Diagnostic Role of Oral Fluorescein Angiography in Pediatric Ambulatory Clinics.

Oral ingestion of fluorescein can be done in ambulatory pediatric clinics. We show that oral ultra-widefield fluorescein angiography is a non-invasive approach to rapidly diagnose and manage a diverse set of pediatric retinal vascular diseases.

Immunology of Retinitis Pigmentosa and Gene Therapy-Associated Uveitis.

The underlying immune state of inherited retinal degenerations (IRDs) and retinitis pigmentosa (RP) has been an emerging area of interest, wherein the consequences have never been greater given the widespread recognition of gene therapy-associated uveitis (GTU) in gene therapy clinical trials. Whereas some evidence suggests that the adaptive immune system may play a role, the majority of studies indicate that the innate immune system is likely the primary driver of neuroinflammation in RP. During retinal degeneration, discrete mechanisms activate resident microglia and promote infiltrating macrophages that can either be protective or detrimental to photoreceptor cell death. This persistent stimulation of innate immunity, overlaid by the introduction of viral antigens as part of gene therapy, has the potential to trigger a complex microglia/macrophage-driven proinflammatory state. A better understanding of the immune pathophysiology in IRD and GTU will be necessary to improve the success of developing novel treatments for IRDs.

Familial co-segregation and the emerging role of long-read sequencing to re-classify variants of uncertain significance in inherited retinal diseases.

Phasing genetic variants is essential in determining those that are potentially disease-causing. In autosomal recessive inherited retinal diseases (IRDs), reclassification of variants of uncertain significance (VUS) can provide a genetic diagnosis in indeterminate compound heterozygote cases. We report four cases in which familial co-segregation demonstrated a VUS resided in trans to a known pathogenic variant, which in concert with other supporting criteria, led to the reclassification of the VUS to likely pathogenic, thereby providing a genetic diagnosis in each case. We also demonstrate in a simplex patient without access to family members for co-segregation analysis that targeted long-read sequencing can provide haplotagged variant calling. This can elucidate if variants reside in trans and provide phase of genetic variants from the proband alone without parental testing. This emerging method can alleviate the bottleneck of haplotype analysis in cases where genetic testing of family members is unfeasible to provide a complete genetic diagnosis.

Targeted adaptive long-read sequencing for discovery of complex phased variants in inherited retinal disease patients.

Inherited retinal degenerations (IRDs) are a heterogeneous group of predominantly monogenic disorders with over 300 causative genes identified. Short-read exome sequencing is commonly used to genotypically diagnose patients with clinical features of IRDs, however, in up to 30% of patients with autosomal recessive IRDs, one or no disease-causing variants are identified. Furthermore, chromosomal maps cannot be reconstructed for allelic variant discovery with short-reads. Long-read genome sequencing can provide complete coverage of disease loci and a targeted approach can focus sequencing bandwidth to a genomic region of interest to provide increased depth and haplotype reconstruction to uncover cases of missing heritability. We demonstrate that targeted adaptive long-read sequencing on the Oxford Nanopore Technologies (ONT) platform of the USH2A gene from three probands in a family with the most common cause of the syndromic IRD, Usher Syndrome, resulted in greater than 12-fold target gene sequencing enrichment on average. This focused depth of sequencing allowed for haplotype reconstruction and phased variant identification. We further show that variants obtained from the haplotype-aware genotyping pipeline can be heuristically ranked to focus on potential pathogenic candidates without a priori knowledge of the disease-causing variants. Moreover, consideration of the variants unique to targeted long-read sequencing that are not covered by short-read technology demonstrated higher precision and F1 scores for variant discovery by long-read sequencing. This work establishes that targeted adaptive long-read sequencing can generate targeted, chromosome-phased data sets for identification of coding and non-coding disease-causing alleles in IRDs and can be applicable to other Mendelian diseases.

FOCAL RETINAL ISCHEMIA REVEALED BY MULTIMODAL IMAGING AFTER TRAUMATIC PARTIAL OPTIC NERVE AVULSION.

