New Approaches to Overcoming Antimicrobial Resistance in Endophthalmitis.

Endophthalmitis is a rare but vision-threatening infection characterized by marked inflammation of intraocular fluids and tissues, uncommonly seen following surgery and intravitreal injection. Antimicrobials are used worldwide in the prophylaxis and treatment of bacterial and fungal infections of the eye and are standard treatment in the preoperative and postoperative care of surgical patients. However, antimicrobials are reported to be overprescribed in many parts of the world, which contributes to antimicrobial resistance (AMR). AMR complicates the prophylaxis and treatment of endophthalmitis. This article examines the prevalence and mechanisms of AMR in ocular microorganisms, emphasizing the importance of understanding AMR patterns for tailored treatments. It also explores prophylaxis and management strategies for endophthalmitis, with a discussion on the use of intracameral antibiotic administration. The use of prophylactic intracameral antibiotics during cataract surgery is common in many parts of the world but is still controversial in some locations, especially in the US. Finally, it highlights the role of stewardship in ophthalmology and its benefits in the treatment of endophthalmitis.

Adjuvant Intravitreal Bevacizumab for Retinal Neovascularization in Eales' Disease Associated With Latent Mycobacterium Tuberculosis.

We report a case of bilateral Eales' disease managed with intravitreal bevacizumab. A 32-year-old woman with a history of bacillus Calmette-Guerin vaccine, administered when she was 10 years old, presented with a five-day history of a scotoma in the temporal field of her right eye. A dilated fundus exam and fluorescein angiography showed bilateral retinal peripheral capillary non-perfusion, retinal neovascularization in the right eye, and deep intraretinal hemorrhages in the left eye. Her laboratory workup resulted in a positive QuantiFERON-TB Gold test (Cellestis Ltd, Carnegie, Victoria, Australia). Chest computed tomography showed a calcified granuloma in her right lung. Angiographic-guided pan-retinal photocoagulation was performed, and intravitreal injections of bevacizumab (1.25 mg/0.05 mL) were administered in both eyes over the course of three months. The intraretinal hemorrhages resolved after three months of therapy. Three months following treatment, the patient showed normal fundus findings without any evidence of recurrence and a visual acuity of 20/20 in both eyes. Intravitreal bevacizumab in combination with angiography-guided pan-retinal photocoagulation may be efficacious in select patients with Eales' disease.

Update on current pharmacologic therapies for diabetic retinopathy.

INTRODUCTION: Diabetic retinopathy is a major cause of visual loss worldwide. The most important clinical findings include diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). AREAS COVERED: PubMed was used for our literature review. Articles from 1995 to 2023 were included. Pharmacologic treatment of diabetic retinopathy generally involves the use of intravitreal anti-vascular endothelial growth factor (VEGF) therapy for DME and PDR. Corticosteroids remain important second-line therapies for patients with DME. Most emerging therapies focus on newly identified inflammatory mediators and biochemical signaling pathways involved in disease pathogenesis. EXPERT OPINION: Emerging anti-VEGF modalities, integrin antagonists, and anti-inflammatory agents have the potential to improve outcomes with reduced treatment burdens.

Bilateral vitreomacular traction syndrome associated with topical pilocarpine 1% ophthalmic solution.

To describe a case of transient bilateral vitreomacular traction syndrome associated with topical 1% pilocarpine ophthalmic solution in both eyes as a treatment for advanced glaucoma. Observations: Spectral-domain OCT demonstrated bilateral vitreomacular traction syndrome after initiation of topical 1% pilocarpine solution in both eyes for advanced glaucoma. Follow-up imaging revealed the resolution of vitreomacular traction after cessation of the drug without a complete posterior vitreous detachment. Conclusions and Importance: In the advent of new pilocarpine formulations, this case raises the concern of vitreomacular traction syndrome as a serious potential sequela of long-term topical pilocarpine use.

Clinical Outcomes of Combined Phacoemulsification With Intraocular Lens Placement and Microincision Vitrectomy in Adult Vitreoretinal Disease.

