Case Report: Optical Coherence Tomography Findings in Glaucoma with Co-existing Vitamin a Deficiency.

This case study reports on the presence of vitamin A deficiency in an adult with asymmetric normal tension glaucoma. The retinal OCT findings demonstrated expected loss of the outer retinal layers, typically seen in Vitamin A deficiency, but also severe and bilateral loss of the inner retinal layers. After Vitamin A supplementation, visual acuity, dark adaptation, and color vision normalized. The outer retinal layers had a restoration of the thickness after vitamin A supplementation but the inner layers did not change. This case is unique because it may give us an insight about the role of vitamin A on the inner retina and demonstrates the recovery of the outer retinal layers with vitamin A supplementation.

Increasing Rates of Herpes Zoster Ophthalmicus and the COVID-19 Pandemic.

Purpose: This epidemiologic study evaluates the variance in incidence of Herpes Zoster (HZ) and Herpes Zoster Ophthalmicus (HZO) within a single healthcare system with an aim to analyze their relationship to the COVID-19 pandemic. Methods: All patients attending the Duke University Health System (DUHS) from January 1, 2018, to December 31, 2021, were included. General and COVID-related trends of HZO and HZ were analyzed based on new ICD-9 or ICD-10 diagnosis codes, compared with the total number of patients seen at DUHS during this period, and the number of reported COVID-19 cases in North Carolina obtained using the CDC data tracker. Results: This study included 16,287 cases of HZ of whom 1,294 (7.94%) presented with HZO. The overall incidence of HZO showed an average yearly increase of 5.6%, however HZ incidence decreased by 5.3% per year. When comparing incidence rates of HZO in the 12-months before and after the COVID-19 pandemic onset in the United States (March 2020), the average incidence from March 2020 to February 2021 was 27.6 ± 11.6 compared to 18.0 ± 2.7 from March 2019 to February 2020 (p = 0.01). Moreover, 10/12 (83.3%) of the months had a higher incidence rate of HZO in the post-COVID onset year compared to their corresponding month in the pre-COVID year. Conclusion: The results show HZO incidence may be increasing, despite an overall lower HZ incidence. This could suggest a distinct mechanism for HZO appearance. The COVID pandemic, directly or indirectly, may have accelerated the already increasing HZO incidence.

Resident involvement in cataract surgery at the Veterans Health Administration: complications, case complexity, and the role of experience.

PURPOSE: To characterize intraoperative complications, case complexity, and changes in complication rates with surgical experience for cataract surgeries involving residents at the Veterans Health Administration (VHA). SETTING: All VHA facilities where cataract surgery was performed. DESIGN: Multicenter, retrospective cohort study. METHODS: A retrospective review of all cataract surgeries within the VHA between July 2010 and June 2021 was conducted. Several parameters, including resident involvement, intraoperative complications, and case complexity as determined by Current Procedural Terminology codes, and use of pupil expansion or capsular support devices, were collected. Complication rates were compared between residents and attendings. RESULTS: Of 392 428 cataract surgeries completed across 108 VHA facilities, 90 504 were performed by attendings alone, while 301 924 involved a resident. Of these, 10 244 (11.3%) of attending cases were complex compared with 32 446 (10.7%) of resident cases. Pupil expansion devices were required in 8191 of attending cases (9.05%) and 31 659 (10.5%) of cases involving residents ( P < .001). Similarly, cases involving residents were more likely than attending-only cases to require a capsular support device (0.835% vs 0.586%, P < .001). Cases involving residents were more likely to have posterior capsular rupture (4.75% vs 2.58%, P < .001) and dropped nucleus (0.338% vs 0.198%, P < .001). Higher resident case volumes were associated with significantly lower complication rates for posterior capsular rupture, dropped nucleus, zonular loss, and suprachoroidal hemorrhage. CONCLUSIONS: Although residents had higher intraoperative complication rates than attendings, these rates were reduced with surgical experience. Residents were involved in a similar number of complex surgical cases as attendings.

Younger Age and Longer Case Times Associated With Emergency Department Visits After Cataract Surgery.

