Appropriate patient population for future visual system axon regeneration therapies.

A number of blinding diseases caused by damage to the optic nerve result in progressive vision loss or loss of visual acuity. Secondary glaucoma results from traumatic injuries, pseudoexfoliation or pigmentary dispersion syndrome. Progressive peripheral vision loss is common to all secondary glaucoma irrespective of the initial event. Axon regeneration is a potential therapeutic avenue to restore lost vision in these patients. In contrast to the usual approach of having the worst possible patient population for initial therapies, axon regeneration may require consideration of appropriate patient population even for initial treatment trials. The current state of axon regeneration therapies, their potential future and suitable patient population when ready is discussed in this perspective. The selection of patients are important for adoption of axon regeneration specifically in the areas of central nervous system regenerative medicine. This article is categorized under: Neurological Diseases > Molecular and Cellular Physiology Neurological Diseases > Biomedical Engineering Metabolic Diseases > Molecular and Cellular Physiology.

Performance of Generative Large Language Models on Ophthalmology Board-Style Questions.

PURPOSE: To investigate the ability of generative artificial intelligence models to answer ophthalmology board-style questions. DESIGN: Experimental study. METHODS: This study evaluated 3 large language models (LLMs) with chat interfaces, Bing Chat (Microsoft) and ChatGPT 3.5 and 4.0 (OpenAI), using 250 questions from the Basic Science and Clinical Science Self-Assessment Program. Although ChatGPT is trained on information last updated in 2021, Bing Chat incorporates a more recently indexed internet search to generate its answers. Performance was compared with human respondents. Questions were categorized by complexity and patient care phase, and instances of information fabrication or nonlogical reasoning were documented. MAIN OUTCOME MEASURES: Primary outcome was response accuracy. Secondary outcomes were performance in question subcategories and hallucination frequency. RESULTS: Human respondents had an average accuracy of 72.2%. ChatGPT-3.5 scored the lowest (58.8%), whereas ChatGPT-4.0 (71.6%) and Bing Chat (71.2%) performed comparably. ChatGPT-4.0 excelled in workup-type questions (odds ratio [OR], 3.89, 95% CI, 1.19-14.73, P = .03) compared with diagnostic questions, but struggled with image interpretation (OR, 0.14, 95% CI, 0.05-0.33, P < .01) when compared with single-step reasoning questions. Against single-step questions, Bing Chat also faced difficulties with image interpretation (OR, 0.18, 95% CI, 0.08-0.44, P < .01) and multi-step reasoning (OR, 0.30, 95% CI, 0.11-0.84, P = .02). ChatGPT-3.5 had the highest rate of hallucinations and nonlogical reasoning (42.4%), followed by ChatGPT-4.0 (18.0%) and Bing Chat (25.6%). CONCLUSIONS: LLMs (particularly ChatGPT-4.0 and Bing Chat) can perform similarly with human respondents answering questions from the Basic Science and Clinical Science Self-Assessment Program. The frequency of hallucinations and nonlogical reasoning suggests room for improvement in the performance of conversational agents in the medical domain.

The Importance of Health Literacy in Addressing Eye Health and Eye Care Disparities.

Disparities in eye health and eye care frequently result from a lack of understanding of ocular diseases and limited use of ophthalmic health services by various populations. The purpose of this article is to describe the principle of health literacy and its central role in enhancing health, and how its absence can result in poorer health outcomes. The article evaluates the current status of health literacy in visual health and disparities that exist among populations. It also explores ways to improve health literacy as a means of reducing disparities in visual health and eye care. Advancing dissemination of health information and enhancing health literacy may help not only to reduce healthcare barriers in the underserved populations but also to lessen visual health disparities.

Squamoid Eccrine Ductal Carcinoma of the Eyelid: Clinicopathologic Correlation of a Case.

