Internal Carotid Artery Stenosis and Ipsilateral Subretinal Drusenoid Deposits.

Purpose: Subretinal drusenoid deposits (SDDs) in age-related macular degeneration (AMD) are strongly associated with vasculopathies such as myocardial infarction and ischemic stroke. This study evaluates ischemic stroke subjects for SDDs to determine whether ocular hypoperfusion from internal carotid artery (ICA) stenosis is associated with ipsilateral SDDs. Methods: A cross-sectional study at Mount Sinai Hospital recruited 39 subjects with ischemic stroke (aged 52-90; 18 women, 21 men); 28 completed all study procedures. Computed tomography (CT) of the head and neck evaluated 54/56 ICAs for stenosis criteria: none (n = 33), mild (n = 12), moderate (n = 3), severe (n = 3), and complete (n = 3). Spectral-domain optical coherence tomography (SD-OCT) scans were read to consensus by two masked graders for soft drusen, SDDs and choroidal thickness (CTh; choroidal thinning = CTh < 250 µm). Univariate testing was done with Fisher's exact test. Multivariate logistic regression models tested age, gender, and ICA stenosis as covariates. Results: Moderate or more ICA stenosis (≥50%-69%) was significantly associated with ipsilateral choroidal thinning (P = 0.021) and ipsilateral SDDs (P = 0.005); the latter were present distal to six of nine stenosed ICAs versus five of 33 normal ICAs. Mild ICA stenosis (≥1%-49%) was not significantly associated with ipsilateral SDDs. Multivariate regression found that older age (P = 0.015) and moderate or more ICA stenosis (P = 0.011) remained significant independent risks for ipsilateral SDDs. Conclusions: At least moderate ICA stenosis (≥50%-69%) is strongly associated with ipsilateral SDDs and choroidal thinning, supporting downstream ophthalmic artery and choroidal hypoperfusion from ICA stenosis as the mechanism for SDD formation. SDDs may thus serve as sensitive biomarkers for ischemic stroke and other vascular diseases.

Performance Assessment of an Artificial Intelligence Chatbot in Clinical Vitreoretinal Scenarios.

PURPOSE: To determine how often ChatGPT is able to provide accurate and comprehensive information regarding clinical vitreoretinal scenarios. To assess the types of sources ChatGPT primarily utilizes and to determine if they are hallucinated. METHODS: A retrospective cross-sectional study. We designed 40 open-ended clinical scenarios across 4 main topics in vitreoretinal disease. Responses were graded on correctness and comprehensiveness by two blinded retina specialists. The primary outcome was the number of clinical scenarios that ChatGPT answered correctly and comprehensively. Secondary outcomes included: theoretical harm to patients, the distribution of the type of references utilized by the chatbot, and the frequency of hallucinated references. RESULTS: In June 2023, ChatGPT answered 83% (33/40) of clinical scenarios correctly but provided a comprehensive answer in only 52.5% (21/40) of cases. Subgroup analysis demonstrated an average correct score of 86.7% in nAMD, 100% in DR, 76.7% in retinal vascular disease and 70% in the surgical domain. There were 6 incorrect responses with 1 (16.7%) case of no harm, 3 (50%) cases of possible harm and 2 (33.3%) cases of definitive harm. CONCLUSION: ChatGPT correctly answered more than 80% of complex open-ended vitreoretinal clinical scenarios, with a reduced capability to provide a comprehensive response.

Subretinal drusenoid deposits, age-related macular degeneration, and cardiovascular disease.

Decades of studies on age-related macular degeneration (AMD), cardiovascular disease and stroke have not found consistent associations between AMD and systemic vascular disease. This study suggests that there is in fact no general relationship, but instead a strong, specific association between only the subretinal drusenoid deposit (SDD) phenotype of AMD on retinal imaging and certain co-existent vascular diseases that are high risk for compromised cardiac output or internal carotid artery stenosis. Future screening initiatives for these high -risk vascular diseases (HRVDs) with fast, inexpensive retinal imaging could make a significant contribution to public health and save lives. Likewise, screening patients with known HRVDs for unrecognized AMD of the SDD form could enable needed treatment and save vision.