PURPOSE: To characterize the frequency, reasons, hospital costs, and risk factors for emergency department (ED) visits within 30 days of cataract surgery. DESIGN: Retrospective cohort study. METHODS: A retrospective review of all cataract surgeries at Duke Health between 2013 and 2021 was conducted. Demographics, case characteristics (length, complexity by billing codes, anesthesia type), ED visit findings, and hospital costs were collected. Logistic regression models were used to determine the odds of ED visits based on several risk factors. RESULTS: Of 34 246 patients (57 656 eyes) undergoing cataract surgery at Duke Health from 2013 to 2021, a total of 607 patients (1.77%) had 680 ED visits within 30 days of surgery. The most common ED diagnosis was cardiovascular (24.4%), whereas ocular complaints constituted 15.4% of visits. The most common ocular diagnoses were high intraocular pressure, rebound iritis, and posterior vitreous detachment. Hospital costs were lowest for ocular diagnoses (mean $467.72) and highest for trauma diagnoses (mean $4660.55). Risk factors for ED visits included case lengths greater than 30 minutes (OR 2.1, 95% CI 1.56-2.83, P < .001), the combination of Monitored Anesthesia Care (MAC) and retrobulbar anesthesia or general anesthesia (OR 2.98, 95% CI 1.73-5.12, P < .001), and age less than 70 years (OR 1.39, 95% CI 1.16-1.65, P < .001). CONCLUSIONS: ED visits within 30 days of cataract surgery are uncommon. Longer case lengths, anesthesia other than MAC alone, and younger age are associated with higher odds of ED visits.

Photochemical Release of Hydropersulfides.

Hydropersulfides (RSSH) have received significant interest in the field of redox biology because of their intriguing biochemical properties. However, because RSSH are inherently unstable, their study is challenging, and as a result, the details of their physiological roles remain ill-defined. Herein, we report strategies to release RSSH utilizing photoremovable protecting groups. RSSH protection with the well-established p-hydroxyphenacyl (pHP) photoprotecting group resulted in inefficient RSSH photorelease along with complex chemistry. Therefore, an alternative precursor was examined in which a self-immolative linker was inserted between the pHP group and RSSH, providing nearly quantitative RSSH release following photolysis at 365 nm. Inspired by these results, we also synthesized an analogous precursor derivatized with 7-diethylaminocoumarin (DEACM), a visible light-cleavable photoprotecting group. Photolysis of this precursor at 420 nm led to efficient RSSH release, and in vitro experiments demonstrated intracellular RSSH delivery in breast cancer MCF-7 cells.

Peripheral Neurectomy With Customized Nerve Reconstruction for Periorbital Neuropathic Pain: Initial Experience and Clinical Outcomes.

PURPOSE: To describe a novel, minimally invasive surgical technique to treat severe, intractable periorbital neuropathic pain. METHODS: A retrospective analysis of patients with severe, treatment-refractory periorbital pain who underwent transection of affected sensory trigeminal branches with nerve repair was performed. Collected data included etiology and duration of neuropathic pain, comorbidities, prior treatment history, surgical technique including site of transected sensory nerves and type of nerve repair, preoperative and postoperative pain scores as well as follow-up duration. Differences between preoperative and postoperative values were analyzed by the Wilcoxon signed-rank test. RESULTS: A total of 5 patients with severe periorbital neuropathic pain underwent transection of affected supraorbital, supratrochlear, infratrochlear, infraorbital, zygomaticotemporal, and zygomaticofacial nerves with customized nerve reconstruction. All 5 had improvement of periorbital pain after surgery, with 3 (60%) noting complete resolution of pain and 2 (40%) experiencing partial pain relief over a median follow-up period of 9 months (interquartile range [IQR], 6-19 months). Of the 3 patients who had complete resolution of pain, all reported continued pain relief. Median McGill pain scores significantly decreased from 8.4 (IQR, 8.2-10.0) preoperatively to 0.0 (IQR, 0.0-4.8; p < 0.001) postoperatively. All patients reported satisfaction with the surgical procedure and stated that they would undergo the procedure again if given the option. One patient with history of postherpetic neuralgia (PHN) had reactivation of herpes zoster at postoperative month 3, which was self-limited, without worsening of her neuropathic pain. Another patient with PHN required a staged procedure to achieve complete pain relief. CONCLUSION: Peripheral neurectomy with customized reconstruction of involved sensory nerves can successfully reduce and even eradicate periorbital neuropathic pain that was previously recalcitrant to combination pharmacotherapy and prior neurolysis procedures.