Squamoid eccrine ductal carcinoma (SEDC) is a rare cutaneous neoplasm that often manifests as a plaque or nodule in sun-exposed areas of older patients. Herein, the authors report the first case of SEDC in the eyelid. A 76-year-old man presented with a 2.5 × 1.5 mm area of left upper eyelid erythema, thickening, ulceration, and scaling with madarosis superotemporally just above the lash line. Full-thickness wedge biopsy demonstrated irregular epithelial tubules with nuclear atypia and focal squamous differentiation, consistent with SEDC. The patient underwent Mohs resection and has had no recurrence approximately 27 months after surgical removal. The authors present this case to raise awareness of SEDC to ophthalmologists as all previous cases have been described in the nonophthalmic literature. A full-thickness biopsy is recommended to avoid misdiagnosing SEDC as squamous cell carcinoma (SCC), a less aggressive tumor. With greater awareness, there may be increased recognition of this likely underreported, more malignant entity.

Lateral Tarsal Strip Complications With and Without Conjunctiva Stripping.

PURPOSE: The lateral tarsal strip (LTS) procedure is commonly used to correct eyelid malposition. When performing LTS, some surgeons elect to remove conjunctiva from the tarsal strip, while others do not. It has been hypothesized that without conjunctival stripping, the buried conjunctival tissue can cause complications such as inclusion cysts and granulomas. However, there is limited data comparing LTS cases with and without conjunctiva removal. The authors sought to evaluate whether conjunctival stripping had any impact on complication rates with LTS. METHODS: LTS operations for ectropion correction were retrospectively reviewed and were separated into 2 cohorts, Con (conjunctiva not removed) or Coff (conjunctival removed). Charts were reviewed for outcomes and complications including inclusion cyst formation, granuloma formation, wound dehiscence, infection, and focal rim tenderness. RESULTS: The complication rate was 10% versus 8% for Con versus Coff respectively ( p = 0.54). The common complications of LTS surgery were granuloma (4%), wound dehiscence (3%), focal rim tenderness (3%), and infection requiring antibiotics (<1%). There was no significant difference in these complications between the Con and Coff cohorts. CONCLUSIONS: Complications in both groups were minimal, similar to prior studies, and there was no difference between the 2 cohorts. While it has been suggested that buried conjunctiva may result in increased complication rates, the author's findings suggest that removing the tarsal conjunctiva is a superfluous step in the LTS surgery and does not affect complication rates.

Primary evisceration for neonatal endogenous endophthalmitis: A report of two cases.

PURPOSE: To present two cases of neonatal endophthalmitis with poor prognosis that were managed with primary evisceration. OBSERVATIONS: Case 1 is a 27-weeks' gestation neonate who developed Pseudomonas aeruginosa endophthalmitis complicated by globe rupture. Case 2 describes a 34-weeks' gestation neonate with Serratia marcescens endophthalmitis. Both patients had poor prognosis and thus underwent primary evisceration with good long-term cosmetic outcomes at 15 years and 17 months, respectively. CONCLUSIONS AND IMPORTANCE: Primary evisceration should be considered in neonates with endophthalmitis with a poor prognosis and can result in good long-term cosmesis.

Thyroid eye disease with choroidal folds.

Purpose: To determine the clinical course of patients with chorioretinal folds (CRF) in thyroid eye disease (TED).Methods: A multi-center retrospective case series of patients with TED who developed CRF.Results: Ten patients (17 eyes) with CRF related to TED were identified. The mean age of presentation was 59.3 ± 8.3 years old. The majority of patients were male (70%), hyperthyroid (70%), hyperopic (53%), had a history of radioactive iodine (60%), and currently on methimazole treatment (30%). Three patients (3 eyes) had unilateral involvement of CRF with bilateral TED. The average clinical activity score was 3.6 ± 2.1 at the time of presentation. The most commonly enlarged extraocular muscles were medial (76%), inferior (64%), superior (64%) and lateral rectus (35%). Compressive optic neuropathy was seen in 47% of eyes. Treatment included oral prednisone (70%), orbital decompression (59%), thyroidectomy (20%) and tocilizumab (10%). The CRF did not resolve over a follow up period of 24.7 ± 23.7 months in 70% of eyes. There was no significant difference in average axial length (25.7 ± 4.9 mm) and optic nerve to optic strut distance (37.8 ± 3.9 mm) between patients with CRF and the eight age-and sex-matched TED control patients without CRF (p = 0.81 and 0.65 respectively). A univariable and multivariable analysis found an enlarged inferior rectus as a factor in TED patients with persistent CRF.Conclusions: CRF are often an indicator of visually threatening situations and often do not resolve despite treatment of TED.

