Optical coherence tomography homography for detection of retinal displacement: a validation study.

PURPOSE: Retinal displacement following rhegmatogenous retinal detachment (RRD) has been associated with inferior functional outcomes. Recent evidence using an overlay technique suggests that fundus-autofluorescence underestimates post-RRD repair retinal displacement. This study aims to validate the overlay technique in normal eyes and to determine its sensitivity and specificity at detecting retinal displacement. METHODS: We conducted a retrospective case series involving 66 normal eyes, each with at least two separate infrared (IR) images at different time points. Overlay of the two images was based on manual marking of choroidal and optic nerve head (ONH) landmarks. For each set of two IR images, computer code for homography generated two outputs, flipping view video and an overlay picture. First, validation of choroidal/ONH alignment was performed using the flipping view video to ensure accurate manual markings. Then, two different masked graders (AB + IM) evaluated the overlays for presence of retinal displacement. 16 control eyes following RRD repair with detected retinal displacement on FAF imaging assessed sensitivity and specificity of the technique. RESULTS: 94% of overlays were found to be well aligned (62/66). 11 cases exhibited errors on flipping view analysis (choroidal/ONH misalignment). Those 11 cases had a significantly higher rate of retinal displacement (false positives) compared to cases without errors (8/11,72% Vs 54/55,98%,P = 0.001). Sensitivity and specificity of the overlay technique for detecting retinal displacement considering only adequate flipping view cases (n = 55) were calculated as 100% and 98%, respectively. CONCLUSIONS: IR overlay emerges as a reliable and valid method for detecting retinal displacement, exhibiting excellent sensitivity and specificity.

Cystoid macular edema occurring after intracameral bimatoprost implantation.

PURPOSE: This case report aims to report the development of cystoid macular edema (CME) unilaterally following the administration of bimatoprost implant (Durysta) injections in both eyes for the treatment of primary open-angle glaucoma (POAG). OBSERVATIONS: An 84-year-old female patient, previously diagnosed with POAG, underwent bimatoprost implant (Durysta) injections in both eyes, spaced one month apart. Subsequently, the patient experienced a gradual decline in visual acuity in her left eye attributed to the development of CME. The condition resolved following a treatment regimen involving topical dexamethasone and nepafenac. CONCLUSION: The use of bimatoprost implant may lead to the occurrence of CME. Ophthalmologists must vigilantly monitor patients post-implantation, especially if they exhibit visual symptoms or have risk factors for a CME.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY MORPHOLOGY AFTER RHEGMATOGENOUS RETINAL DETACHMENT REPAIR: ALIGN Post Hoc Analysis.

PURPOSE: To compare foveal avascular zone (FAZ) geometric indices using optical coherence tomography angiography (OCTA) in pneumatic retinopexy (PnR) versus pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD). FAZ morphology was assessed as a possible imaging feature of retinal displacement. METHODS: This ALIGN post hoc analysis included primary fovea-off RRDs that underwent successful PnR or PPV, and performed OCTA, and fundus autofluorescence at (FAF) 3 months postoperatively at St. Michael's Hospital, Toronto, Canada. FAZ area (mm 2 ), axial ratio, circularity, and roundness were measured, and FAF images were assessed for retinal displacement. RESULTS: Seventy-two patients were included, 78% (56/72) were male mean age was 60 ± 9 years, and 60% (43/72) were phakic. Sixty-five percent (47/72) and 35% (25/72) underwent PnR and PPV, respectively. The mean baseline logarithm of the minimum angle of resolution visual acuity was 1.49 ± 0.76. FAZ circularity was lower after PPV (0.629 ± 0.120) versus PnR (0.703 ± 0.122); P = 0.016. Sixty-six patients had gradable FAF images. Retinal displacement was present in 29% (19/66), 84.2% (16/19) of which had displacement in the macula. FAZ circularity was lower in eyes with displacement in the macula (0.613 ± 0.110) versus those without displacement (0.700 ± 0.124); P = 0.015. There was a moderate negative correlation between 12-month aniseikonia and FAZ circularity(r = -0.262; P = 0.041). CONCLUSION: FAZ circularity was lower after PPV and in eyes with retinal displacement in the macula. Circularity was negatively correlated with 12-month aniseikonia scores. FAZ circularity may be another imaging feature to consider postoperatively after RRD repair.