Transition to a Night Float System in Ophthalmology Residency: Perceptions of Resident Wellness and Performance.

Purpose The purpose of this study is to characterize the influence of a new night float rotation on resident wellness and performance in the Duke University Eye Center Ophthalmology Residency Program. Methods We analyzed three classes of ophthalmology residents: one class ( n = 4) utilized the new night float rotation with no daytime clinical duties, while two senior classes ( n = 12) utilized the traditional call system wherein they had daytime and nighttime responsibilities. Residents completed a questionnaire regarding their perceptions of the night float rotation. Supervising attendings ( n = 15) were also surveyed about their perceptions of the new rotation. Results Zero of the four residents on the night float rotation reported burnout compared with 6 of 11 residents in the traditional call system. Most residents supported the adoption of the night float rotation, but this trend was less apparent among fellows and attendings. Most respondents believed the new night float rotation reduced burnout, fatigue, and work hours while increasing time for nonclinical activities. Perceived skills gained while on call were felt to be similar between the two call systems. Fellows and attendings believed residents in the night float system performed similarly or better than residents in the traditional system in indicators such as knowledge and enthusiasm. There was no significant difference in the average number of patient encounters (290.8 ± 30.5 vs. 310.7 ± 25.4, p = 0.163), phone encounters (430.8 ± 20.2 vs. 357.1 ± 90.0, p = 0.068), or average hours worked per week (57.3 ± 4.6 vs. 58.0 ± 5.7 p = 0.797) per resident between night float residents and traditional call residents. Conclusions This study shows resident support for a night float rotation in ophthalmology residency at Duke, with reductions in burnout and more time for nonclinical activities without affecting perceived clinical performance. We hope this study serves as an impetus for other ophthalmology programs considering a transition to a night float system.

Learning From the 2021 Ophthalmology Match: Virtual Residency Matching During the COVID-19 Pandemic.

Background: The effect of virtual interviews on residency match outcomes during the COVID-19 pandemic is unknown. Examining the ophthalmology match may help inform all specialties undergoing virtual interviews. Objective: To determine the impact of allopathic applicant match characteristics in the first year of the virtual residency Match process. Methods: Using the Association of University Professors of Ophthalmology match database, a retrospective review was conducted of all allopathic applicants to ophthalmology residency programs in the United States from the 2016 through the 2021 match cycles. Demographic information, interview numbers, and match outcomes were compared between the 2016-2020 (in-person) and 2021 (virtual) cycles. Results: A total of 3343 allopathic applicants were analyzed. Applicants in the 2021 Match applied to significantly more programs than 2016-2020 applicants did (78.7±23.6 vs 73.1±22.7, P<.001). Among matched and unmatched applicants, there was no significant difference in the number of interviews granted or completed. There was a significant reduction in the match rate between the 2016-2020 and 2021 Match cycles (81.3% vs 76.6%, P=.0009). A subanalysis of applicants who went to medical schools with ophthalmology residency programs (N=2308) found that the home institution match rate was significantly higher for the 2021 Match compared to the aggregate 2016-2020 Matches (26.1% vs 20.6%, respectively, P=.015). Conclusions: Significantly more applicants to ophthalmology residency programs matched at their home institutions in the 2021 virtual match cycle compared to the previous 5 years without influencing the interview numbers granted and attended.

Development of Hydropersulfide Donors to Study Their Chemical Biology.