Modified Endolaser Instrument for Chandelier Scleral Buckling.

Purpose: To report a new modification of an illuminated endolaser to facilitate safe endophotocoagulation during chandelier-assisted scleral buckling surgery. Methods: This case series comprised phakic patients with rhegmatogenous retinal detachments (RRDs) who had primary scleral buckling with chandelier endoillumination, external drainage, and endophotocoagulation using the modified endolaser instrument. Results: All 6 patients had successful outcomes after primary scleral buckling for RD repair without significant intraoperative or postoperative complications. Conclusions: The new modified endolaser instrument can be safely used in a nonvitrectomized eye during chandelier scleral buckling.

Depression in Individuals With Diabetic Retinopathy in the US National Health and Nutrition Examination Survey, 2005-2008.

PURPOSE: To examine the relationship between diabetic retinopathy (DR) and depression in the United States. DESIGN: Retrospective, cross-sectional study. METHODS: National Health and Nutrition Examination Survey (NHANES) participants between 2005 and 2008 (ages 40-85 years) were included. Prevalence of major depression among DR stages as determined by retinal imaging was estimated. Multivariable models assessed associations between depression and DR. RESULTS: Depression was more common in those with moderate to severe DR (16%) than in those with no DR (7%), mild nonproliferative diabetic retinopathy (NPDR, 6%), or proliferative DR (5%). In a model with DR stages that adjusted for demographic factors, there was an association between moderate to severe DR and depression (odds ratio [OR], 2.46, 95% CI, 1.03-5.85). CONCLUSIONS: Depression was more prevalent in those with moderate to severe NPDR than in those with no DR, mild NPDR, or proliferative DR. This relationship is statistically significant after adjustment for demographic factors.

TACROLIMUS FOR IMMUNOSUPPRESSION IN PATIENTS WITH NONINFECTIOUS INTERMEDIATE, POSTERIOR, OR PANUVEITIDES.

PURPOSE: To evaluate the effectiveness of tacrolimus in patients with noninfectious intermediate, posterior, or panuveitis needing a two-immunosuppressive-agent regimen. METHODS: Design: Retrospective cohort study. Setting: Two tertiary-care uveitis practices at academic medical centers. Patient population: Thirty-two patients with noninfectious intermediate, posterior, or panuveitides in whom single-agent immunosuppression was inadequate to effect successful corticosteroid sparing. Intervention: tacrolimus, added as the second immunosuppressive agent. Main outcome measure: successful corticosteroid sparing, defined as inactive uveitis at a dose of prednisone ≤7.5 mg/day. RESULTS: Active uveitis was present in 65.6% of patients at initiation of tacrolimus, and the median time to inactive uveitis was 1.5 months (95% confidence interval 1.2, 4.08). The median time to successful corticosteroid sparing was 3.9 months (95% confidence interval 1.41, 6.67), and by 6 months of follow-up successful corticosteroid sparing was achieved in 75% of patients. Tacrolimus was discontinued for side effects in five patients, three for tremor, and two for hyperglycemia. All side effects were reversible with tacrolimus discontinuation. CONCLUSION: Tacrolimus seems to have efficacy as a second immunosuppressive agent in two-immunosuppressive drug regimens, when a single agent does not permit successful corticosteroid sparing. Side effects were reversible with tacrolimus discontinuation.

Amniotic Membrane Patching to Assist Closure of Recalcitrant Macular Holes.

BACKGROUND AND OBJECTIVE: This study reports a case series of patients with persistent macular holes (MHs) who underwent human amniotic membrane subretinal placement to achieve successful anatomic MH closure. PATIENTS AND METHODS: This was a retrospective case series of patients with persistently open full-thickness MHs who underwent human amniotic membrane placement. Patients were observed up to 6 months postoperatively. RESULTS: Ten patients were included. The mean preoperative best-corrected visual acuity was 1.6 logMAR (20/800). Postoperatively, mean best-corrected visual acuity improved to 1.3 logMAR (20/400) at 1 month and 1.1 logMAR (20/250) by the 3- and 6-month visits. In all cases, the MH appeared closed at the 1-week visit and remained closed at their last follow-up. Optical coherence tomography showed closure in all cases. No adverse events were reported. CONCLUSIONS: Human amniotic membrane sub-retinal placement may serve as a useful surgical technique to assist in the closure of recalcitrant macular holes. [Ophthalmic Surg Lasers Imaging Retina 2023;54:218-222.].