A Novel Method of Quantifying Retinal Displacement Using Ultra-Widefield Fundus Autofluorescence Imaging.

PURPOSE: To introduce a novel method of quantifying retinal displacement in three dimensions (3D) using ultra-widefield fundus autofluorescence (UWF-FAF). DESIGN: Prospective clinical cohort study. METHODS: Patients with primary macula-off rhegmatogenous retinal detachment (RRD) treated with pneumatic retinopexy (PnR) or vitrectomy were included. Masked graders selected corresponding points on retinal vasculature and retinal vessel printings (RVPs) within Zone 1, a circular region centered on the fovea with a radius extending to the optic disc (OD) center. Two-dimensional (2D) UWF-FAF was projected to 3D using OD and foveal coordinates. Vertical, horizontal, and diagonal distances between corresponding vessel and RVPs were calculated. Vector displacement of the RVPs to vessels were averaged. RESULTS: A total of 170 retinal vessel-RVP pairs were identified from 54 UWF-FAF images. Mean displacement in Zone 1 was 0.36 ± 0.38 mm, with an absolute mean angle of displacement of 94.93 ± 41.48° and directionality of 191.84 ± 97.39°. Mean Zone 1 displacement was 0.44 ± 0.42mm and 0.21 ± 0.27 mm in vitrectomy (n = 35) and PnR (n = 19) eyes, respectively (P = .041), with no differences in mean angle of displacement/directionality. CONCLUSIONS: A novel method of quantifying the magnitude and direction of retinal displacement is presented, accounting for the spherical 3D curvature of the eye by using corresponding points on retinal vessels and RVPs using UWF-FAF. This provides a 3D vector of displacement agnostic of a singular fixation point such as the optic disc. Accurately quantifying the magnitude and angle/direction of displacement may allow for a better understanding of the mechanisms involved in retinal displacement in various surgical techniques, and a better assessment of the association with functional outcomes.

Effect of Music Selection on Anxiety Level during Intravitreal Injections for Individuals of Varying Cultures.

PURPOSE: To investigate music selection as a treatment for anxiety during Intravitreal injections (IVI) for individuals of varying cultures. METHODS: 106 individuals were enrolled in this randomized controlled study. Individuals were randomized into one to three categories: (1) a control group in which the IVI procedure was performed without music (n = 35), (2) an experimental group in which the music was selected by the physician (n = 36), (3) an experimental group in which the music was selected by the patient (n = 35). After the procedure, all patients responded to a questionnaire regarding their level of experienced anxiety, pain and discomfort (grade 0-10). The primary outcome was anxiety level during the procedure. RESULTS: The experimental group in which patients selected music had higher number of patients with low anxiety score compared to the other groups (anxiety score <4 in 19,18 and 27 patients, respectively, p = .04). Interestingly, patients who answered the questionnaire in Arabic were less likely to desire music on subsequent injections compared to Hebrew and English speakers (52% Vs 78% Vs 100%, p = .02). Music was deemed by both experimental groups as an effective method to induce relaxation (average score of 6.6 and 7.2 in group 2 and 3, respectively). Preference for music on subsequent injections was increased in both experimental groups compared to the control group (P < .01). Patients in the third group preferred music selection on future injections more than the other groups (P < .01). CONCLUSION: Music selection may be an effective way to reduce anxiety levels during IVI. Preference for music during future injections is higher in patients who were exposed to music during IVI and may be influenced by culture.

The Impact of COVID-19 on Intravitreal Injection Compliance.