Purpose: To evaluate the safety and clinical outcomes of combined phacoemulsification with intraocular lens (IOL) placement and microincision vitrectomy surgery (MIVS) in adult patients with concomitant cataract and vitreoretinal disease. Methods: A consecutive series of patients with comorbid vitreoretinal disease and cataract who had combined phacoemulsification with IOL placement and MIVS was retrospectively analyzed. The main outcome measures were visual acuity (VA) and intraoperative and postoperative complications. Results: The analysis comprised 648 eyes of 611 patients. The median follow-up was 26.9 months (range, 12-60 months). The most common vitreoretinal pathology was intraocular tumor (53%). The best-corrected Snellen VA improved from 20/192 at baseline to 20/46 at the 12-month follow-up. The most frequent intraoperative complication was capsule tear (3.9%). The most common postoperative adverse events after 3 months of follow-up (mean, 24 months) were vitreous hemorrhage (3.2%) and retinal detachment (1.8%). No patient developed endophthalmitis. Conclusions: Combined phacoemulsification with IOL placement and MIVS is a safe, effective technique to manage a broad range of vitreoretinal diseases in patients with significant cataract.

[Analysis of a clinical ethics committee activities at a general hospital]. / Experiencia del Comité de Ética Asistencial del Hospital Carlos van Buren entre los años 2007-2020.

BACKGROUND: Clinical Ethics Committees are deliberative groups whose main functions are to assess cases with ethical-clinical conflicts, to generate institutional protocols for preventive purposes, and to train health teams. AIM: To analyze the activity of a clinical ethics committee of a general hospital in the period 2007-2020. MATERIAL AND METHODS: A retrospective analysis of all session records, annual reports, case resolution and documents generated by the Clinical Ethics Committee of Carlos van Buren Hospital in Valparaíso, Chile, between 2007 and 2020, was carried out. RESULTS: On average, 12 cases are analyzed per year. Sixty percent correspond to requests from pediatric units and in 78% of these cases there was at least one neurological disease. In 62% of cases, the main ethical dilemma was adequacy of therapeutic effort, followed by dilemmas related to the exercise of autonomy in 18.2%. In education, two courses are identified aimed to doctors, residents, and other members of the health team. Regarding normative functions, several documents were generated at the request of the Hospital management or in different clinical situations. During COVID-19 pandemia, the active role of the committee was linked to the three main functions, namely evaluating cases, participating in morbidity and mortality meetings for preventive purposes, and issuing guidelines and recommendations for action. The active participation of Pediatric Neurology residents in the Committee, for educational and administrative purposes, stands out. CONCLUSIONS: The three main functions described for the ethics committees were exerted by this Committee during the evaluated period. The impact of our recommendations remain to be objectively evaluated.

Risk Factors Leading to Enucleation or Evisceration in Infectious Endophthalmitis.

Endophthalmitis treatment consists of intravitreal antibiotics injections and, in selected circumstances, pars plana vitrectomy. However, severe or refractory cases may require an enucleation or evisceration (ENEV). Our study seeks to identify risk factors leading to enucleation or evisceration in patients with infectious endophthalmitis. A retrospective chart review of subjects with a clinical diagnosis of infectious endophthalmitis was undertaken. The affected eyes were stratified into groups: those that underwent ENEV and those in which the eyeball was preserved (EP). The groups were compared using statistical analyses. In total, 69 eyes diagnosed with infectious endophthalmitis were included in the study. There was a higher frequency of exogenous infectious endophthalmitis in the ENEV group versus the EP group. Postsurgical infectious endophthalmitis was lower in the ENEV than in the EP group. A visual acuity of no light perception was more common in the ENEV compared to the EP group. Panophthalmitis was more frequent in the ENEV versus the EP group. Our findings suggest that eyes with endophthalmitis presenting with a visual acuity of no light perception, panophthalmitis, or exogenous etiology have a higher risk of requiring ENEV. In addition, eyes with a postsurgical etiology may be at a lower risk of requiring ENEV.

Characteristics Upon Presentation of Patients with Type 2 Macular Telangiectasia in Puerto Rico.

OBJECTIVE: To describe the systemic disease associations and clinical features upon initial presentation of a cohort of patients with type 2 macular telangiectasia who live in Puerto Rico. METHODS: A retrospective review of patients with macular telangiectasia was performed in 4 private retina practices in Puerto Rico. The demographic and clinical characteristics were recorded. RESULTS: Twenty-one patients who were diagnosed with macular telangiectasia were included in the analysis. The median age of presentation was 62 years; 86% were female, and all patients were Hispanics. The median visual acuity at presentation was 20/50. A prior medical diagnosis of type II diabetes mellitus was found in 15 (71.4%) patients, essential hypertension in 12 (57.1%), and dyslipidemia in 9 (42.9%). All patients had bilateral disease. The most common ocular findings were the presence of right-angle vessels in 32 (76.2%) eyes and angiographic hyperfluorescence temporal to the fovea, found in 22 (52.4%) of the affected eyes. One eye had evidence of choroidal neovascularization. CONCLUSION: Our cohort showed a higher prevalence of type 2 diabetes in patients with type 2 macular telangiectasia than in other cohorts. It also supports the findings of other studies showing that macular telangiectasia patients are more likely to have type 2 diabetes and hyperlipidemia. However, the increased prevalence of diabetes and hyperlipidemia may be due to selection bias, and further studies are needed to assess the significance of these findings.

