Chorioretinal Findings as the Initial Presentation of Chronic Granulomatous Disease.

To describe a case of chronic granulomatous disease (CGD) with ocular lesions as the presenting findings. An ocular examination of a 4-month-old male infant with poor vision revealed punched-out macular and perivascular chorioretinal fibrosis and atrophy with peripheral retinal nonperfusion. Subsequently, he was hospitalized for recurrent infections and was diagnosed with CGD. Repeated examination demonstrated enlargement of the chorioretinal lesions without evidence of active inflammation or neovascularization. CGD causes recurrent, severe, life-threatening infections in children and should be considered in the differential diagnosis of chorioretinal lesions with peripheral retinal nonperfusion. [Ophthalmic Surg Lasers Imaging Retina. 2022;53(4):234-238.].

Comparing a Home Vision Self-Assessment Test to Office-Based Snellen Visual Acuity.

PURPOSE: To evaluate the agreement of a home vision screening test compared to standard in-office technician-measured Snellen visual acuity to allow for remote screening and triaging of patients. PATIENTS AND METHODS: In this prospective study, English-speaking patients with in-office ophthalmology appointments from May to August 2020 and visual acuity better than 20/125 were asked to complete a home vision test one week before their scheduled in-office appointment. The home vision test was a modified ETDRS chart displayed in a PDF document that could be printed or viewed on a monitor. The primary outcome was the mean difference between office-based and home visual acuity. RESULTS: Eighty-two eyes of 45 patients were included in the study with 45 study eyes analyzed. The mean difference between office-based and home visual acuity was -0.02 logMAR (SD 0.15, P=0.28) among study eyes. Of these eyes, 91% demonstrated agreement between the two methods within 0.2 logMAR of the mean difference, and 60% had agreement within 0.1 logMAR of the mean difference. There were no significant demographic or ocular risk factors leading to a greater difference between the tests. CONCLUSION: There was good agreement between the home and in-office Snellen tests for patients with vision better than 20/125. The home vision test can be used to remotely determine if there is a significant vision change of >0.2 logMAR or approximately 2 lines of visual acuity.

Resident-performed immediate sequential bilateral cataract surgery during the COVID-19 pandemic.

Purpose: To assess visual outcomes and patient satisfaction for senior resident-performed immediate sequential bilateral cataract surgery (ISBCS) versus delayed sequential bilateral cataract surgery (DSBCS) during the COVID-19 pandemic, when minimizing healthcare-related exposures for patients and providers are paramount. Methods: This was a pilot retrospective cohort study of all ISBCS and DSBCS patients who underwent senior resident-performed cataract surgery from May to September 2020 at a single academic institution. Outcome measures were final corrected distance visual acuity (CDVA), final manifest refraction (MRx), intraoperative and postoperative complications rates, total number of visits, and patient satisfaction assessed postoperatively by telephone questionnaire. Results: Twenty-two eyes of 14 patients and 56 eyes of 28 patients underwent senior resident-performed ISBCS and DSBCS, respectively. Final CDVA was 20/25 or better in 21 (95%) ISBCS and 51 (91%) DSBCS eyes (P = 0.670). Deviation of final MRx from target refraction was within 0.50 D in 17 (77%) ISBCS and 47 (84%) DSBCS eyes (P = 0.522). There was no significant difference in intraoperative (P = 1.000) or postoperative (P = 1.000) complications. ISBCS patients averaged 3.5 fewer visits than DSBCS patients (5.9 vs 9.5, P < 0.001). All ISBCS and 20 DSBCS patients (87%) reported they were "very satisfied" or "satisfied" with their experience (P = 0.701). Five of six senior residents responded that they preferred performing ISBCS over DSBCS. Conclusion: This early experience suggests that senior resident-performed ISBCS is as safe and effective as DSBCS, with the added benefit of averaging fewer in-person visits. Residency programs should consider offering senior resident-performed ISBCS to select patients during the COVID-19 pandemic.

Clinical Outcomes of Micropulse Laser Trabeculoplasty Compared to Selective Laser Trabeculoplasty at One Year in Open-Angle Glaucoma.

