Native heart valve thrombosis associated with COVID-19 - a report of 4 cases.

Native heart valve thrombosis (NHVT) is a rare valvular pathology, usually associated with prothrombotic state or disturbed intracardiac blood flow related to structural valve abnormalities. While different venous and arterial thromboembolic complications of COVID-19 have been widely described, so far NHVT has not been reported in the context of the disease. The authors describe 4 cases of NHVT associated with COVID-19, revealed on aortic, mitral (2 patients) and tricuspid valve. In a 29-yearold male with mild pneumonia, large thrombus developed on bicuspid aortic valve (BAV), which resulted in fatal brain emboli. In a 76-yearold male with a history of rheumatoid arthritis (RA) being in a recovery period after COVID-19, central retinal artery occlusion (CRAO) was the first sign of mitral valve thrombus, which disappeared after 3 weeks, during apixaban use. Such therapy was also successful in a 46-yearold female with multiple cardiovascular risk factors in whom mitral valve thrombus was found in a routine echocardiography after she got COVID-19 the third time. In a 75-year-old man with moderate COVID-19 pneumonia and bacterial coinfection, coexistent transient focal LV dysfunction and tricuspid valve thrombus were observed. The patient was treated with apixaban as well; however, in this case only reduction in the thrombus size was seen after 4 months therapy. The authors indicate that in patients with COVID-19 and NHVT, other prothrombotic conditions can usually be found. This complication may involve different valves and occur irrespective of COVID-19 severity. Interdisciplinary evaluation of such patients is necessary.

Variability of Grading DR Screening Images among Non-Trained Retina Specialists.

Poland has never had a widespread diabetic retinopathy (DR) screening program and subsequently has no purpose-trained graders and no established grader training scheme. Herein, we compare the performance and variability of three retinal specialists with no additional DR grading training in assessing images from 335 real-life screening encounters and contrast their performance against IDx-DR, a US Food and Drug Administration (FDA) approved DR screening suite. A total of 1501 fundus images from 670 eyes were assessed by each grader with a final grade on a per-eye level. Unanimous agreement between all graders was achieved for 385 eyes, and 110 patients, out of which 98% had a final grade of no DR. Thirty-six patients had final grades higher than mild DR, out of which only two had no grader disagreements regarding severity. A total of 28 eyes underwent adjudication due to complete grader disagreement. Four patients had discordant grades ranging from no DR to severe DR between the human graders and IDx-DR. Retina specialists achieved kappa scores of 0.52, 0.78, and 0.61. Retina specialists had relatively high grader variability and only a modest concordance with IDx-DR results. Focused training and verification are recommended for any potential DR graders before assessing DR screening images.

Bradycardia during optical timolol therapy: its delayed remission after timolol discontinuation and unexpected further relapse.

Optical betablockers (BBs), including nonselective BB timolol, are commonly used for the management of primary open angle glaucoma and ocular hypertension. About 80% of topically administered timolol is systemically absorbed, which can rarely induce such complications as bradycardia, bronchospasm and depression. A CASE REPORT: The authors describe a case of a 67-year-old female referred because of significant bradycardia and a suggestion of pacemaker implantation. She had no cardiovascular history besides hyperlipidemia and mild hyperglycemia, so her previous treatment was focused on glaucoma due to which she had been using optical timolol for several years. Moreover, she suffered from depression which was treated with venlafaxine and sertraline. Over a few months, she started feeling weak and dizzy. Her daily heart rate (HR) markedly decreased to 40-45/min. 24-hour ECG monitoring revealed multiple episodes of nodal rhythm and of sinoatrial block and the lowest HR of 33/min; bradycardia defined as HR less than 45/min constituted over 40% of the time recorded. Close observation with repeated 24-hour ECG monitoring after timolol discontinuation showed lasting several-daylong gradual bradycardia remission; after 2, 9, 16 and 23 days, bradycardia constituted 19.9%, 13.9%, 0.2% and 0% of the time recorded, respectively. Genetic testing of cytochrome P450 2D6 revealed the presence of the c.506 -1G>A variant with one non-functional allele (CYP2D6 *4/-) which might have slowed down timolol metabolism in the context of simultaneous antidepressants use, so venlafaxine and sertraline were reduced. However, during follow-up, incremental bradycardia relapse, suggestive of an underlying sinus node dysfunction, was observed.

Image registration of the human accommodating eye demonstrates equivalent increases in lens equatorial radius and central thickness.