Intravitreal injections (IVI) of anti-vascular endothelial growth factor (anti-VEGF) agents have become the most prevalent intraocular procedure as they represent the major therapeutic modality for prevalent retinal conditions such as age-related macular degeneration (AMD) and diabetic retinopathy. Effective therapy requires adherence to a schedule of iterative IVI as well as routine clinic appointments. The ongoing coronavirus disease 2019 (COVID-19) pandemic has resulted in the reduction of attendance at scheduled clinic visits and IVI. In this study, we attempted to analyze the effect of COVID-19 on compliance with anti-VEGF therapy. A total of 636 eyes received injections during a 4-week period of the COVID-19 outbreak in the Retina Clinic. The number of clinic visits for IVI during 1 month from March 15 to April 14 of 2020 was compared to a similar time period in each of the last 4 years. The study demonstrates a decrease in clinic visits for IVI when compared with the same 4-week interval in the four previous years. Based on the trend of the previous 4 years, 10.2% of the year's total was expected for this time period. Using this model, the 636 reported number of injections for the March-April 2020 period was ~ 5%. This represents a decrease of ~ 50% of the expected IVI for this time period. The COVID-19 outbreak in Israel severely impacted compliance with anti-VEGF treatments.

Retinal Displacement Following Pneumatic Retinopexy vs Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment.

Importance: Retinal displacement following rhegmatogenous retinal detachment repair may have consequences for visual function. It is important to know whether surgical technique is associated with risk of displacement. Objective: To compare retinal displacement following rhegmatogenous retinal detachment repair with pneumatic retinopexy (PR) vs pars plana vitrectomy (PPV). Interventions or Exposures: Fundus autofluorescence images were assessed by graders masked to surgical technique. Design, Setting, and Participants: A multicenter retrospective consecutive case series in Canada and the UK. A total of 238 patients (238 eyes) with rhegmatogenous retinal detachments treated with PR or PPV who underwent fundus autofluorescence imaging from November 11, 2017, to March 22, 2019, were included. Main Outcomes and Measures: Proportion of patients with retinal displacement detected by retinal vessel printings on fundus autofluorescence imaging in PR vs PPV. Results: Of the 238 patients included in the study, 144 were men (60.5%) and 94 were women (39.5%); mean (SD) age was 62.0 (11.0) years. Of the 238 eyes included in this study, 114 underwent PR (47.9%) and 124 underwent PPV (52.1%) as the final procedure to achieve reattachment. Median time from surgical procedure to fundus autofluorescence imaging was 3 months (interquartile range, 1-5 months). Baseline characteristics in both groups were similar. The proportion of eyes with retinal vessel printing on fundus autofluorescence was 7.0% for PR (8 of 114) and 44.4% for PPV (55 of 124) (37.4% difference; 95% CI, 27.4%-47.3%; P < .001). Analysis based on the initial procedure found that 42.4% (42 of 99) of the eyes in the PPV group vs 15.1% (21 of 139) of the eyes in the PR group (including 13 PR failures with subsequent PPV) had displacement (27.3% difference; 95% CI, 15.9%-38.7%; P < .001). Among eyes with displacement in the macula, the mean (SD) displacement was 0.137 (0.086) mm (n = 6) for PR vs 0.297 (0.283) mm (n = 52) for PPV (0.160-mm difference; 95% CI, 0.057-0.263 mm; P = .006). Mean postoperative logMAR visual acuity was 0.31 (0.32) (n = 134) (Snellen equivalent 20/40) in eyes that initially underwent PR and 0.56 (0.42) (n = 84) (Snellen equivalent 20/72) in eyes that had PPV (-0.25 difference; 95% CI, -0.14 to -0.35; P < .001). Among eyes with displacement, mean postoperative logMAR visual acuity was 0.42 (0.42) (n = 20) (Snellen equivalent 20/52) in those that initially underwent PR and 0.66 (0.47) (n = 33) (Snellen equivalent 20/91) in those that initially underwent PPV (-0.24 difference; 95% CI, -0.48 to 0.01; P = .07). Conclusions and Relevance: These findings suggest that retinal displacement occurs more frequently and is more severe with PPV vs PR when considering the initial and final procedure used to achieve retinal reattachment. Recognizing the importance of anatomic integrity by assessing retinal displacement following reattachment may lead to refinements in vitreoretinal surgery techniques.