BACKGROUND: There is limited long-term data comparing selective laser trabeculoplasty (SLT) to the newer micropulse laser trabeculoplasty (MLT) using a laser emitting at 532 nm. In this study, we determine the effectiveness and safety of MLT compared to SLT. DESIGN: Retrospective comparative cohort study. PARTICIPANTS: A total of 85 consecutive eyes received SLT and 43 consecutive eyes received MLT. METHODS: Patients with open-angle glaucoma receiving their first treatment of laser trabeculoplasty were included. Exclusion criteria are prior laser trabeculoplasty, laser cyclophotocoagulation or glaucoma surgery, and follow-up of less than 1 year. MAIN OUTCOME MEASURES: The primary outcome was success at 1 year, defined as a reduction in intraocular eye pressure (IOP) by ≥20% from baseline or met prespecified target IOP with no additional glaucoma medication or subsequent glaucoma intervention. RESULTS: Baseline IOP was 18.0 mmHg (95% CI=16.4-19.5) in the MLT group on an average of 1.8 (95% CI=1.4-2.2) glaucoma medications compared to 18.2 mmHg (95% CI=17.2-19.3) for the SLT group on an average of 2.0 (95% CI=1.6-2.3) medications. At 1-hour post-laser, the SLT group had more transient IOP spikes (MLT 5% vs SLT 16%, P=0.10). There was a trend toward increased success in the SLT group compared to MLT at 1 year (relative risk=1.4, 95% CI=0.8-2.5, P=0.30). CONCLUSION AND RELEVANCE: Eyes had similar success after MLT compared to SLT at 1 year. Laser trabeculoplasty with either method could be offered as treatment with consideration of MLT in those eyes where IOP spikes should be avoided.

Ophthalmic Microsurgery Lab for Medical Students: Enhancing Learner Intrinsic Motivation and Comfort with Microsurgery.

Objective This study aimed to evaluate the impact of an ophthalmic microsurgery laboratory on medical students' intrinsic motivation, explicit interest in ophthalmology, and comfort with microsurgical skills. Design In this noncontrolled trial, medical students attended a Zoom-based lecture on corneal suturing, watched an instructional video on operating microscopes, and attended a wet laboratory on corneal suturing. Participants completed pre- and posttest surveys assessing comfort with microsurgical skills and explicit interest in ophthalmology. Additionally, the posttest survey included items from the Intrinsic Motivation Inventory (IMI). Setting This study was conducted at a single academic medical center. Participants A total of 20 students enrolled in the MD program at the University of California, San Francisco School of Medicine. Results Pre- and posttest response rates were 100% ( n = 20) and 90% ( n = 18), respectively. Comfort with microsurgical skills increased significantly between pre- and posttest surveys with large effect sizes (95% confidence interval [CI]; p -value): loading a needle, 1.67 (1.04-2.29; p < 0.001); passing a suture, 1.72 (1.04-2.40; p < 0.001); knot tying, 1.05 (0.34-1.76; p = 0.004); using a microscope, 0.83 (0.04-1.63; p = 0.040); and suturing under a microscope, 1.44 (0.88-2.00; p < 0.001). Comparing pre- and posttest surveys, students reporting moderate to extreme interest in ophthalmology increased from 44 to 61%. Intrinsic motivation was high, indicated by the mean IMI Interest score reaching 93% of the maximum score. Multiple linear regression analyses predicted that IMI Interest scores increased with higher scores of familiarity ( p = 0.002), explicit interest in ophthalmology ( p = 0.042), and comfort with microscopes ( p = 0.005), knot tying ( p = 0.026), and performing surgical maneuvers under a microscope ( p = 0.032). Conclusion Ophthalmic microsurgery laboratories may increase medical students' explicit interest in ophthalmology, comfort with microsurgical skills, and intrinsic motivation. Future studies are needed to evaluate the impact of microsurgical electives on students' objective skills and specialty selection.

Characteristics of cataract surgery patients influencing patient satisfaction scores.

PURPOSE: To determine factors that influence patient satisfaction scores in individuals who have recently had cataract surgery. SETTING: Byers Eye Institute, Palo Alto, California, USA. DESIGN: Prospective case series. METHODS: Selected questions from the Press Ganey survey and the National Eye Institute Visual Function Questionnaire-25 were administered to each patient immediately after completion of a clinic visit. The correlation between patient-specific variables and the answer to the survey question "likelihood of recommending our practice to others," a surrogate for overall patient satisfaction, was assessed using the Student t test. A logistical regression model was used to adjust for potentially confounding variables. RESULTS: One hundred forty-three patients were recruited from 4 providers; 57 (39.8%) were men, and the mean age was 70.0 years ± 11.6 (SD). The main outcome was the proportion of scores less than 5, or "very good," for the likelihood of recommending the practice to others. There was a statistically significant association between a non-5 patient satisfaction score and self-reported ethnicity of Asian or Pacific Islander compared with other ethnicities (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.0-5.1; P = .049); other possible correlates were not statistically significant. The relationship persisted after adjustment for potential confounding variables (OR, 2.6; 95% CI, 1.1-6.3; P = .027). CONCLUSION: In postoperative cataract patients, Asian or Pacific Islander ethnicity, a factor out of the control of the provider and clinic staff, was associated with a lower overall Press Ganey patient satisfaction score compared with patients of all other ethnicities.