Optical Coherence Tomography Angiography Findings in Sclerochoroidal Calcification.

Optical coherence tomography angiography (OCT-A) is a modern non invasive imaging technique that may aid in the evaluation of retinal diseases through the assessment of chorioretinal vasculature. The literature regarding OCT-A in sclerochoroidal calcification is scarce. We present the case of a 57-year-old female who was referred to the clinic due to an atypical choroidal lesion in the right eye. OCT-A showed an apparent decrease in the vascular flow of the choroidal/choriocapillaris layers and an apparent increase in the vascular flow of the deep retinal layers. A mass effect may be seen in OCT-A en face imaging that may create artifactual vascular flow pattern. This case reports the first OCT-A findings of sclerochoroidal calcification.

Genetic analysis of patients with nonsyndromic and syndromic retinitis pigmentosa in Puerto Rico: a genetic legacy.

BACKGROUND: Retinitis pigmentosa (RP) is a genetically heterogeneous group of diseases characterized by complete progressive vision loss; it has a prevalence of approximately one in 2500-7000. Patients with RP may have isolated findings, or the disorder can occur as part of a constellation of other abnormalities that, together, are known as syndromic RP. The aim of this study was to describe the results of a genetic analysis of a cohort of Puerto Ricans with a clinical diagnosis of RP. MATERIALS AND METHODS: This was a cross-sectional study with a cohort of 224 Puerto Rican patients who carried a clinical diagnosis of RP. During a local (Puerto Rico) RP convention, the patients were offered genetic analysis. Volunteering patients signed consent forms for the study. Saliva samples were obtained and analyzed. Patients were evaluated by at least one of the authors. Patients with pathogenic mutation(s), according to the panel, were classified as positive and sorted based on the results. RESULTS: Of 224 patients, 161 (71.9%) had pathogenic gene variants associated with IRDs. 54.5% (122/224) of cases were conclusive. More than half (72/122) of these cases are explained by mutations in the BBS1, PDE6B, CNGB1, and USH2A genes. Genetic analysis showed that the highest rate of pathogenic variants in our cohort was found in the BBS1 gene. CONCLUSIONS: This was the first genetic analysis in Puerto Rico of patients with RP. The most common mutation associated with RP was found in the BBS1 gene. The frequency of other pathogenic variants related to RP in Puerto Rico were different to those reported in Spain.

Multimodal treatment of Coats-like exudative vitreoretinopathy in Goldmann-Favre syndrome.

PURPOSE: To report a Coats-like exudative vitreoretinopathy in Goldmann-Favre syndrome. OBSERVATIONS: A 64 year-old woman with prior diagnosis of retinal dystrophy presented with decreased vision in the right eye (OD). Ophthalmologic examination was remarkable for bilateral arteriolar attenuation, mid-peripheral bony-spicules, and waxy disc pallor. Coats-like exudative vitreoretinopathy and cystoid macular edema were present OD. Genetic testing showed a homozygous pathogenic mutation in gene NR2E3, variant c.932G>A (p.Arg311Gln), consistent with Goldmann-Favre syndrome. Targeted laser ablation and combination intravitreal therapy were effective in decreasing macular edema. CONCLUSIONS AND IMPORTANCE: A Coats-like exudative vitreoretinopathy may occur in the setting of Goldmann-Favre syndrome. Targeted laser ablation in combination with intravitreal therapy can be efficacious in select patients.