PURPOSE: Traumatic optic neuropathy can have varying presentations. Blunt focal trauma can lead to optic nerve avulsion with underlying retinal findings. A case of partial optic nerve avulsion after finger poke injury leading to focal retinal ischemia is reported. METHODS: Visual acuity, fundus photography with fluorescein angiography, and spectral-domain optical coherence tomography were performed to document the findings in a 16-year-old man who presented after a finger poke injury to the left orbit during a water polo match. RESULTS: On initial presentation, examination revealed decreased visual acuity with a fixed left pupil and afferent pupillary defect by reverse. On slit-lamp examination of the left eye, a hyphema was present. Dilated fundus examination revealed layering vitreous hemorrhage over the posterior pole and an avulsed vitreous base. On follow-up, a gap temporal to the optic nerve head consistent with a partial optic nerve avulsion was noted once the vitreous hemorrhage cleared. Multimodal imaging revealed retinal ischemia temporal to the disc on fluorescein angiography with corresponding changes in the inner retinal layers and retinal nerve fiber layer using spectral-domain optical coherence tomography. CONCLUSION: Clinicians should have a high suspicion for optic nerve avulsion if a patient presents with new vitreous hemorrhage and afferent pupillary defect after a finger-poke injury. Optic nerve avulsion injury can cause retinal ischemia, likely because of interruption of retinal blood flow as a result of nerve shearing injury. Multimodal imaging can reveal focal retinal injury and aid in proper diagnosis and follow-up.

RARE CASE OF ABIOTROPHIA DEFECTIVA BLEB-ASSOCIATED ENDOPHTHALMITIS.

PURPOSE: To report a rare case of Abiotrophia defectiva bleb-associated endophthalmitis. METHODS: In this case report of a patient with bleb-associated endophthalmitis, the authors describe the features of severe and rapid onset, associated retinitis, and a favorable outcome after aggressive early intervention. RESULTS: A 75-year-old woman presented decreased visual acuity of hand motions with an elevated intraocular pressure of 39 mmHg in the left eye. Her ocular history was notable for severe primary open-angle glaucoma with uneventful trabeculectomy and cataract surgery in both eyes 7 years before. Examination revealed conjunctival injection and an opaque avascular cystic bleb along with anterior chamber cellular reaction with a B-scan ultrasound concerning for vitritis. A. defectiva was isolated from the vitreous tap within 48 hours and confirmed later with 16S ribosomal RNA sequencing. After initial vitreous tap and inject and subsequent pars plana vitrectomy, her best-corrected visual acuity had improved to 20/500 at postoperative week one and then improved to 20/40 at postoperative month 2. Her examination was notable for resolved corneal edema, a deep and quiet anterior chamber, and resolved intraretinal hemorrhages. CONCLUSION: This is one of the first bleb-associated endophthalmitis cases with rapid identification of A. defectiva . A. defectiva was isolated from the initial vitreous tap within 48 hours and confirmed with 16S ribosomal RNA sequencing. This case highlights that rapid identification of A. defectiva may be indicative of a greater bacterial load and should prompt aggressive intervention and that the visual prognosis can be favorable.

Targeted long-read sequencing allows for rapid identification of pathogenic disease-causing variants in retinoblastoma.

BACKGROUND: Identification of disease-causing variants of the retinoblastoma gene (RB1), the predominant cause of retinoblastoma, is challenging. Targeted long-read genome sequencing offers a novel approach to resolve the diverse range of pathogenic variants in RB1 and provides haplotype information rapidly. MATERIALS AND METHODS: Genomic DNA was isolated from a venipuncture blood draw of a retinoblastoma patient. Whole genome sequencing (WGS) was carried out using the short-read Ilumina platform. WGS and targeted sequencing of RB1 was accomplished using the long-read Oxford Nanopore Technologies (ONT) platform. Deep-learning frameworks allowed haplotagging, variant calling, and variant annotation of both short- and long-read data. RESULTS: Targeted long-read sequencing of the RB1 gene allowed for enhanced depth of read coverage for discovery of rare variants and haplotype analysis. A duplication leading to a frameshift and early termination in RB1 was identified as the most deleterious variant by all sequencing methods, with long-read technology providing additional information of methylation signal and haplotype information. More importantly, there was greater than 98% concordance of RB1 variants identified between short-read and targeted long-read sequencing modalities. CONCLUSIONS: Targeted long-read technology allows for focused sequencing effort for variant discovery. Application of this for the first time in a retinoblastoma patient allowed haplotagged variant identification and demonstrated excellent concordance with benchmark short-read sequencing. The added benefit of targeted long-read sequencing to resolve disease-causing genomic variation in RB1 rapidly from a blood draw will provide a more definitive diagnosis of heritable RB and guide management decisions for patients and their families.

