Unexpected Vision Loss following Six Intravitreal Injections for Neovascular Age-Related Macular Degeneration.

Introduction: We present a case of a patient with preceding vitreomacular traction (VMT) who developed a full-thickness macular hole (FTMH) following his sixth intravitreal aflibercept injection for the treatment of age-related macular degeneration and review the literature on risk factors and pathogenesis of this adverse event. Case Presentation: FTMH can occur after an extended number of repeat intravitreal injections in the setting of worsening vitreomacular adhesion or VMT. This patient's FTMH was successfully treated surgically in a timely manner, and additional injections were resumed safely. Conclusions: Patients with an unexpected decrease in vision after intravitreal injections should be reevaluated with optical coherence tomography to rule out alternative pathology including vitreomacular interface abnormalities. FTMH, if present, should be treated promptly to allow for resumption of therapy as needed and visual optimization.

Implementation of a Teleophthalmology Screening Program for Diabetic Retinopathy in New York City.

Purpose: To examine the implementation of a teleophthalmology program for diabetic retinopathy (DR) screening at a metropolitan hospital system and identify the challenges that the clinical teams encountered using the program. Methods: The study was conducted in 2 parts. The first was a pilot retrospective chart review of 300 consecutive patients screened for DR by the teleophthalmology screening program. The baseline variables, DR capture rate and staging, and continuity of care for those diagnosed with DR were analyzed. The second was a web-based survey identifying the barriers encountered by 36 physicians and clinical staff as they participated in the teleophthalmology screening program. Results: Part 1: Of the patients evaluated, 57 (19.0%) were diagnosed with DR; 42 (73.7%) had mild nonproliferative DR (NPDR), 7 (12.3%) had moderate NPDR, none had severe NPDR, and 8 (14.0%) had PDR. Thirty-one patients (54.4%) with retinopathy diagnoses were referred for an in-person follow-up at the clinic while the rest continued monitoring via the program. Of this subset, 22 (71.0%) completed the follow-up visit. Part 2: The survey respondents comprised 28 physicians (77.8%), 6 licensed nurse practitioners (16.7%), and 2 medical assistants (5.6%). Twenty-two providers (71.0%) preferred initiating referrals for in-person annual examinations over teleophthalmology screening referrals. The most common barriers described were related to workflow interruption, time constraints, and staff shortages. Conclusions: The teleophthalmology DR screening program allowed identification of early or absent DR at clinics in an urban setting (New York City). The findings suggest areas for targeted improvement in the screening program to better complement internal referral practices' workflows.

Frosted Branch Angiitis in the Setting of Active COVID-19 Infection and Underlying Mixed Connective Tissue Disease.

Frosted branch angiitis (FBA) is an uncommon form of retinal vasculitis and is typically associated with vision loss. We report a unique case of FBA that manifested in the setting of an active COVID-19 infection in a patient with Mixed Connective Tissue Disease (MCTD). A 34-year-old female with a history of MCTD, including overlapping findings of dermatomyositis, systemic lupus erythematosus, and rheumatoid arthritis, on immunosuppressive medications, presented for left-sided vision loss. She was also found to have an active COVID-19 infection with symptoms including sore throat and dry cough. The patient's visual acuity was counting fingers in her affected eye with a fundus exam revealing diffuse retinal hemorrhages, retinal whitening, cystoid macular edema, and perivascular sheathing of tertiary arterioles and venules, characteristic of FBA. Labs showed mildly elevated inflammatory markers. She exhibited no other signs or symptoms concerning systemic rheumatologic flare. There was no evidence of COVID-19 on viral PCR testing of intraocular fluid but given her positive nasopharyngeal PCR, COVID-induced retinal vasculitis with FBA remained high on the differential. The patient's retinal vasculitis later improved with heightened immunosuppressive therapy including high-dose intravenous corticosteroids. Clinicians should be aware of the possibility of COVID-related FBA, particularly in patients with an underlying predisposition to autoimmune inflammation. Our experience with this patient highlights the utility of high-dose systemic immunosuppressive therapy in treating such inflammatory occlusive retinal vasculitis. Further studies are needed to characterize retinal manifestations of COVID-19 in the setting of autoimmune disease.