Experiencia del Comité de Ética Asistencial del Hospital Carlos van Buren entre los años 2007-2020

Background: Clinical Ethics Committees are deliberative groups whose main functions are to assess cases with ethical-clinical conflicts, to generate institutional protocols for preventive purposes, and to train health teams. Aim: To analyze the activity of a clinical ethics committee of a general hospital in the period 2007-2020. Material and Methods: A retrospective analysis of all session records, annual reports, case resolution and documents generated by the Clinical Ethics Committee of Carlos van Buren Hospital in Valparaíso, Chile, between 2007 and 2020, was carried out. Results: On average, 12 cases are analyzed per year. Sixty percent correspond to requests from pediatric units and in 78% of these cases there was at least one neurological disease. In 62% of cases, the main ethical dilemma was adequacy of therapeutic effort, followed by dilemmas related to the exercise of autonomy in 18.2%. In education, two courses are identified aimed to doctors, residents, and other members of the health team. Regarding normative functions, several documents were generated at the request of the Hospital management or in different clinical situations. During COVID-19 pandemia, the active role of the committee was linked to the three main functions, namely evaluating cases, participating in morbidity and mortality meetings for preventive purposes, and issuing guidelines and recommendations for action. The active participation of Pediatric Neurology residents in the Committee, for educational and administrative purposes, stands out. Conclusions: The three main functions described for the ethics committees were exerted by this Committee during the evaluated period. The impact of our recommendations remain to be objectively evaluated.

Acute macular neuroretinopathy in dengue virus serotype 1.

PURPOSE: To report a case of acute macular neuroretinopathy (AMN) associated with dengue virus serotype 1 infection. OBSERVATION: An 18-year-old Puerto Rican female was evaluated due to painless paracentral scotomas in each eye that developed after being hospitalized for dengue fever a week before. Clinical examination and multimodal imaging revealed bilateral hypopigmented macular lesions, hyperreflectivity at the outer nuclear and photoreceptor layer, and reduced flow signal in the deep capillary plexus. Additionally, hypoautofluorescent parafoveal lesions were found in the left eye. AMN was diagnosed. Two-month follow-up after the initial evaluation showed resolution of symptoms but persistence of some findings on optical coherence tomography. CONCLUSIONS AND IMPORTANCE: Patients with dengue virus serotype 1 may develop paracentral scotomas with classic AMN findings and obtain complete symptomatic recovery without treatment.

Clinical spectrum of blunted foveal contour.

Foveal hypoplasia is the absence of a foveal depression and the presence of the ganglion cell layer in the foveola. A spectrum of clinical characteristics, including normal or variably decreased visual acuity, has been described in patients with blunted foveal contours. Multiple systemic and ophthalmologic conditions including albinism, aniridia, nanophthalmos, prematurity, and fovea plana have been associated with this anomaly. This article illustrates select clinical conditions characterized by a blunted foveal contour. Given the heterogeneity of findings, a thorough medical history and detailed physical and ocular examinations are usually sufficient for the clinician to make the correct diagnosis.

Atypical Event Profiling of Intra-Arterial Chemotherapy.

Purpose: Three cases of atypical events following intra-arterial chemotherapy for the treatment of retinoblastoma are presented. Methods: Case report. Results: One patient had acute orbital swelling with proptosis, another with extravasation of the chemotherapeutic agent, and the final with total ipsilateral hearing loss. Conclusions: These cases underscore the importance of maintaining close follow-up when using intra-arterial chemotherapy for treatment of retinoblastoma.

Adolescent Plaque Brachytherapy for Large Choroidal Metastasis from Lung Carcinoid Tumor.

The purpose of this publication is to report a child with choroidal metastasis from a primary lung carcinoid tumor treated with 125-iodine plaque brachytherapy while achieving complete tumor regression. A 15-year-old girl with a history of stage IV lung carcinoid tumor developed painless progressive visual loss in her right eye. Ophthalmological exam documented a unilateral solitary large choroidal mass with complete exudative retinal detachment. Planned palliative treatment with plaque brachytherapy was performed utilizing a total dose of 45 Gy to the tumor apex. No tumor regression was noted after 6 months of follow-up. Ten months after primary therapy, re-treatment with a total dose of 90 Gy to the tumor apex was performed due to tumor progression. Complete regression was achieved after secondary treatment without evidence of recurrence after 18 months of follow-up. In conclusion, high-dose plaque brachytherapy may induce complete tumor regression in select adolescent patients with choroidal metastasis from lung carcinoid tumor.

Alphabet Soup: Clinical Pearls for the Retina Specialist-Ocular Toxicity of Advanced Antineoplastic Agents in Systemic Cancer Care.

Targeted antineoplastic agents and immunotherapies have revolutionized management strategies available for previously refractory cancer. Despite the growing list of pharmacologic agents and indications, many of the currently Food and Drug Administration-approved therapies are associated with ocular adverse effects. Retina specialists and oncologists should be aware of potential side effects because some may be severe and permanent. Although most ocular side effects require conservative treatment without discontinuation of life-preserving therapies, rare severe adverse reactions can be potentially blinding and may warrant an extensive discussion regarding different management strategies, including cessation of life-preserving therapy.