Significance: Hydropersulfides (RSSH) are ubiquitous in prokaryotes, eukaryotic cells, and mammalian tissues. The unique chemical properties and prevalent nature of these species suggest a crucial role of RSSH in cell regulatory processes, yet little is known about their physiological functions. Recent Advances: Examining the biological roles of RSSH species is challenging because of their inherent instability. In recent years, researchers have developed a number of small-molecule donors that efficiently release RSSH in response to various stimuli, including pH, thiols, reactive oxygen species, enzymes, and light. These RSSH donors have provided researchers with chemical tools to uncover the potential function and role of RSSH as physiological signaling and/or protecting agents. Critical Issues: Because RSSH, hydrogen sulfide (H2S), and higher order polysulfides are related to each other and can be present simultaneously in biological systems, distinguishing among the activities due to each of these species is difficult. Discerning this activity is critical to elucidate the chemical biology and physiology of RSSH. Moreover, although RSSH donors have been shown to confer cytoprotection against oxidative and electrophilic stress, their biological targets remain to be elucidated. Future Directions: The development of RSSH donors with optimal drug-like properties and selectivity toward specific tissues/pathologies represents a promising approach. Further investigation of releasing efficiencies in vivo and a clear understanding of RSSH biological responses remain targets for future investigation. Antioxid. Redox Signal. 36, 309-326.

Alkylsulfenyl thiocarbonates: precursors to hydropersulfides potently attenuate oxidative stress.

The recent discovery of the prevalence of hydropersulfides (RSSH) species in biological systems suggests their potential roles in cell regulatory processes. However, the reactive and transient nature of RSSH makes their study difficult, and dependent on the use of donor molecules. Herein, we report alkylsulfenyl thiocarbonates as a new class of RSSH precursors that efficiently release RSSH under physiologically relevant conditions. RSSH release kinetics from these precursors are tunable through electronic modification of the thiocarbonate carbonyl group's electrophilicity. In addition, these precursors also react with thiols to release RSSH with a minor amount of carbonyl sulfide (COS). Importantly, RSSH generation by these precursors protects against oxidative stress in H9c2 cardiac myoblasts. Furthermore, we demonstrate the ability of these precursors to increase intracellular RSSH levels.

Comparison of Intraocular Pressure, Usage of Topical Steroids, Need for Intraocular Pressure Lowering Drops, and Incidence of Glaucoma Surgery Up to 2 Years After Penetrating Keratoplasty and Endothelial Keratoplasty.

PRECIS: A retrospective review of 239 eyes comparing intraocular pressure (IOP), steroid needs, IOP-lowering drop needs, and incidence of glaucoma surgery between endothelial keratoplasty and penetrating keratoplasties (PKP) at multiple timepoints postoperatively up to 2 years. PURPOSE: The purpose of this study was to compare postoperative IOP, steroid use, IOP-lowering drop use, and need for glaucoma surgery between PKP, Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSEK). MATERIALS AND METHODS: A retrospective chart review of all PKP, DMEK, and DSEK surgeries was performed between July 1, 2012 and July 1, 2017 at the University of California, Irvine. Patients with a prior history of glaucoma, corneal or glaucoma surgery, concurrent major or emergent surgery, active infection, and eye disease with synechiae were excluded. A total of 239 patients who underwent PKP (N=127), DMEK (N=46), or DSEK (N=66) were included. IOP, steroid use, IOP-lowering drop use, and need for glaucoma surgery were compared at postoperative day 1, postoperative week 1 (POW1), and postoperative month 1 to 24 (POM1-24). RESULTS: IOP for PKP was higher than DMEK and DSEK at POW1, POM1, POM6, and POM24 (P<0.05). IOP for PKP was higher than DMEK at POM12 (P=0.028). There was no significant difference in IOP between DMEK and DSEK for all timepoints. PKP required more steroids than DSEK and DMEK at POM3, POM6, POM12, and POM24 (P<0.05). More IOP-lowering drops were required for DSEK than DMEK and PKP at postoperative day 1 and POW1 (P<0.05). More IOP-lowering medications were used for DSEK than DMEK at POM3 and POM12 (P<0.05). About 6% to 7% of patients needed glaucoma surgery by POM24. CONCLUSIONS: Endothelial keratoplasties had decreased IOP and steroid needs compared with PKPs postoperatively up to 2 years. The rate of glaucoma surgery and IOP-lowering drop needs were similar between the groups.