HUMAN CELLULAR MODELS FOR RETINAL DISEASE: From Induced Pluripotent Stem Cells to Organoids.

PURPOSE: To provide a concise review of induced pluripotent stem cells (iPSCs) and retinal organoids as models for human retinal diseases and their role in gene discovery and treatment of inherited retinal diseases (IRDs). METHODS: A PubMed literature review was performed for models of human retinal disease, including animal models and human pluripotent stem cell-derived models. RESULTS: There is a growing body of research on retinal disease using human pluripotent stem cells. This is a significant change from just a decade ago when most research was performed on animal models. The advent of induced pluripotent stem cells has permitted not only the generation of two-dimensional human cell cultures such as RPE but also more recently the generation of three-dimensional retinal organoids that better reflect the multicellular laminar architecture of the human retina. CONCLUSION: Modern stem cell techniques are improving our ability to model human retinal disease in vitro, especially with the use of patient-derived induced pluripotent stem cells. In the future, a personalized approach may be used in which the individual's unique genotype can be modeled in two-dimensional culture or three-dimensional organoids and then rescued with an optimized therapy before treating the patient.

Long-term outcomes of modified glued versus flanged intrascleral haptic fixation techniques for secondary intraocular lenses.

PURPOSE: To report the long-term refractive outcomes and complications of two scleral fixation techniques for secondary intraocular lenses (IOL). METHODS: Consecutive patients who underwent secondary IOL insertion at a tertiary care academic hospital using either modified glued ("glued") or flanged intrascleral haptic fixation (FISHF) techniques with over 12 months of follow-up were retrospectively reviewed. Pre- and postoperative corrected distance visual acuity (CDVA), postoperative complications, and refractive surprises were reported. RESULTS: Thirty-eight patients underwent "glued" fixation and 22 underwent FISHF, with mean follow-up times of 3.1 ± 0.5 and 2.0 ± 1.2 years, respectively. Aphakia secondary to trauma was the main surgical indication. MA50BM or MA60AC IOLs (Alcon Laboratories Inc., Fort Worth, TX) were implanted in 92% of "glued" patients, while CT Lucia 602 IOLs (Carl Zeiss Meditec Inc., Dublin, CA) were used in 96% of FISHF patients. Postoperative spherical equivalent significantly improved compared to preoperative values (p < 0.001). No significant difference in CDVA was seen between the two techniques. FISHF resulted in mean hyperopic surprises of + 0.81D and + 0.69D using the Holladay 2 and Barrett Universal II formulae, respectively, which was significantly greater than the "glued" patients. A higher rate of IOL dislocation was seen in the "glued" cohort (13%) compared to FISHF (0%). CONCLUSIONS: Retrospective long-term outcomes of patients with complex ocular comorbidities undergoing a modified "glued" technique demonstrated a higher rate of IOL dislocation but more predictable refractive outcomes compared to the FISHF technique. The FISHF technique resulted in a significant hyperopic shift using fourth-generation IOL calculators.

The Current State of Genetic Testing Platforms for Inherited Retinal Diseases.

PURPOSE: To evaluate genetic testing platforms used to aid in the diagnosis of inherited retinal degenerations (IRDs). DESIGN: Evaluation of diagnostic tests and technologies. SUBJECTS: Targeted genetic panel testing for IRDs. METHODS: Data collected regarding targeted genetic panel testing for IRDs offered by different laboratories were investigated for the inclusion of coding and noncoding variants in disease genes. Both large IRD panels and smaller, more focused, disease-specific panels were included in the analysis. MAIN OUTCOME MEASURES: Number of disease genes tested as well as the commonality and uniqueness across testing platforms in both coding and noncoding variants of disease. RESULTS: Across the 3 IRD panel tests investigated, 409 unique genes are represented, of which 269 genes are tested by all 3 panels. The top 20 genes known to cause over 70% of all IRDs are represented in the 269 common genes tested by all 3 panels. In addition, 138 noncoding variants in 50 unique genes are assayed across the 3 platforms. Focused, disease-specific panels exhibit significant variability across the 5 testing platforms that were studied. CONCLUSIONS: Ordering genetic testing for IRDs is not straightforward, as evidenced by the multitude of panels available to providers. It is important that there is coverage of both coding and noncoding regions in IRD genes to offer diagnoses in these patients. This paper details the diversity of testing platforms currently available to clinicians and provides a thorough explanation of the genes tested in the different IRD panels. In a time of increased importance of the clinical genetic testing of patients with IRDs, knowledge of the proper test to order is paramount.