SUBRETINAL DRUSENOID DEPOSITS AND SOFT DRUSEN: Are They Markers for Distinct Retinal Diseases?

PURPOSE: Soft drusen and subretinal drusenoid deposits (SDDs) characterize two pathways to advanced age-related macular degeneration (AMD), with distinct genetic risks, serum risks, and associated systemic diseases. METHODS: One hundred and twenty-six subjects with AMD were classified as SDD (with or without soft drusen) or non-SDD (drusen only) by retinal imaging, with serum risks, genetic testing, and histories of cardiovascular disease (CVD) and stroke. RESULTS: There were 62 subjects with SDD and 64 non-SDD subjects, of whom 51 had CVD or stroke. SDD correlated significantly with lower mean serum high-density lipoprotein (61 ± 18 vs. 69 ± 22 mg/dL, P = 0.038, t-test), CVD and stroke (34 of 51 SDD, P = 0.001, chi square), ARMS2 risk allele (P = 0.019, chi square), but not with CFH risk allele (P = 0.66). Non-SDD (drusen only) correlated/trended with APOE2 (P = 0.032) and CETP (P = 0.072) risk alleles (chi square). Multivariate independent risks for SDD were CVD and stroke (P = 0.008) and ARMS2 homozygous risk (P = 0.038). CONCLUSION: Subjects with subretinal drusenoid deposits and non-SDD subjects have distinct systemic associations and serum and genetic risks. Subretinal drusenoid deposits are associated with CVD and stroke, ARMS2 risk, and lower high-density lipoprotein; non-SDDs are associated with higher high-density lipoprotein, CFH risk, and two lipid risk genes. These and other distinct associations suggest that these lesions are markers for distinct diseases.

Unilateral panuveitis secondary to JAK2 mutation-associated lymphoproliferative disease.

A woman in her 70s experienced painless vision loss in the right eye for 1 month. Acute retinal necrosis-induced panuveitis was the referral diagnosis. With dense vitreous haze, a vitrectomy was performed for vitreous biopsy followed by multimodal imaging. Vitreous biopsy yielded negative PCR results for herpes viruses and only inflammatory cells. Post-vitrectomy imaging showed involuted but pervasive pigmentary foci in the outer retina and the retinal pigment epithelium. Concurrently, peripheral blood showed pancytosis with giant platelets and a Janus kinase 2 (JAK2) mutation, which prompted a haematological evaluation. CT and MRI revealed a right frontal lobe intra-axial mass, diagnosed as diffuse large B cell lymphoma (DLBCL). Subsequently, bone marrow aspirate confirmed the pathogenic V617F JAK2 mutation. Following chemotherapy, the patient achieved lymphoma regression and uveitic quiescence. This is the first case report of acute unilateral panuveitis in a patient with JAK2 mutation and DLBCL but without evidence of intraocular involvement.

Intravitreal dexamethasone insert in diabetic macular edema super-refractory to anti-vascular endothelial growth factor therapy.