Complicated case of Mycobacterium abscessus conjunctivitis in Sjögren's syndrome.

PURPOSE: To report a case of conjunctivitis due to Mycobacterium abscessus in the setting of keratoconjunctivitis sicca due to Sjögren's syndrome in the absence of other known risk factors such as surgery, trauma or immunosuppressive therapy. OBSERVATIONS: A 61-year-old woman with a history of keratoconjunctivitis sicca secondary to Sjögren's syndrome presented with dryness, irritation, redness, and discharge in her left eye for 2 months. She was diagnosed with chronic conjunctivitis and began a regimen of moxifloxacin and an ocular ointment of dexamethasone, neomycin, and polymyxin with no improvement of symptoms. Concurrent cultures grew Mycobacterium abscessus and the patient began treatment with amikacin drops, oral clarithromycin and intravenous imipenem, followed by amikacin drops, oral clarithromycin, and oral clofazimine, but her course was complicated by a perforated corneal ulcer that required a corneal patch graft. The patient eventually recovered despite persistent colonization. CONCLUSIONS/IMPORTANCE: We present a case of Mycobacterium abscessus conjunctivitis in a patient with keratoconjunctivitis sicca secondary to Sjögren's syndrome without previous history of surgery, trauma, or other known risk factors. Because of low suspicion and clinician awareness, ocular nontuberculous mycobacteria (NTM) infection may have a delayed diagnosis and treatment. Clinicians should consider NTM in the differential diagnosis in patients with autoimmune disease such as Sjögren's syndrome. Treatment may be lengthy, requiring topical and systemic antibiotics and is often complicated due to resistance.

Prevalence of Retinal Diseases and Associated Risk Factors in an African Population From Mwanza, Tanzania.

BACKGROUND AND OBJECTIVE: To determine the prevalence of retinal disease among a population in Mwanza, Tanzania, and to identify relevant risk factors for retinal disorders in this cohort. PATIENTS AND METHODS: A cross-sectional population-based study was conducted in Mwanza, Tanzania, among patients older than 18 years. Participants completed a demographics survey and underwent an ophthalmic examination that included fundus photography. RESULTS: Complete data were available for 1,007 (93.8%) of the 1,073 persons examined. The prevalence of vitreoretinal disorders was 22.8% (230/1,007). The leading retinal diseases were age-related macular degeneration (7.0%), hypertensive retinopathy (4.5%), and macular scars (2.7%). CONCLUSION: This study is the first population-based study of retinal disease in Mwanza. The findings reveal a considerable burden of retinal disease in this region, suggesting a need for trained local ophthalmic personnel and resources. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:S17-S25.].

Visual acuity after cataract surgery in patients with optic neuropathies.

PURPOSE: To compare visual acuity outcomes of cataract surgery between patients with and without non-glaucomatous optic neuropathies. METHODS: Retrospective case-control study of patients with and without optic neuropathies who underwent cataract surgery from 2010 to 2017. For all eyes, the last preoperative best corrected visual acuity (BCVA) and first BCVA greater than 1 month postoperatively (to ensure sustained refractive stabilization) were recorded in logarithm of the minimum angle of resolution (logMAR) units. RESULTS: Thirty patients (42 eyes) with optic neuropathies and 30 control patients (42 eyes) underwent uncomplicated cataract surgery. The mean age at surgery was significantly younger in the optic neuropathy group (64 versus 71.2 years, p < 0.01). The mean improvement in visual acuity in the optic neuropathy group was 0.4 ± 0.6 logMAR units (roughly 4 Snellen lines) from 0.7 ± 0.8 units preoperatively to 0.3 ± 0.5 postoperatively. Between the cases and controls, there was no significant difference in preoperative BCVA (p = 0.48), postoperative BCVA (p = 0.42), or the mean improvement in BCVA (p = 0.82). When stratified by optic neuropathy subtype, patients with optic neuropathies secondary to multiple sclerosis (n = 12) or non-arteritic ischaemic optic neuropathy (n = 11) had significant improvement in BCVA postoperatively (p < 0.01 and p = 0.03, respectively). CONCLUSION: Contrary to what may be expected from such a severe ocular comorbidity, our data suggest that the mean BCVA improvement after cataract surgery in patients with non-glaucomatous optic neuropathies was comparable to that of control patients. Cataract surgery may be performed in patients with both optic neuropathies and advanced cataracts with a reasonable preoperative expectation that visual acuity improvement can be significant.