A Spectrum of Regression Following Intravitreal Bevacizumab in Retinopathy of Prematurity.

PURPOSE: To describe an improved understanding of the regression patterns following off-label intravitreal bevacizumab (IVB) treatment for retinopathy of prematurity (ROP). DESIGN: Retrospective cohort study. METHODS: All infants treated with IVB for type 1 ROP at a single institution from June 2013 to March 2018 were retrospectively reviewed and the amount of retinal nonperfusion on fluorescein angiogram was calculated. RESULTS: In the 92 eyes of 46 patients analyzed, only 3 eyes (3.3%) reached full vascular maturity. Of the 89 eyes not reaching maturity, 39 eyes (43.8%) had vascular arrest alone (VAA), 34 eyes (38.2%) had vascular arrest with persistent tortuosity (VAT), and 16 eyes (18.0%) had ROP reactivation. Those eyes that reactivated were more likely to be initially classified as having aggressive posterior ROP (P = .004) and of Asian ethnicity (P = .008). There were greater areas of ischemia in eyes with reactivation as compared to VAT and VAA (112.1 mm2 vs 72.5 mm2 vs 56.6 mm2, respectively, P = .007). Younger gestational age at birth was found to be an independent predictor of persistent tortuosity (VAT vs VAA) in a logistic regression model. CONCLUSIONS: Incomplete vascularization following IVB is very common and is associated with a younger gestational age at birth, Asian ethnicity, and aggressive posterior ROP. The presence of tortuosity following IVB may be indicative of persistently elevated vascular endothelial growth factor levels and an early indicator of potential reactivation.

A novel classification of high myopia into anterior and posterior pathologic subtypes.

PURPOSE: High myopia and pathologic myopia are common causes of visual morbidity. Myopic pathology can affect all regions of the retina, though there is currently no classification system to distinguish anterior (peripheral) and posterior (macular) pathology. We hypothesize that these classifications are characterized by distinct demographic and refractive features, highlighting the disparity in types of pathologic myopia. METHODS: Institutional retrospective cohort study. The Stanford University Medical Center Clinical Data Warehouse was used to identify patients with high myopia by ICD-9 and ICD-10 codes. Predetermined ICD diagnoses were then used to classify patients with high myopia into isolated high myopia (IHM), anterior pathologic myopia (APM), posterior pathologic myopia (PPM), and combined pathologic myopia (CPM). A cohort of this population was then manually reviewed to gather refractive data and confirm accuracy of ICD coding. RESULTS: Patients (3274) were identified with high myopia. Overall, 22.1% individuals met criteria for APM, 10.7% for PPM, 17.0% for CPM, and 50.2% for IHM. We identified a significantly higher frequency of females with PPM compared to APM (62.3 vs. 48.3%; OR, 1.73; 95% CI, 1.34 to 2.25), Asian patients with PPM as compared to APM (42.9 vs. 33.3%; OR, 1.50; 95% CI, 1.16 to 1.95), and younger patients with APM compared to PPM (median 45.3 vs. 63.4 years). The refractive error was significantly more myopic in the CPM (median - 9.8D; interquartile range, IQR 6.7) and PPM (median - 10.5D; IQR 9.8) subgroups as compared to the APM (median - 8.1D; IQR 3.5), and IHM (median - 8.2D; IQR 4.1) subgroups (p = 0.003). CONCLUSIONS: High myopia may be divided into four distinct subgroups based on presence and location of pathology, which is associated with differences in age, gender, race, and refractive error.

Disseminated silicone granulomatosis in the face and orbit.

PURPOSE: To report a case of disseminated silicone granulomatosis presenting with ptosis, proptosis and vision loss. OBSERVATIONS: A 56-year-old female presented with ptosis, proptosis, and vision loss and was noted to have palpable, erythematous masses involving the orbit, face, trunk, and body. She had a history of bilateral silicone breast implants and cosmetic facial filler injections. Orbital biopsy demonstrated non-caseating granulomas with foreign-body giant cells and vacuoles containing material consistent with silicone. Removal of the patient's breast implants and systemic immunosuppression led to dramatic granuloma regression. CONCLUSIONS: Silicone can induce a severe, systemic inflammatory response and should be considered in the differential for facial and periorbital granulomas in patients with a history of silicone breast implants. Management of disseminated silicone granulomatosis is challenging and requires multimodal treatment with silicone removal and systemic immunomodulation.