Ocular Toxoplasmosis: No Stranger to the Masquerade Ball.

Purpose: This article illustrates multiple atypical manifestations of ocular toxoplasmosis masquerading as acute retinal necrosis and vitreoretinal lymphoma. Methods: Two case presentations are discussed, and the body of pertinent literature is reviewed and discussed. Results: In these cases, an extensive workup and attention to history lead to the correct diagnosis and management. Conclusions: Aggressive cases of ocular toxoplasmosis may present in a variety of phenotypes that may mimic other vision- and potentially life-threatening conditions, particularly in a milieu of inadequate endogenous and exogenous antimicrobial defenses.

Monitoring Ischemic Changes in Retinal Vasculitis With Optical Coherence Tomography Angiography.

Purpose: This article illustrates the ability of optical coherence tomography angiography (OCTA) to aid in the diagnostic workup and management of occlusive retinal vasculitis over time. Methods: A case presentation is discussed. Results: In this case, OCTA helped define the extent and evolution of superficial and deep retinal capillary plexus occlusion and reperfusion over the treatment course. Conclusions: OCTA detects blood flow and maps retinal vasculature at the capillary level without the use of intravenous dye. Serial image acquisition can reveal patterns of ischemia and reperfusion in retinal vascular conditions as they evolve and respond to therapy, providing more granular information regarding the status of the retinal microvasculature that may guide treatment.

Advances in Vitiligo: An Update on Medical and Surgical Treatments.

Vitiligo is one of the most common cutaneous disorders of depigmentation. Although its underlying causes are still being studied and no definitive cure currently exists, recent research has provided insight into pathogenic mechanisms and new treatment options. Objective: The aim of this paper is to provide a comprehensive overview of the medical and surgical therapies for vitiligo with emphasis on the most recent treatment modalities. Design: This review was conducted through a literature search using PubMed and the National institutes of Health's clinicalTrials.gov databases from January 2010 to July 2015. This yielded 86 studies, 12 of which were excluded, and 74 of which were reviewed. Results: Recent studies and ongoing clinical trials indicate that there are many promising new medical and surgical treatment modalities for this chronic condition. Conclusion: A combination of traditional and newer treatments may work synergistically to provide additional improvement in patients' disease state and quality of life.

Minimal exposure intra-arterial chemotherapy for children with retinoblastoma and 13q syndrome.

Two infants with retinoblastoma and 13q syndrome with multiorgan system anomalies were treated with targeted intra-arterial chemotherapy (IAC) using one-to-three cycles of melphalan 5 mg to avoid systemic chemotherapeutic side effects. Both patients showed good response, with tumor control and no systemic chemotherapy side effects. Of the treatment modalities currently available, IAC may represent an optimal balance between tumor extermination and adverse drug reactions in this patient population with classically reduced multiorgan reserve.

Vitamin A deficiency and xerophthalmia in children of a developed country.

AIM: We aim (i) to characterise the clinical features of vitamin A deficiency (VAD) in a small cohort of Australian children; (ii) to determine the effects of VAD; and (iii) to quantify the prevalence of ophthalmic review in this group. METHODS: Data collected from the charts incorporated patient demographics, laboratory results, past medical history, ophthalmic symptoms and dietary history. Outcome measures were (i) occurrence of VAD in our study population; (ii) presence of associated systemic effects and ocular manifestations in those diagnosed with VAD; and (iii) determination of whether children with VAD had an ophthalmology review. RESULTS: Fifty-two of the 146 children had VAD; their average age was 8.4 years (range 11 days to 18 years old). In this Australian cohort, the most common pre-existing medical conditions in those children whose vitamin A status was investigated were cystic fibrosis, gastro-oesophageal reflux disease, micronutrient deficiency and short gut syndrome. The most common medical conditions affecting children with measured VAD in this cohort include autism, coeliac disease and cystic fibrosis. A significant association was found between VAD and anaemia and serum iron levels. Of the 146 children, 28 had ophthalmology review, of whom 13 had VAD. The most common reason for ophthalmology review was retinopathy of prematurity; there was only one referral for review for xerophthalmia. There was one case of xerophthalmia referred due to microbial keratitis. CONCLUSION: Vitamin A deficiency and xerophthalmia do exist in children of developed country. The potential for xerophthalmia should be considered, and there should be a consideration of an ophthalmology review.