Vaso-occlusive Infarction of the Lateral Orbital Wall With Ipsilateral Temporalis Muscle Ischemia.

An 18-month-old boy with sickle cell disease developed progressive left periorbital edema and temporalis fullness. Imaging revealed two inferotemporal subperiosteal fluid collections and adjacent temporalis muscle thickening. After undergoing an anterior orbitotomy with drainage and biopsy, the patient was diagnosed as having a vaso-occlusive sickle cell crisis involving the lateral orbit. [J Pediatr Ophthalmol Strabismus. 2020;57:e78-e81.].

Evaluating the Effectiveness of Small-Group Training in Teaching Medical Students Integral Clinical Eye Examination Skills.

OBJECTIVE: The aim of this study is to evaluate the effectiveness of an interactive, small-group ophthalmology clinical training session by assessing medical students' self-confidence with eye examination skills and long-term retention of direct ophthalmoscopy skills. METHODS: The second-year medical students participated in a one-time small-group clinical training session that taught essential components of the eye examination. Students reported their confidence with each component in pre- and postsession surveys. Eight months later, direct ophthalmoscopy skills were reassessed by having students visualize the optic nerves of standardized patients and identify the matching optic nerve photograph in a multiple-choice quiz. RESULTS: Among 197 second-year medical students who participated in the training session, 172 students completed the presession survey (87.3% response rate) and 108 students completed the postsession survey (54.8% response rate). Following the training session, students reported increased self-confidence (p < 0.01) overall. A total of 107 (107/108; 99.1%) students reported that they visualized the optic nerve head, and 80 out of 85 (94.1%) students stated that they preferred the PanOptic ophthalmoscope over the traditional direct ophthalmoscope. Students reported greater self-confidence using the PanOptic ophthalmoscope (p < 0.01). In the 8-month follow-up assessment, 42 medical students (42/197; 21.3%) completed the exercise. A total of 41 (41/42; 97.6%) students stated that they saw the optic nerve with the PanOptic ophthalmoscope; 24 (24/42; 57.1%) students identified the correct optic nerve image using the PanOptic ophthalmoscope on a standardized patient; 14 (14/42; 33.3%) students stated that they saw the optic nerve with the traditional direct ophthalmoscope; and 4 (4/42; 9.1%) students from the same cohort identified the correct optic nerve image with the traditional direct ophthalmoscope on a standardized patient. CONCLUSION: Our comprehensive, one-time eye examination skills training session seeks to prepare students to incorporate these skills in future patient care. Students' overall confidence improved in each aspect of the eye examination that was covered. A follow-up assessment on students' direct ophthalmoscopy skills suggests that the PanOptic ophthalmoscope allows for superior skills retention as compared with the traditional direct ophthalmoscope. We believe that the PanOptic ophthalmoscope should be further integrated into medical education and clinical practice.

Etiologies of Proptosis: A review.

Proptosis, the protrusion of the eyeball from the orbit, results from a wide variety of pathologies that can be vision- or life-threatening. Clinical history, associated physical exam findings, and imaging features are all crucial in establishing the underlying etiology. The differential diagnosis is broad, and includes infectious, inflammatory, vascular, and neoplastic entities that range from benign and indolent, to malignant and aggressive. While treatment varies significantly based on the disease process, all are aimed at preserving vision, salvaging the globe, preventing disfigurement, and reducing mortality. Both internists and general ophthalmologists should be familiar with the causes of proptosis in order to initiate the work-up for, and appropriately triage, affected patients.