Outcomes of Intravitreal Bevacizumab and Diode Laser Photocoagulation for Treatment-Warranted Retinopathy of Prematurity.

BACKGROUND AND OBJECTIVE: To investigate the outcomes of infants with treatment-warranted retinopathy of prematurity (TW-ROP) who received intravitreal bevacizumab (Avastin; Genentech, South San Francisco, CA) (IVB) injections as compared to diode laser photocoagulation (DLP). PATIENTS AND METHODS: Data from the Stanford University Network for Diagnosis of Retinopathy of Prematurity database and inpatients at Stanford Children's Hospital were retrospectively reviewed for premature newborns with TW-ROP treated with DLP or 0.625 mg of IVB. Patient characteristics, hospital course, and neurodevelopmental outcomes were compared. RESULTS: In all, 49 eyes from 25 patients were included; 10 infants (20 eyes) received DLP and 15 infants (29 eyes) received IVB. The IVB infants had significantly fewer diagnoses at the time of discharge and fewer readmissions after initial hospital discharge than the DLP infants (four versus six diagnoses, P = .004; zero versus one readmission, P = .038). At an average of 20 months corrected age, there was no significant difference in neurodevelopmental delay (adjusted odds ratio = 0.87; 95% CI, 0.08-9.46). CONCLUSION: Systemic morbidity may be similar among infants treated initially with bevacizumab compared to DLP. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:126-131.].

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.

The Epidemiology of Retinopathy of Prematurity in the United States.

BACKGROUND AND OBJECTIVE: Retinopathy of prematurity (ROP) is a leading cause of blindness in premature and low birth weight infants. Here, the authors examine the incidence of ROP in the United States and evaluate risk factors associated with ROP development. PATIENTS AND METHODS: The National Healthcare Cost and Utilization Project Kids' Inpatient Database was queried for all newborns with and without ROP. Adjusted odds ratios were constructed for predictors of ROP using multivariate logistic regression modeling. RESULTS: The incidence of ROP increased from 14.70% in 2000 to 19.88% in 2012. Multivariate regression analysis indicated that female gender, birth weight, and gestational age predicted ROP. The frequency of ROP was 2.40% in newborns weighing more than 2,500 grams (g) and 30.22% in newborns with a birth weight between 750 g and 999 g. CONCLUSIONS: The authors' report examines a nationwide cohort of ROP infants and reveals an increase in the incidence of ROP from 2000 to 2012. This trend is inversely related to a simultaneous decline in newborn mortality. [ Ophthalmic Surg Lasers Imaging Retina . 2017;48:553-562.].

Porcine Collagen Transconjunctival Wound Closure System for Microincisional Vitrectomy Surgery.

BACKGROUND AND OBJECTIVE: Microincisional vitrectomy surgery has improved outcomes for vitrectomies; however, wound closure complications remain an important concern. The authors introduce a technique to improve transconjunctival wound closure in vitrectomy surgery. PATIENTS AND METHODS: The authors evaluated the efficacy of porcine collagen plugs on stopping leakage from sclerotomy test sites in vitro and in vivo and assessed wound site healing with histology samples. RESULTS: The porcine collagen plugs successfully prevented leakage of trypan blue dye in enucleated rabbit eyes and of fluid flow in the rabbit model. Histology showed excellent wound reconstruction and healing, with essentially no inflammation for either angled or straight incisions with a 23-gauge system. CONCLUSIONS: The authors describe a simple and effective novel approach to wound closure in any-gauge vitrectomy surgery using porcine collagen plugs. This method can help reduce complications related to wound leakage. The authors plan to conduct human studies to demonstrate the safety of the approach in the future. [ Ophthalmic Surg Lasers Imaging Retina. 2017;48:576-579.].

Should We Excise Native Breast Skin Envelope to Achieve Symmetric Scars in Bilateral Autologous Breast Reconstruction?--A Survey of Surgeon and Patient Preference.

