Ultra-wide field imaging to assess the optic nerve and retina in Boston type I and II keratoprosthesis patients.

BACKGROUND: The ability to view the posterior segment in keratoprosthesis (Kpro) implanted patients is limited. The purpose of this retrospective, observational study was to investigate the use of ultra-wide field (UWF) scanning laser ophthalmoscopy imaging and its utility for serial evaluation of the retina and optic nerve in patients with either a Boston type I or II Kpro. METHODS: A retrospective chart review was performed for patients with a Boston type I or II Kpro seen at The Ohio State University Wexner Medical Center. Images were graded for quality by two masked observers on a defined four-point scale ("Poor", "Fair", "Good", or "Very good") and assessed for visible posterior segment anatomy. Interobserver agreement was described using the Kappa statistic coefficient (κ) with 95% confidence intervals. RESULTS: A total of 19 eyes from 17 patients were included in this study. Eighteen eyes had a type I Kpro, while one eye had a type II Kpro. UWF imaging from 41 patient visits were reviewed by two observers. Interobserver agreement between the two graders was fair for image quality (κ = 0.36), moderate for visibility of the macula with discernible details (κ = 0.59), moderate for visibility of the anterior retina with discernable details (κ = 0.60), and perfect agreement for visibility of the optic nerve with discernible details (κ = 1.0). In 6 eyes, UWF imaging was performed longitudinally (range 3-9 individual visits), allowing for long-term follow-up (range 3-46 months) of posterior segment clinical pathology. CONCLUSIONS: UWF imaging provides adequate and reliable visualization of the posterior segment in Kpro implanted patients. This imaging modality allowed for noninvasive longitudinal monitoring of retinal and optic nerve disease in this selected patient population.

Electroretinographic Findings in Melanoma-Associated Retinopathy Treated by Intravitreal Dexamethasone Implant.

A 63-year-old male with a history of bladder cancer in remission presented with progressive vision loss during a period of 2 years. Slit-lamp and funduscopic examination were unremarkable. Electroretinogram (ERG) revealed an unrecordable scotopic response and a moderately decreased photopic response. Computed tomography of the chest, abdomen, and pelvis showed a new duodenal mass. Subsequent biopsy disclosed malignant melanoma, and a diagnosis of melanoma-associated retinopathy (MAR) was made. The patient was then treated with a dexamethasone intravitreal implant 0.7 mg in his left eye. Two months after the implant, the patient reported a mild symptomatic improvement in his left eye, and ERG testing performed after the implant insertion revealed partial improvement in several scotopic and photopic ERG parameters. Repeat spectral-domain optical coherence tomography disclosed an improvement in retinal thickening. To the best of the authors' knowledge, this is the first report illustrating potential subjective visual improvement, improvement in retinal thickening, and ERG changes following treatment by intravitreal dexamethasone implant for MAR. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:454-456.].

Multiple Evanescent White Dot Syndrome Following Intradermal Influenza Vaccination.

Purpose: To present a case report of MEWDS following an intradermal influenza vaccination. Methods: Review of the clinical, laboratory, photographic, and angiographic records of a patient with MEWDS. Results: 27-year-old female that presented to our clinic with photopsias OD. These symptoms began 2 weeks following an influenza intradermal vaccination. Fundus examination and diagnostic testing were consistent with MEWDS. Conclusion: While rare, MEWDS can occur following influenza vaccination.

Multifocal choroiditis following simultaneous hepatitis A, typhoid, and yellow fever vaccination.

The paper describes the first reported case of multifocal choroiditis following simultaneous hepatitis-A, typhoid, and yellow fever vaccinations. A 33-year-old male developed sudden onset of flashing lights and floaters in his right eye 3 weeks following hepatitis A, typhoid, and yellow fever vaccinations. Fundus examination and angiography confirmed the presence of multiple peripheral chorioretinal lesions. These lesions demonstrated characteristic morphologic changes over a period of 8 weeks which were consistent with a diagnosis of self-resolving multifocal choroiditis. Vaccine-induced intraocular inflammation has been described infrequently. We demonstrate the first case of self-resolving multifocal choroiditis following simultaneous administration of hepatitis A, yellow fever, and typhoid immunizations.

Cytomegalovirus retinitis after central retinal vein occlusion in a patient on systemic immunosuppression: does venooclusive disease predispose to cytomegalovirus retinitis in patients already at risk?

Cytomegalovirus (CMV) retinitis remains the most common opportunistic ocular infection in immunocompromised patients. Patients with immunocompromising diseases, such as acquired immunodeficiency syndrome, inherited immunodeficiency states, malignancies, and those on systemic immunosuppressive therapy, are known to be at risk. Recently, it has been suggested that patients undergoing intravitreal injection of immunosuppressive agents may also be predisposed. One previous case report speculated that there may be an additional risk for CMV retinitis in acquired immunodeficiency syndrome patients with venoocclusive disease. This case study presents a case of CMV retinitis following central retinal vein occlusion in a patient on systemic immunosuppressants.