Microcornea, posterior megalolenticonus, persistent fetal vasculature, chorioretinal coloboma (MPPC) syndrome: Case series post vitrectomy.

PURPOSE: MPPC syndrome has been described as a syndrome that presents with chorioretinal coloboma, posterior megalolenticonus, persistent fetal vasculature, and chorioretinal coloboma. The purpose of our study is to report three patients who present with a variation of MPPC syndrome who each underwent pars plana vitrectomy, pars plana lensectomy, and amblyopic management. Clinical characteristics, ancillary test findings, and post-surgical functional results are compared to what is reported in the literature. METHODS: Retrospective review of medical records of patients who presented with microcornea, persistent fetal vasculature, chorioretinal coloboma, and microphthalmia who underwent surgical correction at Bascom Palmer Eye Institute. RESULTS: 3 patients (6 eyes) were included, two males and one female. All patients were born full term, vaginally, and had no family history of genetic abnormalities affecting the eye. All patients had color fundus images, fluorescein angiography (FA) and echography. Four eyes underwent surgery. Following surgical intervention, patients demonstrated improved visual acuity, and improved functional status. CONCLUSION AND IMPORTANCE: Patients with microcornea, PFV, chorioretinal coloboma, and microphthalmos, can benefit from surgical intervention when functional decline or media opacities are noted. Though difficult to assess accurate visual acuity and visual improvement pre-operatively and post-operatively, it is evident that our patients demonstrated improvement in functionality and vision following surgical intervention.

Multi-drug resistant Mycobacterium chelonae scleral buckle infection.

PURPOSE: To describe a case of Multi-drug resistant Mycobacterium chelonae scleral buckle infection. OBSERVATIONS: A 56 year-old male with history of retinal detachment repair with scleral buckle 20 years prior presented with 8 months of intermittent pain and redness in the left eye. The patient was diagnosed with scleral buckle infection, the buckle was removed, and cultures revealed multi-drug resistant Mycobacterium chelonae. The postoperative course included orbital cellulitis treated with systemic linezolid, clarithromycin, and imipenem. All systemic antibiotics were discontinued on post-operative day 25, visual acuity improved to 20/25, the retina remained attached, and no recurrence occurred over 3 years of follow-up. CONCLUSIONS AND IMPORTANCE: NTM infections are typically chronic and often require lengthy treatment. SB infection is rare, but often associated with biofilm and antibiotic resistance. In spite of removing the SB, anchoring sutures, sheath surrounding the buckle and associated biofilm, a prolonged course of systemic antibiotics may be necessary in some patients.

Bioengineered dermal substitutes for the management of traumatic periocular tissue loss.

PURPOSE: Traumatic periocular injuries occasionally result in significant soft tissue loss, for which there are limited management options that provide satisfactory cosmetic and functional outcomes. The authors describe the use of a bioengineered dermal substitute (Integra® Dermal Regeneration Template [DRT], Integra LifeSciences, Plainsboro, NJ) as an alternative to immediate flap reconstruction or skin grafting. METHODS: Retrospective interventional case series of patients who underwent DRT placement for periocular tissue loss at the time of trauma. In each case, primary closure or immediate flap reconstruction was deemed impractical or undesirable due to the size and location of the primary and associated secondary defects. One to four weeks later, the outer silicone layer was removed and healing assessed. Additional reconstructive techniques were performed as needed. RESULTS: Three patients were treated at Bascom Palmer Eye Institute and one at Byers Eye Institute at Stanford. The defects healed completely in two patients, and by 79.2% in a third, with no need for additional reconstructive surgery. In the remaining patient, the defect was significantly downsized by 56.1%, allowing for a simpler flap reconstruction. CONCLUSIONS: Bioengineered dermal substitutes should be considered as a viable alternative to traditional reconstructive techniques for large periocular defects resulting from trauma. The outer silicone layer prevents desiccation and serves as a protective barrier, while the inner collagen matrix organizes the growth of neo-dermis and minimizes wound contraction. The dimensions of cutaneous defects can therefore be reduced dramatically, potentially eliminating the need for skin grafting and/or reducing the ultimate complexity of flap reconstruction.