AIM: To compare the results of in vivo human high resolution image registration studies of the eye during accommodation to the predictions of mathematical and finite element models of accommodation. METHODS: Data from published high quality image registration studies of pilocarpine induced accommodative changes of equatorial lens radius (ELR) and central lens thickness (CLT) were statistically analyzed. RESULTS: The mean changes in ELR and CLT were 6.76 µm/diopter and 6.51 µm/diopter, respectively. The linear regressions, reflecting the association between ELR and accommodative amplitude (AAELR) was: slope=6.58 µm/diopter, r2 =0.98, P<0.0001 and between CLT and AACLT was: slope=6.75 µm/diopter, r2 =0.83, P<0.001. On the basis of these relationships, the CLT slope and the AAELR were used to predict the measured change in ELR (ELRpredicted). There was no statistical difference between ELRpredicted and the measured ELR as demonstrated by a Student's paired t-test: P=0.96 and linear regression analysis: slope=0.97, r2 =0.98, P<0.00001. CONCLUSION: Image registration with invariant positional references demonstrates that ELR and CLT equivalently minimally increase ∼7.0 µm/diopter during accommodation. The small equivalent increases in ELR and CLT are associated with a large accommodative amplitude. These findings are consistent with the predictions of mathematical and finite element models that specified the stiffness of the lens nucleus is the same or greater than the lens cortex and that accommodation involves a small force (<5 g).

Identification of Retinal Biomarkers in Alzheimer's Disease Using Optical Coherence Tomography: Recent Insights, Challenges, and Opportunities.

This review will highlight recent insights into measuring retinal structure in Alzheimer's disease (AD). A growing body of evidence indicates that disturbances in retinal blood flow and structure are related to cognitive function, which can severely impair vision. Optical coherence tomography (OCT) is an optical imaging technology that may allow researchers and physicians to gain deeper insights into retinal morphology and clarify the impact of AD on retinal health and function. Direct and noninvasive measurement of retinal morphology using OCT has provided useful diagnostic and therapeutic indications in several central nervous system (CNS) diseases, including AD, multiple sclerosis, and Parkinson disease. Despite several limitations, morphology assessment in the retinal layers is a significant advancement in the understanding of ocular diseases. Nevertheless, additional studies are required to validate the use of OCT in AD and its complications in the eye.

Cardiovascular risk factors in patients with combined central retinal vein occlusion and cilioretinal artery occlusion: Case report.

RATIONALE: To analyze cardiovascular risk factors and comorbidity of acute unilateral visual loss due to combined central retinal vein occlusion (CRVO) and cilioretinal artery occlusion (CLRAO). PATIENT CONCERNS: Among patients with retinal vein or artery occlusion hospitalized at the Department of Ophthalmology between January 2011 and August 2017, subjects with combined CRVO/CLRAO were selected. All of them underwent ophthalmologic and cardiologic examination, including fluorescein angiography, optical coherence tomography, 12-lead electrocardiogram, transthoracic and transesophageal echocardiography, carotid Doppler sonography, cerebral magnetic resonance imaging, and a panel of laboratory tests. DIAGNOSES: Four subjects with coexisting CRVO and CLRAO were found among 146 patients with retinal vein or artery occlusion. There were no other types of concomitance of CRVO and retinal artery occlusion. INTERVENTIONS: All patients were treated with low molecular heparin in a full dose for 2 weeks, then with 1 mg/kg once daily for the next 2 weeks, followed by acetylsalicylic acid 75 mg/kg/d. Other medication included long-term statins, angiotensin-converting-enzyme inhibitor in 3 patients and beta-blocker in one patient. OUTCOMES: All patients with CRVO/CLRAO presented multiple cardiovascular risk factors, including hypertension, obesity, hyperlipidemia, chronic nicotine addiction, and a positive family history of coronary artery disease or stroke. In all of them, echocardiography revealed left ventricular hypertrophy and atherosclerotic lesions in the descending aorta; in addition, 3 patients had insignificant atherosclerotic plaques in the carotid artery. Also, in 3 subjects, focal ischemic cerebral changes were diagnosed. LESSONS: Patients with combined CRVO and CLRAO present numerous cardiovascular risk factors and abnormalities on imaging examinations, which should be routinely evaluated and treated.

Maximum human objectively measured pharmacologically stimulated accommodative amplitude.

PURPOSE: To measure the maximum, objectively measured, accommodative amplitude, produced by pharmacologic stimulation. METHODS: Thirty-seven healthy subjects were enrolled, with a mean age of 20.2±1.1 years, corrected visual acuity of 20/20, and mean spherical equivalent refraction (SER) =-0.83±1.60 diopters. For each subject, the right pupil was dilated with phenylephrine 10%. After 30 minutes, the pupil was measured, the left eye was patched, and the right eye was autorefracted. Pilocarpine 4% was then instilled in the right eye, followed by phenylephrine. At 45 minutes after the pilocarpine, autorefraction and pupil size were again measured. RESULTS: Mean pupil size pre- and postpilocarpine was 8.0±0.8 mm and 4.4±1.9 mm, respectively. Pre- and postpilocarpine, the mean SER was -0.83±1.60 and -10.55±4.26 diopters, respectively. The mean pilocarpine-induced accommodative amplitude was 9.73±3.64 diopters. Five subjects had accommodative amplitudes ≥14.00 diopters. Accommodative amplitude was not significantly related to baseline SER (p-value =0.24), pre- or postpilocarpine pupil size (p-values =0.13 and 0.74), or change in pupil size (p-value =0.37). Iris color did not statistically significantly affect accommodative amplitude (p-value =0.83). CONCLUSION: Following topically applied pilocarpine, the induced objectively measured accommodation in the young eye is greater than or equal to the reported subjectively measured voluntary maximum accommodative amplitude.