Enhanced depth imaging in swept-source optical coherence tomography: Improving visibility of choroid and sclera, a masked study.

PURPOSE: To compare enhanced depth imaging in swept-source optical coherence tomography and non-enhanced depth imaging optical coherence tomography in their ability to capture choroidal and scleral details. METHODS: Averaged foveal B-Scans were obtained from 40 eyes of 20 healthy volunteers by swept-source optical coherence tomography with and without enhanced depth imaging. Visibility and contrast of vascular details within the choroid, choroidoscleral junction, and sclera were evaluated by masked readers using an ordinal scoring scale. Outcomes were analyzed using the Wilcoxon signed rank-sum test. RESULTS: Visibility of the choroidal vascular details (Z = 5.94, p < .001), the choroidoscleral junction (Z = 5.85, p < .001), and the sclera (Z = 6.80, p < .001) was significantly higher with enhanced depth imaging than with non-enhanced depth imaging swept-source optical coherence tomography. Similarly, image contrast was significantly higher with enhanced depth imaging than with non-enhanced depth imaging swept-source optical coherence tomography for the choroidal vascular details (Z = 9.47, p < .001), for the choroidoscleral junction (Z = 9.28, p < .001), and for the sclera (Z = 9.42, p < .001). CONCLUSION: Enhanced depth imaging applied to swept-source optical coherence tomography-averaged foveal B-scans enhances visualization of the choroidal details, of the choroidoscleral junction, and of the sclera. This novel modality can easily be implemented in clinics and could improve our understanding of conditions involving the choroid or the sclera.

An unusual case of globe-sparing penetrating orbital injury by a nail.

We describe a case of a 28-month-old boy who presented to our emergency department with a right orbital penetration by an iron nail. At presentation, no pain or functional loss were noted. Plain head radiographs and computed tomography were performed and demonstrated a two centimeters long nail penetrating the right orbit. The foreign body was extracted carefully in the operating room. No complications were observed upon follow-up. Rarely, orbital penetration by an iron-nail can present without functional disturbances or pain and is not necessarily accompanied by sequelae.

Vitreous hemorrhage as an early sign of acute bacterial endophthalmitis following intravitreal ranibizumab injection.

PURPOSE: To report a case of acute bacterial endophthalmitis after antivascular endothelial growth factor injection with a rare presentation of vitreous hemorrhage. METHODS: An 84-year-old woman presented with sudden painless vision loss in her left eye, 3 days after intravitreal ranibizumab injection for cystoid macular edema due to neovascular age-related macular degeneration. The patient was otherwise asymptomatic. Dense vitreous hemorrhage was observed. At follow-up the next day, the patient complained on severe left eye pain. After examination, acute endophthalmitis was diagnosed. RESULTS: Intravitreal injection of vancomycin, ceftazidime and dexamethasone was performed. Vitreous and aqueous cultures grew Enterococcus faecalis. After treatment, the inflammation subsided but it took 3 months for the vitreous hemorrhage to totally resorb. Visual acuity was reduced to light perception. CONCLUSIONS: Vitreous hemorrhage may be an atypical presentation of acute bacterial endophthalmitis occurring after intravitreal injection.

Chemical Burn-Induced Stromal Demarcation Line.

