevacizumab and aflibercept. The number of patients per clinic day, the cost per visit, and the daily revenues were compared between the 2 models. RESULTS: Optimized schedules with and without VA assessments and DFEs allowed for 48 and 96 patients to be injected per day, respectively. Excluding drug costs, the cost per encounter for the visits with and without a DFE were $39.33 and $22.63, respectively. Including the drug costs, the costs per encounter for the visits with and without a DFE were $85.55 and $68.85 for bevacizumab and $1787.58 and $17770.88 for aflibercept, respectively. Once the reimbursements for each visit type were included, the clinics that eliminated the VA and DFEs were more cost efficient. CONCLUSION: Eliminating both VA assessments and DFEs for patients undergoing OCT-guided retreatment with intravitreal injections resulted in decreased exposure times between patients and clinic staff, decreased cost per encounter, and increased patient volumes per clinic day, resulting in improved clinic efficiency and safety while seeing more patients in a clinic day.

Clinical Characteristics of a Case Series of Ocular Syphilis With 3 Cases Requiring Multiple Vitrectomies After Late Diagnosis.

Purpose: This work describes the characteristics and unique features of ocular syphilis. Methods: Ten serologically proven cases of ocular syphilis were retrospectively analyzed. Results: Eighteen eyes of 10 patients were affected. Nine of 10 patients were male and the mean age was 58 years (range, 36-81 years). HIV antibody testing was positive in 3 patients (30%). Five cases were first diagnosed by an ophthalmologist. One patient presented with a syphilitic rash. The most common ocular findings were panuveitis (n = 6) and cystoid macular edema (n = 4). Ocular involvement was unilateral in 2 cases and bilateral in 8. Best-corrected visual acuity improved in 13 of 18 eyes (72%) after treatment. Three cases developed recurrent retinal detachments that required repair with silicone oil. Conclusions: Most cases were HIV negative. Syphilitic uveitis can be the initial presentation of syphilis without classic systemic manifestation. Ophthalmologists play an important role in the diagnosis and treatment of syphilis.

Carcinoid tumor presenting as a primary mesenteric mass: a case report and review of the literature.

We report a case of a primary carcinoid tumor arising in the mesentery of the small bowel of a 52-year-old man. The mesenteric mass in this patient was first identified as an incidental finding on CT imaging for bilateral nephrolithiasis. As a result of the abnormal findings, follow-up evaluation identified a partially calcified lobulated mesenteric lymph node. Diagnostic laparoscopy with lymph node sampling showed no evidence of hepatic or other metastatic disease. Pathologic analysis and immunohistochemistry of the mesenteric tissue revealed a malignant neuroendocrine tumor. Since all radiographic studies and subsequent workup revealed no evidence of other primary masses, this was determined to be a primary carcinoid tumor arising in the mesentery of the small bowel. Primary mesenteric carcinoid tumors are very rare because of their location of origin.