Mechanism of accommodation assessed by change in precisely registered ocular images associated with concurrent change in auto-refraction.

PURPOSE: Our purpose was to determine the changes in anterior chamber depth (ACD) and central lens thickness (CLT) during pharmacologically induced accommodation. METHODS: Following pupillary dilation with phenylephrine 10%, baseline auto-refractions and swept-source optical coherence tomographic biometric images (Zeiss IOLMaster 700) were obtained from the right eyes of 25 subjects aged 19 to 24 years. Pilocarpine 4% and phenylephrine 10% were then instilled into these right eyes. One hour later, auto-refractions and biometric imaging were repeated. Only data from eight of 25 subjects met the following stringent criteria to be included in the study analysis: pre and post-pilocarpine biometric foveal images were registerable, the images of the corneal centers were shifted by ≤100 µm, pupils >5 mm and the pharmacologically induced refractive change was ≥ -7 diopters. RESULTS: The mean auto-refractive accommodative change for the eight included subjects was -12.45 diopters (± 3.45 diopters). The mean change in CLT was 81 µm (± 54 µm) and the mean change in ACD was -145 µm (± 86 µm). Superimposition of the registered pre and post-pilocarpine biometric images of the sagittal sections of the whole eye from each subject demonstrated that the position of the whole lens did not shift either anteriorly, posteriorly or vertically during pharmacologically induced accommodation. CONCLUSIONS: A small increase in lens thickness was associated with a large change in accommodative amplitude and no significant change in lens position as predicted by the Schachar theory.

[Current view on chloroquine derivative treatment from rheumatologist perspective and possible ocular side effects]. / Wspólczesne spojrzenie na leczenie pochodnymi chlorochiny z perspektywy reumatologa a mozliwe powiklania okulistyczne.

Anti-malarial drugs specifically hydroxychloroquine (HCQ) or chloroquine (CQ) are very effective in treating and preventing the symptoms of systemic lupus erythematosus and other connective tissue diseases. These medications have shown to improve joint and muscle pain and arthritis, skin rashes, fatique, fever and also to control systemic signs of lupus as pericarditis or pleuritis. Shortterm and long-term treatment reduce cholesterol and have anti-platelet effect with decreasing risk of cardiovascular disease. The lupus patients on anti-malarials have also lower risk of cumulative organ damage due to reduce the amount of steroids. They may help to decrease lupus flares, mortality and are the key to controlling lupus long term outcome. Some lupus patients should be on anti-malarials for the rest of their life. For this reason, the key question is weather these drugs are absolutely safe and can be long term used in all lupus patients as a background therapy? Potential non-specific side effects occur very rare and are usually minor and last for short period. The major concerns are retinal deposits damage which could be potential reversible especially during hydroxychloroquine treatment. Nevertheless, ophthalmologist examination is still needed before starting to take HCQ or CQ and at to follow-up visits every 6-12 months. In conclusion it seems that anti-malarials are safe and have more clinical benefits than risks and from rheumatologist point of view should be more widely use in all lupus patients.

Perioperative endophthalmitis prevention in cataract surgery in Mazovia and Greater Poland in 2013 and 2014. / [Profilaktyka okolooperacyjna w chirurgii zacmy w województwach mazowieckim i wielkopolskim w latach 2013 i 2014].

Aim: This is the first overview of practice patterns in endophthalmitis prevention after cataract surgery in Poland. Material and methods: The study is based on a survey carried out in 33 centres performing cataract surgery in two provinces of Poland (a total of 8.8 million inhabitants, i.e. 23% of the entire country population). Approximately 39.000 cataract surgery procedures are performed in these regions annually, i.e. 20% of all cataract surgery procedures in Poland. The questionnaire-based survey focused on the following aspects: duration of preoperative antibiotic treatment, type of antiseptics, intraoperative administration of antibiotics and duration of postoperative antibiotic treatment. Results: All surveyed centres use povidone-iodine as antiseptic on the periocular skin and conjunctival sac, and perioperative topical antibiotics are adopted by most. Intracameral cefuroxime is increasingly used in endophthalmitis prevention. Conclusion: The methods of endophthalmitis prevention vary widely between ophthalmology departments and clinics in Poland, there is no scientific rationale for most preventive measures used and a further debate is needed among Polish ophthalmic surgeons on optimal practice patterns.