Gene Expression Profiling and Heterogeneity of Nonspecific Orbital Inflammation Affecting the Lacrimal Gland.

Importance: Although a variety of well-characterized diseases, such as sarcoidosis and granulomatosis with polyangiitis, affect the lacrimal gland, many patients with dacryoadenitis are diagnosed as having nonspecific orbital inflammation (NSOI) on the basis of histology and systemic disease evaluation. The ability to further classify the disease in these patients should facilitate selection of effective therapies. Objective: To test the a priori hypothesis that gene expression profiles would complement clinical and histopathologic evaluations in identifying well-characterized diseases and in subdividing NSOI into clinically relevant groups. Design, Setting, and Participants: In this cohort study, gene expression levels in biopsy specimens of inflamed and control lacrimal glands were measured with microarrays. Stained sections of the same biopsy specimens were used for evaluation of histopathology. Tissue samples of patients were obtained from oculoplastic surgeons at 7 international centers representing 4 countries (United States, Saudi Arabia, Canada, and Taiwan). Gene expression analysis was done at Oregon Health & Science University. Participants were 48 patients, including 3 with granulomatosis with polyangiitis, 28 with NSOI, 7 with sarcoidosis, 4 with thyroid eye disease, and 6 healthy controls. The study dates were March 2012 to April 2017. Main Outcomes and Measures: The primary outcome was subdivision of biopsy specimens based on gene expression of a published list of approximately 40 differentially expressed transcripts in blood, lacrimal gland, and orbital adipose tissue from patients with sarcoidosis. Stained sections were evaluated for inflammation (none, mild, moderate, or marked), granulomas, nodules, or fibrosis by 2 independent ocular pathologists masked to the clinical diagnosis. Results: Among 48 patients (mean [SD] age, 41.6 [19.0] years; 32 [67%] female), the mclust algorithm segregated the biopsy specimens into 4 subsets, with the differences illustrated by a heat map and multidimensional scaling plots. Most of the sarcoidosis biopsy specimens were in subset 1, which had the highest granuloma score. Three NSOI biopsy specimens in subset 1 had no apparent granulomas. Thirty-two percent (9 of 28) of the NSOI biopsy specimens could not be distinguished from biopsy specimens of healthy controls in subset 4, while other examples of NSOI tended to group with gene expression resembling granulomatosis with polyangiitis or thyroid eye disease. The 4 subsets could also be partially differentiated by their fibrosis, granulomas, and inflammation pathology scores but not their lymphoid nodule scores. Conclusions and Relevance: Gene expression profiling discloses clear heterogeneity among patients with lacrimal inflammatory disease. Comparison of the expression profiles suggests that a subset of patients with nonspecific dacryoadenitis might have a limited form of sarcoidosis, while other patients with NSOI cannot be distinguished from healthy controls.

Split face evaluation of long-pulsed non-ablative 1,064 nm Nd:YAG laser for treatment of direct browplasty scars.