Plastic Surgery Mortality: An 11-Year, Single-Institution Experience.

BACKGROUND: Systematic reporting of mortality data is lacking in many surgical fields including plastic surgery. Current plastic surgery literature is largely limited to adverse events associated with specific procedures. Without mortality data, it is unclear how the recent growth of patient safety initiatives can rationally impact outcomes. METHODS: We evaluated 11 years of patient outcome data collected prospectively and updated monthly by our department. Paper records were entered into a Health Insurance Portability and Accountability Act-compliant digital database capable of prospectively maintaining future data. Data were reviewed for 5 surgical services in 4 different hospitals that comprise our department's activity. RESULTS: Between 2000 and 2011, a total of 60,834 cases were performed. In this time, a total of 829 (1.4%) negative outcome reports were identified. Of these, a total of 25 (0.04%) cases had an outcome of death (24) or brain death (1). Deaths were either directly or indirectly associated with cardiopulmonary causes, multisystem organ failure, sepsis, massive bleeding, CVA, saddle embolism, or unknown causes. CONCLUSIONS: This study is the largest reported series of cases performed by a single academic plastic surgery service to report overall mortality data.

Immunotherapy in Melanoma, Gastrointestinal (GI), and Pulmonary Malignancies.

Oncologic immunotherapy involves stimulating the immune system to more effectively identify and eradicate tumor cells that have successfully adapted to survive the body's natural immune defenses. Immunotherapy has shown great promise thus far by prolonging the lives of patients with a variety of malignancies, and has added a crucial new set of tools to the oncologists' armamentarium. The aim of this paper is to provide an overview of immunotherapy treatment options that are currently available and under active research for melanoma, gastrointestinal (esophageal, gastric, pancreatic, and colorectal), and pulmonary malignancies. Potential biomarkers that may predict favorable responses to immunotherapies are discussed where applicable, as are future avenues of research in this rapidly evolving field.

Differences in the association of hip cartilage lesions and cam-type femoroacetabular impingement with movement patterns: a preliminary study.

OBJECTIVE: To investigate the differences in hip movement patterns during different daily and athletic activities in persons with cam-type femoroacetabular impingement (FAI) with and without cartilage lesions compared with control subjects in a preliminary study. DESIGN: Controlled laboratory study using a cross-sectional design. SETTING: Research institution with a tertiary care medical center. PARTICIPANTS: Fifteen subjects [M:F, 13:2; age, 31.6 ± 9.7 years (range, 22-52 years); body mass index, 24.9 ± 4.6 (range, 18.8-38.4); FAI:control, 7:8]. METHODS: All subjects had 3-Tesla magnetic resonance imaging of the hip and also underwent 3-dimensional motion capture during walking, deep-squat, and drop-landing tasks. Experienced radiologists graded cartilage lesions on clinical magnetic resonance images. OUTCOMES: Peak kinematic and kinetic variables were compared between subjects who did and did not have FAI, and subjects who had FAI and cartilage lesions were compared with subjects who did not have cartilage lesions. RESULTS: Subjects who had FAI demonstrated no significant differences for walking or drop landing compared with control subjects. However, during the deep-squat task, subjects with FAI adducted more and had a greater internal rotation moment. Subjects who had cartilage lesions in the presence of a cam lesion demonstrated (1) no difference for walking; (2) greater adduction, greater internal rotation moment, and lower transverse plane range of motion during the deep-squat task; and (3) greater adduction and lower internal rotation during the drop-landing task compared with subjects who did not have cartilage lesions. CONCLUSIONS: We observed differences in movement patterns between subjects who had FAI compared with control subjects. However, the differences were more pronounced between subjects with FAI who had cartilage lesions compared with subjects who did not have cartilage lesions. These findings highlight the importance of understanding the complex interplay between bony morphologic features, cartilage lesions, and movement patterns in persons with cam-type FAI.