PURPOSE: A stromal demarcation line is a well-known sign after collagen cross-linking. It has been proposed that this line is the transition zone between cellular and acellular stroma, and thus it might reveal the depth of photochemical changes in the corneal stroma. We report 2 cases of a similar demarcation line after chemical alkali burns. To the best of our knowledge, this is the first report of a stromal demarcation line after a chemical burn. OBSERVATION: Two patients presented to the emergency department after an ocular alkali burn. At presentation, both had total corneal erosion, corneal edema, and limbal ischemia. After 12 to 15 days, a stromal line was apparent by both slit-lamp examination and anterior segment optical coherence tomography. The stromal demarcation lines disappeared approximately 3 months after the injury. CONCLUSIONS: A stromal demarcation line may appear not only after collagen cross-linking but also after a chemical burn. The line depth may be associated with the severity of the injury, and therefore, may have prognostic significance. Patients with chemical burns should be examined for evidence of a stromal line in the cornea.

[Unique mechanism in heart-shaped balloon burst resulting in blunt ocular injury].

We have previously shown that heart-shaped balloons have a different explosion mechanism than spherical balloons in which the former splits into two rubber parts still attached to the balloon base with a backward whiplash motion. This backward whiplash motion may cause significant blunt ocular trauma if the balloon is inflated by mouth. In this article, the energy of the blunt ocular trauma is estimated by the high speed camera photos analysis of the balloon burst. Furthermore, we describe the followup of eight patients with ocular trauma following inflation of heart-shaped balloons.

Unilateral papilledema in pseudotumor cerebri.

PURPOSE: To report a case of a 25-year-old girl with pseudotumor cerebri who presented with unilateral swollen optic disk. METHODS: A 25-year-old obese patient admitted to our ophthalmic department complaining of headaches, tinnitus, and transient visual obscurations for the last three months. Upon ophthalmic examination, the left optic nerve was swollen with a few hemorrhages compared to the normal-appearing right optic nerve. Following lumbar puncture with opening pressure of 350 mmHg, a diagnosis of pseudotumor cerebri was made and treatment with acetazolamide was started. RESULTS: Three months later there were no episodes of visual obscurations and headache improved. CONCLUSION: Although rare, unilateral swollen disk could be a sign of unilateral papilledema due to increased intracranial pressure.

Teratogenic determinants of first-trimester exposure to antiepileptic medications.

OBJECTIVE: To investigate the potential impact of exposure to anti epileptic medications during the first-trimester of pregnancy on major malformations. STUDY DESIGN: A retrospective cohort study comparing all pregnancies of women with and without exposure to antiepileptic medications during pregnancy was performed. A computerized database of medications dispensed from 1998 to 2008 to all women registered in the "Clalit" health maintenance organization, was linked with computerized and non computerized databases containing maternal and infant hospitalization records from the district hospital. Exposed women were further analyzed by mono and poly- antiepileptic therapy during pregnancy. Stratified analyses, using multiple logistic regression models were performed to control for confounders. RESULTS: During the study period 99,724 deliveries and 1012 pregnancy terminations occurred; of those, 421 (0.42%) were exposed to one or more antiepileptic medications during the first trimester. A higher rate of major congenital malformations was detected among women who were exposed, as compared to those unexposed to antiepileptic medications during the first-trimester (10.0% vs. 7.0%; P=0.02). The association remained significant after adjusting for maternal age, ethnicity, smoking, diabetes and parity (adjusted OR= 1.50; 95% CI 1.06-2.12; p=0.02). Specifically, the risk was significant for antiepileptic anti folate drugs (n=210; adjusted OR= 1.95; 95% CI 1.25-3.03; P=0.003). Poly-antiepileptic therapy was significantly associated with major congenital malformations (26.5% vs. 5.7%, P<0.001). Using a multiple logistic regression model, controlling for ethnicity, diabetes, smoking, maternal age and parity, poly-antiepileptic therapy was an independent risk factor for major congenital malformations (adjusted OR= 7.98; 95% CI 3.4-18.7; P<0.001), while mono-therapy lost its independent association with major congenital malformations (adjusted OR= 1.23; 95% CI 0.8-1.8; P=0.28). CONCLUSION: First-trimester exposure to antiepileptic medications is an independent risk factor for major congenital malformations. The risk is significantly higher for anti folate antiepileptic drugs and for poly-antiepileptic therapy.