Non-mydriatic single-field fundus photography for the screening of retinal diseases in an executive health clinic.

BACKGROUND AND OBJECTIVE: To determine the accuracy and sensitivity of a single-field non-mydriatic digital fundus image interpreted by an ophthalmologist and performed within a primary care setting. PATIENTS AND METHODS: Fundus photography using a digital non-mydriatic camera was performed on both eyes of 1,175 consecutive patients as part of an executive health program. All fundus images included a 45° field of the posterior pole capturing the optic nerve and macular area. Diagnostic findings were recorded and appropriate recommendations for follow-up were made. Patients were then contacted to see whether appropriate follow-up was successfully completed and chart reviews were performed to determine biomicroscopic findings. RESULTS: Photographs were adequate in both eyes in 1,117 patients (95.1%). Examination findings were normal in both eyes in 951 (85.1%) patients. Abnormal findings were noted in either eye in 166 (14.9%) patients. The most common abnormal findings were macular degeneration (57/166, 34.3%), optic nerve cupping (45/166, 27.1%), hypertensive retinopathy (15/166, 9.0%), and choroidal nevi (10/166, 6.0%). In all patients with abnormal findings, routine follow-up ophthalmologic examination with an eye care specialist was indicated and none of the patients required urgent attention. Sensitivity was found to be 87% and stratification was performed based on the initial diagnosis. False-positive results were from confounding diagnoses rather than true false-positives. CONCLUSION: Single-field non-mydriatic fundus photography is accurate and sensitive for screening retinal disease in a primary care setting.

Ocular complications in patients with lung transplants.

AIM: To describe infectious and non-infectious ocular complications found in patients with lung transplants. METHODS: 545 patients underwent lung transplantation from January 1998 to September 2008 at the Cleveland Clinic. Patients who underwent ophthalmic examination at the Cole Eye Institute after lung transplantation were included in the study. OUTCOMES: Diagnoses, treatments, surgeries, laboratory parameters of immune status and patient survival were examined. RESULTS: Of the 545 patients who received a lung transplant during the study period at the Cleveland Clinic, 46 (8.4%) patients underwent ophthalmology examination after a lung transplant. The most common ocular finding was posterior subcapsular cataract, found in 13/46 (28.3%) patients. Infectious ocular complications were present in 6/46 patients (13.0%) including fungal infections (rhino-orbital mucormycosis (n=1), disseminated Pseudallescheria boydii infection (n=2)), cytomegalovirus retinitis (n=1), varicella-zoster virus keratouveitis (n=1) and herpes zoster ophthalmicus (n=1). Five of six patients with infectious ocular complications died within 6 months of evaluation. Decreased absolute lymphocyte count was associated with infectious ocular complications (p=0.014). CONCLUSIONS: Many ocular conditions can occur in patients with lung transplants. Ocular infectious complications were uncommon but may be associated with increased mortality.

Wegener's granulomatosis: clinical manifestations, differential diagnosis, and management of ocular and systemic disease.

Wegener's granulomatosis (WG) is a systemic inflammatory disease whose histopathologic features often include necrosis, granuloma formation, and vasculitis of small-to-medium-sized vessels. WG involves many interrelated pathogenic pathways that are genetic, cell-mediated, neutrophil-mediated, humoral, and environmental. WG most commonly involves the upper respiratory tract, lungs, and kidneys, but has been reported to affect almost any organ. Ophthalmologic involvement is an important cause of morbidity in WG patients, occurring in approximately one-half of patients. The presence of unexplained orbital inflammatory disease, scleritis, peripheral ulcerative keratitis, cicatricial conjunctivitis, nasolacrimal duct stenosis, retinal vascular occlusion, or infrequently uveitis should raise the question of possible WG. A thorough clinical examination, laboratory testing, radiologic imaging, and histologic examination are essential to diagnosing WG and excluding potential mimics. Previously a uniformly fatal disease, treatment with cytotoxic and immunosuppressive agents has greatly improved survival. Treatment-related morbidity is a serious limitation of conventional therapies, leading to numerous ongoing studies of alternative agents.

Suture-related keratitis following cataract surgery caused by methicillin-resistant Staphylococcus aureus.

A 54-year old-man presented with a two-day history of severe pain and decreased vision. Examination revealed a corneal ulcer associated with a loose suture from cataract surgery done approximately two years ago. The suture was removed and the patient was started on topic antibiotic treatment with cefazolin and gentamycin. Cultures revealed methicillin-resistant Staphylococcus aureus (MRSA). The antibiotic regimen was changed to include vancomycin but the ulcer continued to progress. Three days later, the ulcer had perforated and an emergent corneal patch graft was performed. To our knowledge, this is the first reported case of suture-related MRSA keratitis after uncomplicated clear corneal cataract surgery.