BACKGROUND: Some patients with diabetic macular edema (DME) fail to completely respond to anti-vascular endothelial growth factor (VEGF) therapy. These patients have a high treatment burden in the absence of significant improvement. We investigate the role of intravitreal dexamethasone insert (IDI) in eyes with super-refractory DME. METHODS: A non-randomized interventional study was performed among eyes with super-refractory DME refractory to anti-VEGF therapy. Eyes were treated with IDI after failing clinical response to anti-VEGF, with a minimum of 15 prior. Failure to respond was defined as failure of vision to improve at least one line on Snellen Acuity chart, central subfield thickness (CST) greater than 320 µm, or failure of CST to improve by 10% or more. Eyes with glaucoma or prior uncontrolled steroid-responsive ocular hypertension were excluded. Patient outcomes were analyzed at weeks 6, 12, 24, and year 1. RESULTS: Six eyes of four patients were identified. All patients had failed aflibercept. The mean number of prior anti-VEGF injections was 34.5. Eyes received an average of 2.92 dexamethasone injections per person-year (PY) and required breakthrough anti-VEGF injection at 1.95/PY. Mean pre-treatment visual acuity was 0.475 LogMAR, improving to 0.342 at week 6, and 0.375 at 1 year. Mean CST pre-injection was 386.5 mm, improving to 315 mm at 1 year. No glaucoma developed. CONCLUSIONS: Intravitreal dexamethasone insert appears effective in eyes with super-refractory DME. IDI resulted in excellent anatomic improvement on SD-OCT as well as modest visual improvement. Injection burden was reduced in those who may otherwise receive years of monthly treatments.

Fundus albipunctatus photoreceptor microstructure revealed using adaptive optics scanning light ophthalmoscopy.

PURPOSE: Fundus albipunctatus is an inherited cause of congenital stationary night blindness. The objective of this report is to describe structural changes occurring in a macular phenotype of a novel RDH5 mutation producing fundus albipunctatus using high-resolution in vivo imaging. A 62-year-old male with longstanding night blindness underwent imaging and genetic evaluation. High-resolution images of the photoreceptor mosaic were compared to those of a healthy subject. Results of a comprehensive ophthalmic evaluation and genetic testing with imaging including fundus photography, spectral-domain optical coherence tomography (OCT), fluorescein angiography (FA), OCT angiography (OCT-A), and adaptive optics scanning light ophthalmoscopy (AOSLO) are described. OBSERVATIONS: The patient presented with visual acuity of 20/25 in both eyes and longstanding poor dark adaptation. Anterior segment examination was unremarkable. Fundoscopy revealed well circumscribed bilateral perifoveal mottling and atrophy in both eyes. Discrete white-yellow flecks were present beyond the vascular arcades extending to the far periphery. Genetic testing revealed a novel compound heterozygous RDH5 mutation (c.388C > T, p.Gln130*; c.665T > C, p.Leu222Pro). OCT demonstrated perifoveal photoreceptor and outer retinal irregularities, which corresponded to a window defect with late staining on FA. OCT-A demonstrated normal retinal vasculature with patchy areas of non-perfusion in the choriocapillaris. Macular abnormalities in both eyes were imaged using AOSLO to assess cone and rod photoreceptor architecture. While clinical features are consistent with a primary rod disorder, confocal AOSLO showed a paucity of normal cones with a small spared central island in both eyes. Rods appeared larger and more irregular throughout the macula. Non-confocal split detection AOSLO imaging revealed the presence of cone inner segments in dark regions of confocal imaging, indicating some degree of photoreceptor preservation. CONCLUSIONS AND IMPORTANCE: The AOSLO imaging of this particular macular phenotype of fundus albipunctatus demonstrates some of the structural photoreceptor abnormalities that occur in this condition, adding insight to the variable presentation of RDH5 retinopathy. The presence of preserved inner segment architecture suggests the possibility that gene therapy could play a future role in treating this condition.

Automated diabetic retinopathy screening for primary care settings using deep learning.