Frequency of Urgent or Emergent Vitreoretinal Surgical Procedures in the United States During the COVID-19 Pandemic.

Importance: The American Academy of Ophthalmology (AAO) indicated that urgent or emergent vitreoretinal surgical procedures should continue during the coronavirus disease 2019 (COVID-19) pandemic. Although decreases in the frequency of critical procedures have been reported outside the field of ophthalmology, analyses are limited by volume, geography, and time. Objective: To evaluate whether the frequency of ophthalmic surgical procedures deemed urgent or emergent by the AAO changed across the United States during the COVID-19 pandemic. Design, Setting, and Participants: Vitreoretinal practices from 17 institutions throughout the US participated in this multicenter cross-sectional study. The frequency of 11 billed vitreoretinal Current Procedural Terminology (CPT) codes across respective weeks was obtained from each practice between January 1, 2019, and May 31, 2020. Data were clustered into intravitreal injections (code 67028), lasers and cryotherapy (codes 67141, 67145, and 67228), retinal detachment (RD) repairs (codes 67107, 67108, 67110, and 67113), and other vitrectomies (codes 67036, 67039, and 67040). Institutions were categorized by region (Northeast, Midwest, South, and West Coast), practice setting (academic [tax-exempt] or private [non-tax-exempt]), and date of respective statewide stay-at-home orders. Main Outcomes and Measures: Nationwide changes in the frequency of billing for urgent or emergent vitreoretinal surgical procedures during the COVID-19 pandemic. Results: A total of 526 536 CPT codes were ascertained: 483 313 injections, 19 257 lasers or cryotherapy, 14 949 RD repairs, and 9017 other vitrectomies. Relative to 2019, a weekly institutional decrease in injections was observed from March 30 to May 2, 2020, with a maximal 38.6% decrease (from a mean [SD] of 437.8 [436.3] to 273.8 [269.0] injections) from April 6 to 12, 2020 (95% CI, -259 to -69 injections; P = .002). A weekly decrease was also identified that spanned a longer interval, at least until study conclusion (March 16 to May 31, 2020), for lasers and cryotherapy, with a maximal 79.6% decrease (from a mean [SD] of 6.6 [7.7] to 1.5 [2.0] procedures) from April 6 to 12, 2020 (95% CI, -6.8 to -3.3 procedures; P < .001), for RD repairs, with a maximal 59.4% decrease (from a mean [SD] of 3.5 [4.0] to 1.6 [2.2] repairs) from April 13 to 19, 2020 (95% CI, -2.7 to -1.4 repairs; P < .001), and for other vitrectomies, with a maximal 84.3% decrease (from a mean [SD] of 3.0 [3.1] to 0.4 [0.8] other vitrectomies) from April 6 to 12, 2020 (95% CI, -3.3 to -1.8 other vitrectomies; P < .001). No differences were identified by region, setting, or state-level stay-at-home order adjustment. Conclusions and Relevance: Although the AAO endorsed the continued performance of urgent or emergent vitreoretinal surgical procedures, the frequency of such procedures throughout the country experienced a substantial decrease that may persist after the COVID-19 pandemic's initial exponential growth phase. This decrease appears independent of region, setting, and state-level stay-at-home orders. It is unknown to what extent vitreoretinal intervention would have decreased without AAO recommendations, and how the decrease is associated with outcomes. Although safety is paramount during the COVID-19 pandemic, practices should consider prioritizing availability for managing high-acuity conditions until underlying reasons for the reduction are fully appreciated.

Relationship of Epiretinal Membrane Formation and Macular Edema Development in a Large Cohort of Uveitic Eyes.