PURPOSE: To investigate 1,064 nm long-pulse Nd:YAG laser for postoperative treatment of direct browplasty scars. METHODS: Nine patients who underwent direct browplasty were enrolled in this prospective study. Subjects were randomized to unilateral laser treatment at 2-week intervals for six total treatments, with the contralateral scar used as a control. Prior to each treatment, subjects rated treated and control scars on overall cosmesis. Post-treatment, subjects rated each for erythema, swelling, discomfort, and perceived hair loss. Finally, examiners masked to treatment side were asked to judge side-by-side photographs of first and final visits for improvement and side effects. RESULTS: Subjects rated the overall appearance of the treated scar significantly higher at the time of treatment number 5 (mean score 5.13 ± 2.03, P = 0.008) and treatment number 6 (6.25 ± 1.98, P = 0.005) compared to treatment 1 (3.75 ± 2.12); by contrast, they failed to rate the control scar more highly. On masked examination of photographs, the treated scar was selected as most improved 50.0 ± 12.5% of the time. Both subjects and graders reported side effects as transient and mild to moderate (mean score 1-4), with no reports of hair loss from either subjects or observers. CONCLUSIONS: The 1,064 nm Nd:YAG laser provided significant improvement in scar cosmesis after direct browplasty, as rated by subject self-report, but not by masked observers, and appears to be a useful tool for increasing satisfaction among those dissatisfied with direct browplasty scars. Side effects-including erythema, edema, and discomfort-were transient and universally rated as mild to moderate. Lasers Surg. Med. 48:742-747, 2016. © 2016 Wiley Periodicals, Inc.

Impact of Eyelid Laxity on Symptoms and Signs of Dry Eye Disease.

PURPOSE: To study the relationship between eyelid laxity and ocular symptoms and signs of dry eye (DE). METHODS: A total of 138 patients with normal external anatomy were prospectively recruited from a Veterans Administration hospital. Symptoms (via the Dry Eye Questionnaire 5 and Ocular Surface Disease Index) and signs of DE were assessed along with presence or absence of eyelid laxity. RESULTS: It was observed that 71% of participants (n = 98) had clinical evidence of eyelid laxity (upper and/or lower) compared with 29% (n = 40) with no eyelid laxity. Individuals with eyelid laxity were older (67 ± 10 vs. 55 ± 8 years without laxity, P < 0.005) and more frequently male (76% of males had laxity vs. 18% females, P < 0.005). Patients with eyelid laxity had increased symptoms and signs of DE compared with their counterparts without laxity including ocular pain described as grittiness (63% vs. 45%, P = 0.049), decreased tear break-up time (8.6 ± 3 vs. 10.3 ± 4 seconds, P = 0.02), increased corneal staining (2.5 ± 3 vs. 1 ± 2, P = 0.002), decreased Schirmer score (14±6 vs. 17±7 mm, P = 0.01), increased meibomian gland drop out (2 ± 1 vs. 0.8 ± 0.8, P < 0.005), increased eyelid vascularity (0.8 ± 0.8 vs. 0.2 ± 0.5, P < 0.005), and more abnormal meibum quality (2 ± 1.3 vs. 1.4 ± 1.2, P = 0.02). In a multivariable analysis considering both signs of DE and laxity, lower eyelid laxity remained significantly associated with ocular surface disease index scores, suggesting a direct effect of laxity on symptoms of DE. CONCLUSIONS: The presence of eyelid laxity associates with abnormal tear parameters compared with the absence of eyelid laxity. Based on these data, it is important for clinicians to test for eyelid laxity in patients with symptoms and/or signs of DE.

Purtscher-Like Retinopathy and Diffuse Alveolar Hemorrhage Caused by Soft Tissue Injection for Gluteal Augmentation.

PURPOSE: To describe a rare occurrence of acute vision loss and diffuse alveolar hemorrhage following a treatment of injectable gluteal cosmetic filler. PATIENT AND METHODS: A 20-year-old female underwent a cosmetic injection of unknown components for gluteal augmentation. Within hours she developed progressive shortness of breath secondary to diffuse alveolar hemorrhage. She presented to ophthalmology 6 weeks later with a history of bilateral decreased vision. Clinical examination revealed cotton wool spots and retinal hemorrhages. Fluorescein angiography demonstrated macular vascular pruning and an enlarged foveal avascular zone. RESULTS: The patient was observed and vision did not improve after 8 months of follow-up. CONCLUSION: These findings were attributed to a Purtscher-like retinopathy secondary to systemic inflammation induced by the filler and/or direct microembolization of the injected material or fat. To the best of the authors' knowledge, this is the first documented case of diffuse alveolar hemorrhage and ischemic bilateral vision loss in a patient undergoing gluteal augmentation with dermal filler.