BACKGROUND: Given the multiple possible scar patterns in autologous breast reconstruction and combinations of such patterns in bilateral reconstruction, the present study aimed to determine the importance of scar symmetry in achieving aesthetically pleasing results. METHODS: A survey was administered to 128 participants including plastic surgeons and female breast reconstruction patients. In part A of the survey, participants were provided with photos of bilateral autologous breast reconstructions, and scar placement was varied to represent bilateral (1) immediate, (2) delayed symmetric, (3) delayed asymmetric, and (4) a mixture of immediate and delayed free flap reconstructions. Participants were asked to rank the photos in order of best to worst aesthetic outcome. In part B, pairs of the same reconstruction before and after nipple-areolar complex (NAC) reconstruction were presented, and participants were asked to assign a score to each photo according to aesthetic outcome. RESULTS: In part A, immediate reconstructions that included the smallest flap skin paddles ranked best among 52.5% ± 30% of participants, followed by delayed symmetric reconstructions that ranked best in 46.7% ± 29.6%. Mixed reconstructions ranked worst among 53.6% ± 37.6% of participants, followed by delayed asymmetric reconstructions (42.5% ± 37.9%). When NAC reconstruction was added to 1 set of the photos in part A, the same immediate reconstruction was ranked best, a significantly higher proportion of the time (36.3% increase, P < 0.001). This was accompanied by a significant decrease in top ranking for the delayed symmetric reconstruction (37.9% decrease, P < 0.001). In part B, addition of NAC increased each reconstruction's score by an average of 1.36 points on a 5-point scale with patients citing less improvement between the conditions (0.93 ± 0.03) than plastic surgeons (1.13 ± 0.49) (P = 0.03). CONCLUSIONS: More symmetric breast scars led to higher aesthetic ranking of bilateral autologous breast reconstructions. Participants in our survey preferred symmetric scars, even if achieving such a scar pattern would require excision of native breast skin and inclusion of more flap skin. Furthermore, NAC reconstruction alone improves aesthetic outcome, and improvement was most notable among immediate reconstructions.

Clinical outcomes in breast cancer expander-implant reconstructive patients with radiation therapy.

Immediate expander-implant breast reconstruction (EIBR) with external beam radiation therapy (XRT) is pursued by many breast cancer patients; however, there is still a lack of consensus on the expected clinical outcomes. We performed a critical analysis of postoperative outcomes in EIBR patients with XRT exposure through a retrospective review from January 2007 to December 2013. Patients were stratified into three groups: exposure to preoperative XRT (XRT-pre), postoperative XRT (XRT-post), or no XRT (control). A subset of XRT patients with bilateral EIBR was assessed using a matched-pair analysis with the patients serving as their own controls. A total of 76 patients were included in the study. Major complications were observed in 6 of 8, 26 of 38, and 14 of 30 patients in the XRT-pre, XRT-post, and control groups, respectively, and were not statistically different (p > 0.05). EIBR failure rates were 13.3% in the control group compared to 50.0% in the XRT-pre group (p = 0.044) and 26.3% in the XRT-post group (p > 0.05). In the matched-pair analysis, 16 of 26 irradiated breasts developed complications compared to only 7 of 26 contralateral non-irradiated breasts (p = 0.043). In conclusion, we detected a significantly increased risk of complications in patients with pre-mastectomy radiotherapy. Patients with this history of XRT should strongly consider autologous reconstruction instead of EIBR to avoid the high risk of developing complications and subsequently losing their implant. Increased complications in irradiated breasts when compared to the contralateral non-irradiated breasts in bilateral EIBR patients confirmed the detrimental role of XRT in the setting of EIBR.

Nkx2-1 represses a latent gastric differentiation program in lung adenocarcinoma.

Tissue-specific differentiation programs become dysregulated during cancer evolution. The transcription factor Nkx2-1 is a master regulator of pulmonary differentiation that is downregulated in poorly differentiated lung adenocarcinoma. Here we use conditional murine genetics to determine how the identity of lung epithelial cells changes upon loss of their master cell-fate regulator. Nkx2-1 deletion in normal and neoplastic lungs causes not only loss of pulmonary identity but also conversion to a gastric lineage. Nkx2-1 is likely to maintain pulmonary identity by recruiting transcription factors Foxa1 and Foxa2 to lung-specific loci, thus preventing them from binding gastrointestinal targets. Nkx2-1-negative murine lung tumors mimic mucinous human lung adenocarcinomas, which express gastric markers. Loss of the gastrointestinal transcription factor Hnf4α leads to derepression of the embryonal proto-oncogene Hmga2 in Nkx2-1-negative tumors. These observations suggest that loss of both active and latent differentiation programs is required for tumors to reach a primitive, poorly differentiated state.