Long-Term Results of Femtosecond Laser-Enabled Keratoplasty With Zig-Zag Trephination.

PURPOSE: To report long-term visual and astigmatism outcomes in cases of zig-zag femtosecond laser-enabled penetrating keratoplasty (FLEK). METHODS: Retrospective review. Three hundred thirty-five eyes of 287 patients underwent (FLEK) with a zig-zag incision pattern. Patients were assessed preoperatively and underwent postoperative comprehensive examinations at standard intervals of 1, 3, 6, 9, and 12 months, and 6 months thereafter. Postoperative uncorrected distance visual acuity and spectacle-corrected distance visual acuity and manifest and topographical (Mrx cyl and Topo cyl) astigmatism were compared with preoperative values. RESULTS: Three hundred thirty-five eyes received FLEK with zig-zag configuration. Data are presented for the last recorded visit before any refractive procedure. Sutures were removed in 202 of 335 eyes at an average time to removal of 1.3 ± 1.1 years, and a mean follow-up period of 2.9 ± 2.1 years (range 0-10 years). After full suture removal, mean uncorrected distance visual acuity and spectacle-corrected distance visual acuity were logarithm of the minimum angle of resolution 0.84 (Snellen 20/138) ± 0.55 and 0.33 (Snellen 20/42) ± 0.33, respectively. Mean Mrx cyl and Topo cyl of these groups were 3.38 ± 2.22 and 4.77 ± 3.15, respectively. Of the total number of grafts, the rate of graft rejections was 14.0%, and the failure rate was 5.6%. CONCLUSIONS: The femtosecond laser-generated zig-zag-shaped incision results in lower manifest and topographical astigmatism than the reported average for conventional penetrating keratoplasty. Graft rejection and failure rates are similar to published data for conventional penetrating keratoplasty.

Penetrating Keratoplasty Using the Femtosecond Laser: A Comparison of Postoperative Visual Acuity and Astigmatism by Suture Pattern.

PURPOSE: To compare the effect of 3 common suturing techniques on eyes that received femtosecond laser-enabled penetrating keratoplasty (FLEK) with a zig-zag configuration at the Gavin Herbert Eye Institute, University of California- Irvine, California. METHODS: This is a retrospective chart review of a series of 319 eyes of 286 patients who underwent FLEK with a zig-zag configuration. One hundred fifty-seven eyes had running sutures, 136 eyes had simple interrupted sutures, and 26 eyes had combined sutures (single running and simple interrupted). The main outcome measures were uncorrected distance visual acuity, best spectacle-corrected visual acuity (BSCVA), and topographic astigmatism (TCyl). These parameters were recorded for the first year of follow-up regardless of suture removal status and also after full suture removal. RESULTS: At 3 months, the BSCVA of the running, interrupted, and combined suture groups was 0.22 (±0.2), 0.41 (±0.3), and 0.29 (±0.1), respectively (P < 0.01). The mean TCyl of the running, interrupted, and combined groups at 3 months was 3.95 (±2.7), 6.41 (±4.4), and 5.44 (±3.3) D, respectively (P < 0.01) All sutures were removed in 190 of 319 eyes, and at the last recorded visit, the mean BSCVA was 0.18 (±0.2), 0.34 (±0.2), and 0.19 (±0.2) logarithm of the minimum angle of resolution in the running, interrupted, and combined groups, respectively (P < 0.01) and mean TCyl was 4.51 (±2.8), 5.62 (±3.7), and 4.57 (±2.9) D, respectively (P = 0.11). CONCLUSIONS: Better visual acuity after full suture removal was observed in the running suture group; however, the subgroups of patients with keratoconus were similar after all sutures were removed.