Diabetic Retinopathy (DR) is one of the leading causes of blindness in the United States and other high-income countries. Early detection is key to prevention, which could be achieved effectively with a fully automated screening tool performing well on clinically relevant measures in primary care settings. We have built an artificial intelligence-based tool on a cloud-based platform for large-scale screening of DR as referable or non-referable. In this paper, we aim to validate this tool built using deep learning based techniques. The cloud-based screening model was developed and tested using deep learning techniques with 88702 images from the Kaggle dataset and externally validated using 1748 high-resolution images of the retina (or fundus images) from the Messidor-2 dataset. For validation in the primary care settings, 264 images were taken prospectively from two diabetes clinics in Queens, New York. The images were uploaded to the cloud-based software for testing the automated system as compared to expert ophthalmologists' evaluations of referable DR. Measures used were area under the curve (AUC), sensitivity, and specificity of the screening model with respect to professional graders. The screening system achieved a high sensitivity of 99.21% and a specificity of 97.59% on the Kaggle test dataset with an AUC of 0.9992. The system was also externally validated in Messidor-2, where it achieved a sensitivity of 97.63% and a specificity of 99.49% (AUC, 0.9985). On primary care data, the sensitivity was 92.3% overall (12/13 referable images are correctly identified), and overall specificity was 94.8% (233/251 non-referable images). The proposed DR screening tool achieves state-of-the-art performance among the publicly available datasets: Kaggle and Messidor-2 to the best of our knowledge. The performance on various clinically relevant measures demonstrates that the tool is suitable for screening and early diagnosis of DR in primary care settings.

Acute Vitreous and Intraretinal Hemorrhage with Multifocal Subretinal Fluid in Juvenile X-Linked Retinoschisis.

PURPOSE: To report a rare case of spontaneous vitreous and intraretinal hemorrhage in a patient with juvenile X-linked retinoschisis which was managed conservatively. METHODS: Single patient case report. INTRODUCTION: Juvenile X-linked retinoschisis (JXLR) most often occurs as a result of a genetic defect in the retinoschisin (RS1) gene, causing a separation between the ganglion cell layer and the nerve fiber layer. Spontaneous vitreous hemorrhage has been reported as an uncommon secondary consequence of JXLR. We present a case of spontaneous vitreous and diffuse macular intraretinal hemorrhages in a patient with JXLR which resolved with medical management alone. RESULTS: A 23-year-old man with a history of juvenile X-linked retinoschisis presented to the ophthalmic emergency room complaining of acute onset of floaters in his right eye. On examination, the patient was found to have a new vitreous hemorrhage with diffuse intraretinal hemorrhages in his right eye, without new retinal tears or detachment. SD-OCT demonstrated multifocal pockets of subretinal fluid. The genetic testing panel revealed a hemizygous mutation in the RS-1 gene. He was managed conservatively on oral acetazolamide, with the resolution of the subretinal fluid and with both visual and symptomatic improvement. CONCLUSIONS: Spontaneous vitreous hemorrhage may rarely occur in patients with JXLR, even in the absence of acute retinal tear or detachment. This case demonstrates an atypical presentation of vitreous hemorrhage with diffuse intraretinal hemorrhage and new multifocal areas of subretinal fluid which improved without surgical intervention. Good outcomes may be achieved in these patients with conservative management alone, even in atypical presentations.

Outcomes of pars plana vitrectomy with subretinal tissue plasminogen activator injection and pneumatic displacement of fovea-involving submacular haemorrhage.

OBJECTIVE: Fovea-involving subretinal haemorrhage is challenging to manage with uncertain visual outcomes. We reviewed outcomes of patients with fovea-involving macular haemorrhage treated with pars plana vitrectomy (PPV) and subretinal tissue plasminogen activator (tPA) with pneumatic displacement. METHODS AND ANALYSIS: This is a retrospective interventional case series. All patients with submacular haemorrhage who underwent PPV with subretinal tPA injection were included. Reasons for exclusion encompassed patients who underwent intravitreal tPA injection in the office without surgery, insufficient follow-up or documentation. Primary outcomes of interest were postoperative visual acuity (VA) at month 1 and 3. Secondary outcomes were median VA at month 3 by location of haemorrhage and underlying diagnosis. RESULTS: Thirty-seven total patients were included. The mean age was 68.2 years, with 54.1% (20/37) females. The most common aetiology was exudative macular degeneration (43.2%), followed by undifferentiated choroidal neovascularisation (CNV) (18.9%), polypoidal choroidal vasculopathy (18.9%), traumatic CNV (10.8%), macroaneurysm (5.4%) and proliferative diabetic retinopathy (2.7%). Median preoperative VA was 20/2000, postoperative month 1 was 20/347 (p<0.01), improving to 20/152 (p<0.01) at month 3. Proportion of patients gaining vision 3+ lines in vision was 15/36 (42%). Mean preoperative central subfield thickness on optical coherence tomography was 512.2 µm for sub-retinal pigment epithelium haemorrhage and 648.2 µm for subretinal haemorrhage (p=0.48). Difference in VA by diagnosis was not significant (p=0.60). CONCLUSIONS: PPV with subretinal tPA injection and pneumatic displacement of submacular haemorrhage offers modest visual recovery for a diverse group of patients. Location of haemorrhage or specific diagnosis may not predict outcome.