Pharmacotherapy as an adjunct to vitrectomy.

Vitreoretinal surgery has advanced extensively from the first days of vitrectomy. During the last decade, new developments in intravitreal pharmacotherapy have created new opportunities to enhance the surgical outcomes of our patients. In this article, we review and discuss some of the supporting evidence of different pharmacotherapies that may be used as an adjunct to vitrectomy for select common etiologies. Triamcinolone acetonide, dexamethasone, and angiogenesis inhibitors are among the most commonly used drugs given their safety profile and proven efficacy. Other pharmaceuticals have also shown promising results in small studies. The adoption of individualized medical treatments prior, during, and after vitrectomy will continue to increase as new evidence supporting the benefit of pharmacotherapy as an adjunct to vitrectomy becomes available.

Multimodal Imaging in the Diagnosis of Exophytic Juxtapapillary Retinal Capillary Hemangioblastoma.

PURPOSE: Exophytic juxtapapillary retinal capillary hemangioblastoma (JRCH) can be difficult to diagnose. We explore the value of multimodal imaging to aid in the diagnosis. DESIGN: Retrospective case series. METHODS: Medical records and multimodal imaging studies were reviewed on all patients diagnosed with RCH at Bascom Palmer Eye Institute, Miami, Florida, between January 2013 and December 2019. Patients with exophytic lesions within 2 mm of the disc were included. One patient from the Baylor College of Medicine, Houston, Texas was included. Patient demographics, referring diagnosis, history of von Hippel-Lindau syndrome, initial and last visual acuity, and treatments were recorded. Fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, optical coherence tomography (OCT), OCT angiography, and B-scan images were reviewed. RESULTS: Twelve patients were identified with exophytic JRCH. The mean age was 54 years (range 38-73 years). Five patients had von Hippel-Lindau syndrome. The most common referral diagnoses were choroidal neovascularization and neuroretinitis. Imaging features included nodular outer retinal thickening with shadowing and intra-/subretinal fluid on OCT, hypoautofluorescence on fundus autofluorescence, middle to outer retinal hypervascularity on OCT angiography, early hyperfluorescence with late leakage on fluorescein angiography, and lack of choroidal vascular lesion on indocyanine green angiography. Treatments included photodynamic therapy (6 patients), intravitreal anti-vascular endothelial growth factor therapy (6 patients), argon laser photocoagulation (2 patients), intravitreal or sub-Tenon's triamcinolone (3 patients), and observation (4 patients). CONCLUSIONS: A key to the accurate diagnosis of exophytic JRCH is its intraretinal location, typically involving the outer retinal layers, which results in a clinical appearance that is distinct from the more common and easily recognizable endophytic RCH. Multimodal imaging can aid in ruling out choroidal neovascularization and disc edema by demonstrating an absence of involvement of those structures.

Bilateral hypopyon in syphilitic uveitis.

PURPOSE: To report an atypical bilateral hypopyon presentation of syphilitic uveitis. OBSERVATIONS: A 38-year-old male presented with a 2-day history of bilateral progressive visual loss, conjunctival hyperemia, and photophobia. Initial ophthalmologic examination revealed bilateral hypopyon and vitritis that limited the examination of the posterior segment. The physical exam revealed cervical lymphadenopathy, glossal leukoplakia, erythematous maculae on the hard palate, erythematous macular lesions on both palms, onychodystrophy, onycholysis, and psoriasiform plaques on both plantar surfaces, testicular tenderness, and hypopigmented patches on the scrotal and perianal skin. A therapeutic and diagnostic vitrectomy was performed on the right eye, and the intraoperative findings were consistent with severe vitritis and pre-retinal precipitates. The cytopathologic analysis of the right vitreous revealed a mixed inflammatory process composed of lymphocytes, histiocytes, and neutrophils in a proteinaceous background. Laboratory testing revealed positive serum RPR, CSF FTA-Abs and VDRL, and HIV serology. Treatment with a 2-week course of intravenous penicillin G 4 million units every 4 hours and topical corticosteroids resulted in complete resolution of the uveitis. CONCLUSIONS AND IMPORTANCE: Bilateral hypopyon uveitis may be a rare presentation of syphilitic uveitis. As with most forms of uveitis, syphilis should be considered in the differential diagnosis of patients presenting with bilateral hypopyon.