Retinal vasculitis associated with the anti-synthetase syndrome.

A 50-year-old woman with a history of anti-Jo1-positive inflammatory myositis and interstitial lung disease presented with decreased vision in her right eye. Examination revealed white-centered hemorrhages scattered across the posterior pole in addition to several areas of vascular sheathing. Treatment was initiated with intravenous pulse solumedrol, with improvement in vision and resolution of the patient's white-centered hemorrhages. A thorough workup for other causes of vasculitis was unrevealing. Anti-synthetase syndrome is a serologically defined disorder clinically characterized by inflammatory myositis, interstitial lung disease, and other systemic findings. To our knowledge, retinal vasculitis has not been previously reported in patients with anti-synthetase syndrome.

Bacterial conjunctivitis: a review for internists.

Bacterial conjunctivitis is common and occurs in patients of all ages. Typical signs are a red eye and purulent drainage that persists throughout the day. Gonococcal and chlamydial conjunctivitis must be treated with systemic antibiotics. Bacterial conjunctivitis due to most other organisms can be treated empirically with topical antibiotics. Red flags suggesting a complicated case requiring referral to an ophthalmologist include reduced vision, severe eye pain, a hazy-appearing cornea, contact lens use, and poor response to empirical treatment.

MyD88 regulation of Fusarium keratitis is dependent on TLR4 and IL-1R1 but not TLR2.

The fungal pathogens Fusarium solani and Fusarium oxysporum cause severe corneal disease in the United States and worldwide and were the causative organisms in a recent outbreak of contact lens-associated keratitis. To characterize innate immunity in Fusarium keratitis, we developed a murine model in which conidia are injected into the corneal stroma. Immunocompetent C57BL/6 mice rapidly developed severe corneal opacification associated with neutrophil infiltration and clearance of Fusarium hyphae. In contrast, neutrophil infiltration was delayed in MyD88-/- mice, resulting in uncontrolled growth of Fusarium hyphae in the corneal stroma and anterior chamber, and eventually resulting in corneal perforation. Corneal opacification scores in TLR2-/-, TLR4-/-, and TLR2/4-/- mice were similar to those of C57BL/6 mice; however, TLR4-/- and TLR2/4-/- mice had impaired antifungal responses. The phenotype of infected IL-1R1-/- mice was similar to that of MyD88-/- mice, with uncontrolled fungal growth resulting in corneal perforation. IL-1R1-/- mice also produced significantly less CXCL1/KC in the corneal stroma compared with C57BL/6 mice consistent with delayed neutrophil recruitment to the corneal stroma. Together, these findings indicate that IL-1R1 and MyD88 regulate CXC chemokine production and neutrophil recruitment to the cornea, and that TLR4 has an important role in controlling growth and replication of these pathogenic fungi.

Syndrome of myelinated retinal nerve fibers, myopia, and amblyopia: a review.

Myelinated retinal nerve fibers are developmental anomalies that are present in approximately 1% of all eyes. They may be associated with ipsilateral high myopia and amblyopia, and also may occur in association with various ocular and systemic abnormalities. Lesions may be congenital or acquired, static or dynamic, and can regress in the setting of several described conditions. The pathogenesis is thought to be due to the presence of ectopic oligodendrocyte-like cells in the retina as a result of a development or acquired insult. Visual acuity is typically poor to begin with, and the improvement of visual function in patients undergoing occlusion therapy has been, in general, limited. We discuss a series of 11 patients seen at the Cole Eye Institute with the condition of myelinated retinal nerve fibers, myopia, and amblyopia and describe the clinical characteristics. Three patients also had optic nerve dysplasia and a discussion of the literature related to this association was also performed.

Bacterial culture isolates from hospitalized pediatric patients with conjunctivitis.

PURPOSE: To determine the spectrum of organisms causing acute bacterial conjunctivitis in hospitalized children at a tertiary care referral center. DESIGN: Retrospective chart review. METHODS: Charts of hospitalized children with positive conjunctival cultures were reviewed, and patients with clinical description of conjunctivitis were studied. RESULTS: One hundred and seven isolates from 59 patients were included in the study. The most common organisms cultured were coagulase-negative Staphylococcus (59.3% of patients), viridans Streptococcus (47.5%), and Staphylococcus aureus (20.3%). The type of organisms differed based on age, with S. aureus and Haemophilus influenzae being more common in nonneonates. Gram-negative bacilli and methicillin-resistant Staphylococcus species were more common in patients hospitalized longer than two days. CONCLUSIONS: The distribution of bacterial organisms causing acute bacterial conjunctivitis in our hospitalized children differs from that of previous reports in the outpatient setting. Conjunctival swabbing for culture and sensitivities before instituting empiric broad-spectrum antibiotic therapy may be useful.