Gender-Specific Trends in Ophthalmologist Medicare Collections.

PURPOSE: To assess the factors influencing the Medicare collections disparity between male and female ophthalmologists. DESIGN: Retrospective cohort study. METHODS: The Medicare Provider Utilization and Payment Data from 2012-2015 were combined with the 2015 Physician Compare National Downloadable file and US Census data. Three complementary regression models were generated for number of patients seen, number of services performed per patient, and the amount collected per service. Predictor variables included gender, calendar year, geography, years since medical school graduation, and subspecialty. RESULTS: After adjusting for age, geography, and subspecialty, women ophthalmologists collected 42% less as compared to male ophthalmologists, with the median male ophthalmologist out-earning the 75th-percentile female ophthalmologist across almost all age groups, practice categories, and geographic regions. Although women are entering more lucrative subspecialties (cataract and retina) at a higher rate than before, the percentage of women pursuing these subspecialties remains lower than that of men. CONCLUSIONS: Compared with men, women ophthalmologists see fewer patients and have lower Medicare collections. The observed gender gap in collections was highly persistent across years in practice, subspecialty, and geographic region. Future studies are warranted to examine whether the observed gender collections gap results from structural inequities, social circumstances, or personal choices.

Retinal Tamponades: Current Uses and Future Technologies.

PURPOSE OF REVIEW: In this article, the current use and limitations of existing retinal tamponades are discussed. Potential novel developments that address those limitations are subsequently highlighted, along with areas of future improvements. RECENT FINDINGS: While retinal tamponades have existed for decades and improved the treatment of retinal detachments, many problems still exist with their use, including inadequate tamponade of the inferior retina, toxicity from retained heavy liquids, glaucoma, and keratopathy, among others. New advancements in the components of heavy liquids and vitreous substitutes aim to mitigate those issues. SUMMARY: Existing retinal tamponades, including perflurocarbon heavy liquids, fluorinated gases, and silicone oil, have specific limitations that cause potentially avoidable morbidity. New developments, such as heavy silicone oil, novel vitreous gels, and future avenues of approach, such as potentially reabsorbing heavy liquids may help increase our ability to treat retinal detachments with fewer complications.

ASSOCIATION OF RETINAL VEIN OCCLUSION WITH CARDIOVASCULAR EVENTS AND MORTALITY: A Systematic Review and Meta-analysis.

PURPOSE: Previous studies examining the association of retinal vein occlusion (RVO) and cardiovascular events have been inconsistent and have mostly focused on stroke and myocardial infarction. The goal of this study is to use meta-analysis to examine the available evidence examining the association of RVO with incident cardiovascular events and mortality. METHODS: Systematic review and meta-analysis of all longitudinal cohort studies published in PubMed, Embase, and the Cochrane Library from inception to April 7, 2018, that evaluated the association of baseline RVO and incident cardiovascular events and/or mortality, that provided multivariate-adjusted risk estimates with 95% confidence intervals (95% CIs), and that had average follow-up ≥1 year. The Newcastle-Ottawa scale was used to assess study quality. Multivariate-adjusted risk estimates with 95% CI along with study characteristics were extracted from each study, and pooled risk ratios (RRs) with 95% CI were generated using a random-effects model with inverse-variance weighting to account for heterogeneity. Main outcomes were incident stroke (fatal or nonfatal), myocardial infarction, heart failure, peripheral arterial disease, all-cause mortality, and cardiovascular mortality. RESULTS: Fifteen cohort studies with a total of 474,466 patients (60,069 with RVO and 414,397 without RVO) were included. Each study had Newcastle-Ottawa scale score ≥6, indicating moderate-to-high quality. Retinal vein occlusion was associated with increased risk of stroke (RR = 1.45; 95% CI, 1.31-1.60), myocardial infarction (RR = 1.26; 95% CI, 1.17-1.37), heart failure (RR = 1.53; 95% CI, 1.22-1.92), peripheral arterial disease (RR = 1.26; 95% CI, 1.09-1.46), and all-cause mortality (RR = 1.36; 95% CI, 1.02-1.81), but was not associated with increased risk of cardiovascular mortality (RR = 1.78; 95% CI, 0.70-4.48). CONCLUSION: This review suggests patients with RVO have an increased risk of cardiovascular events and all-cause mortality. More studies are needed to determine the highest risk periods for cardiovascular events and mortality after RVO and whether immediate cardiovascular evaluation and intervention will improve outcomes.