Purpose: To identify the temporal relationship and clinical characteristics of epiretinal membrane (ERM) and macular edema (ME) formation in uveitic eyes.Methods: A total of 269 subjects (444 uveitic eyes) met study inclusion criteria. Comprehensive ophthalmic examination, spectral domain-optical coherence tomography (SD-OCT), and clinical testing were carried out.Results: Of the 444 uveitic eyes, 229 eyes (51.6%) developed an ERM, whereas 87 eyes (19.1%) developed ME. The odds ratios (ORs) of systemic disease causing uveitis and resulting in ERM and ME were significantly higher in posterior uveitis (OR 6.56, 95% CI 2.98-14.46; p < .0001) and panuveitis (OR 10.09, 95% CI 4.05-25.15; p < .0001). Temporal analysis revealed that an ERM was noted concurrently or prior to ME development in 93.8% of eyes.Conclusions: ERM and ME are primarily observed in posterior uveitis and panuveitis associated with systemic diseases. The temporal relationship highlights the importance of characterization of ERM as it relates to the development of uveitic ME.

Outcomes of sutureless secondary intraocular lens fixation with haptic flanging in a cohort of surgically complex eyes.

PURPOSE: To describe clinical outcomes of secondary intraocular lens (IOL) implantation using sutureless trans-scleral techniques in surgically complex eyes. METHODS: Retrospective surgical case series of 45 eyes that underwent secondary IOL implantation using a sutureless haptic flange technique. Demographic data of age, sex, primary diagnosis, best-corrected visual acuity (BCVA), refractive error, intraocular pressure, full ophthalmic exam findings, surgical approach, and any intraoperative complications were noted. RESULTS: The most common indication for secondary IOL implantation was aphakia, most commonly after ocular trauma. The primary outcome measures were pre-operative and post-operative BCVA, which revealed recovery of pre-operative vision levels by post-operative week 1 and improved vision by post-operative month 1 (p = 0.03). Secondary outcome measures of target refraction pre-operatively and post-operatively revealed significant reduction in post-operative spherical equivalent to achieve BCVA (p < 0.001). Targeting of the secondary IOLs using Barrett Universal II, Holladay 1, Holladay 2, and SRK/T all exhibited a hyperopic shift post-operatively in post-traumatic aphakic eyes and a myopic shift in the post complicated cataract extraction eyes. No intraoperative adverse events were noted. The most common post-operative complication was transient IOP elevation, with most patients completing 6 months of follow-up. CONCLUSION: There is rapid visual rehabilitation and reduction of spherical equivalent correction to attain BCVA in eyes with a history of ocular trauma that undergo secondary IOL implantation using a trans-scleral flange technique. Moreover, this study highlights that a specific IOL power formula can be more predictive of the desired refractive outcome depending on the indication for secondary IOL implantation.

New developments in angiography for the diagnosis and management of diabetic retinopathy.

The most common microvascular complication of diabetes is diabetic retinopathy, the leading cause of blindness in adults of working age. Our understanding of the vascular changes in diabetic retinopathy was enhanced by the demonstration of fluorescein angiography (FA) in the human retina for the first time in 1961. It was subsequently integrated with digital fundoscopic imaging to become an invaluable technique in evaluation of the retinal vasculature. The recent development of OCT-angiography (OCT-A) has revolutionized the clinician's ability to examine the retinal vasculature without the need for injection of a contrast dye. By coupling OCT, which can provide noninvasive cross-sectional imaging of the central retina, with angiography in OCT-A, one can reveal retinal perfusion by allowing visualization of the depth-resolved retinal capillary plexus. OCT-A has allowed for more precise delineation of changes in the retinal microvasculature, specifically the alterations of retinal vasculature and loss of capillary perfusion from chronic microvascular occlusion in diabetic retinopathy.

Multimodal imaging reveals pathological edges of disease activity in tuberculosis-associated multifocal serpiginoid chorioiditis.

Tuberculosis associated serpiginous-like choroidopathy can lead to significant vision loss. The anatomical cause for this visual decline can be elucidated using multimodal retinal imaging. Imaging modalities used in this case, most notably, optical coherence tomography angiography (OCTA), demonstrated specific atrophy of the choriocapillaris.