Regional variations in MR relaxation of hip joint cartilage in subjects with and without femoralacetabular impingement.

The objective of this study was to analyze regional variations of magnetic resonance (MR) relaxation times (T1ρ and T2) in hip joint cartilage of healthy volunteers and subjects with femoral acetabular impingement (FAI). Morphological and quantitative images of the hip joints of 12 healthy volunteers and 9 FAI patients were obtained using a 3T MR scanner. Both femoral and acetabular cartilage layers in each joint were semi-automatically segmented on sagittal 3D high-resolution spoiled gradient echo (SPGR) images. These segmented regions of interest (ROIs) were automatically divided radially into twelve equal sub-regions (30(0) intervals) based on the fitted center of the femur head. The mean value of T1ρ/T2 was calculated in each sub-region after superimposing the divided cartilage contours on the MR relaxation (T1ρ/T2) maps to quantify the relaxation times. T1ρ and T2 relaxation times of the femoral cartilage were significantly higher in FAI subjects compared to healthy controls (39.9±3.3 msec in FAI vs. 35.4±2.3msec in controls for T1ρ (P=0.0020); 33.9±3.1 msec in FAI vs. 31.1±1.7 msec in controls for T2 (P=0.0160)). Sub-regional analysis showed significantly different T1ρ and T2 relaxation times in the anterior-superior region (R9) of the hip joint cartilage between subjects with FAI and healthy subjects, suggesting possible regional differences in cartilage matrix composition between these two groups. Receiver operating characteristic (ROC) analysis showed that sub-regional analysis in femoral cartilage was more sensitive in discriminating FAI joint cartilage from that of healthy joints than global analysis of the whole region (T1ρ: area under the curve (AUC)=0.981, P=0.0001 for R9 sub-region; AUC=0.901, P=0.002 for whole region; T2: AUC=0.976, P=0.0005 for R9 sub-region; AUC=0.808, P=0.0124 for whole region). The results of this study demonstrated regional variations in hip cartilage composition using MR relaxation times (T1ρ and T2) and suggested that analysis based on local regions was more sensitive than global measures in subjects with and without FAI.

Has anti-D prophylaxis increased the rate of positive direct antiglobulin test results and can the direct antiglobulin test predict need for phototherapy in Rh/ABO incompatibility?

AIM: To determine the impact of Rhesus (Rh) D prophylaxis on positive direct antiglobulin test (DAT) results and ability of a DAT grade to predict an infant's need for phototherapy. METHODS: Laboratory and infant medical records were reviewed for DAT status, DAT grade, interventions for hyperbilirubinemia including phototherapy, blood transfusion, exchange transfusion and intravenous immunoglobulin. Two epochs of DAT results were reviewed, the first in the era prior to Rh D prophylaxis, the second after introduction of standardised Rh D prophylaxis for Rh negative women. RESULTS: A total of 165 DAT-positive infants' medical records were reviewed. The number of positive DAT results increased from 1.5% to 2.3% (P < 0.0001) following introduction of anti-Rh D prophylaxis, the increase related to an increase in anti-D DATs (7.4% to 32% -P < 0.0001). An infant with a DAT grade of 5-8 was 2.6 times more likely to need phototherapy than an infant with a DAT grade of 2-4 (odds ratio (OR), 2.571; 95% confidence interval (CI), 1.225-5.393; P = 0.08) and an infant with a DAT grade of 10-12 was 4.7 times more likely to need phototherapy than an infant with a DAT grade of 2-4 (OR, 4.724; 95% CI, 1.602-13.926, P =0.013). CONCLUSIONS: Rh D prophylaxis has increased positive DAT results, which may increase the number of unnecessary bilirubin measurements. A low or high DAT grade is strongly predictive of whether an infant does or does not require phototherapy. However, an intermediate DAT requires concomitant bilirubin measurements to determine phototherapy requirements.