Central retinal artery occlusion secondary to Barlow's disease.

PURPOSE: To report a rare case of isolated, unilateral CRAO in a young patient with mitral valve prolapse secondary to Barlow's disease. OBSERVATIONS: A 29-year-old woman with history of premature ventricular contractions and cardiac ablation presented to the emergency room after sudden onset painless visual loss in her left eye (OS). Her vision was 20/20 in her right eye and hand motion in the left. Fundus exam demonstrated a central retinal artery occlusion (CRAO) OS. Computerized tomography of head and neck were unremarkable. She underwent cerebral angiogram and local intra-arterial thrombolysis. Her vision remained stable post-procedure, with marked APD and stable fundus examination. Her cardiac work-up revealed a left atrial mass with calcified mitral valve, and small atrial septal defect. Rheumatologic, hematologic, and auto-immune work-up were unremarkable. She underwent resection of the mass with repair of mitral valve and ASD closure. Surgical pathology was compatible with diagnosis of Barlow's disease, a cause of mitral valve prolapse. The patient underwent intravitreal injection of anti-VEGF therapy at one month follow-up, with vision stable at hand motion and without neovascularization on subsequent evaluation. CONCLUSIONS: In young patients presenting with CRAO, aggressive work-up for systemic disease or embolic source must be undertaken to avoid future sequelae.

ASSOCIATION OF OBSTRUCTIVE SLEEP APNEA WITH CENTRAL SEROUS CHORIORETINOPATHY AND CHOROIDAL THICKNESS: A Systematic Review and Meta-Analysis.

PURPOSE: Obstructive sleep apnea (OSA) has been associated with an array of ocular disorders. This systematic review aims to investigate the association of OSA with central serous chorioretinopathy (CSCR) and subfoveal choroidal thickness changes on enhanced depth imaging optical coherence tomography. METHODS: Systematic review and meta-analysis of all articles published up to November 2017 examining rate of OSA in patients with CSCR versus controls or examining subfoveal choroidal thickness measurements on enhanced depth imaging optical coherence tomography in patients with OSA versus controls. Pooled odds ratios and weighted mean difference with 95% confidence intervals (CIs) were calculated. RESULTS: For the CSCR/OSA analysis, 7,238 patients (1,479 with CSCR and 5,759 controls) from 6 studies were eligible. For the choroidal thickness/OSA analysis, 778 eyes of 778 patients (514 with OSA and 264 controls) from 9 studies were eligible. Patients with CSCR had a 1.56 increased odds of having OSA than controls (odds ratio, 1.56; 95% CI, 1.16-2.10). There was no statistically significant difference in choroidal thickness between mild OSA subjects and controls (weighted mean difference = -3.17; 95% CI, -19.10 to 12.76). Patients with moderate OSA (weighted mean difference = -24.14; 95% CI, -42.16 to -6.12) and severe OSA (weighted mean difference = -51.19; 95% CI, -99.30 to -3.08) had thinner choroidal thickness measurements than controls. CONCLUSION: In summary, our results suggest that patients with CSCR are more likely to have OSA, and that moderate/severe OSA is associated with smaller subfoveal choroidal measurements on enhanced depth imaging optical coherence tomography.