Evaluation of Virtual Vitreoretinal Surgery Fellowship Interview and Match Experience.

Purpose: To evaluate applicants' and programs' experiences during the 2019 and 2020 fellowship application seasons. Methods: An anonymous survey of vitreoretinal surgery fellowship program directors (PDs) (n = 21) and applicants from the 2019 traditional (n = 24) and 2020 virtual (n = 17) match cycles (before and during COVID-19 pandemic, respectively) was conducted. The questions assessed demographics, interview experiences, and overall interview costs. Statistical significance was determined using unpaired and paired 2-sided t tests for applicants and PDs, respectively (P < .05). Results: In 2020, 17.6% of applicants and 15.8% of PDs strongly agreed that they were able to convey themselves well during the interview compared with 50% and 73.7%, respectively, in 2019 (P = .002 and P < .001, respectively). In 2020, 5.9% of applicants and 10.5% of PDs strongly agreed that they gained a good understanding of their counterpart compared with 41.7% and 47.4%, respectively, in 2019 (P < .001 and P = .01, respectively). Regarding cost, 83.3% of applicants and 21.1% of programs spent more than $2000 in 2019, whereas 17.6% of applicants and no program did so in 2020. Conclusions: Although virtual interviews allowed fellowship recruitment to continue during the pandemic, both applicants and PDs expressed uncertainty regarding their abilities to portray themselves and gauge those with whom they interviewed. The benefits of virtual interviews, including decreased cost, increased efficiency, and convenience, must be weighed against these factors.

TEMPORARY KERATOPROSTHESIS WITH PENETRATING KERATOPLASTY IN CONJUNCTION WITH PARS PLANA VITRECTOMY FOR REPAIR OF RETINAL DETACHMENTS IN PATIENTS WITH ANTERIOR AND POSTERIOR SEGMENT PATHOLOGY.

PURPOSE: To review the visual and anatomical outcomes of combined anterior and posterior segment surgery for retinal detachment repair. METHODS AND PATIENTS: Eight patients with combined retinal and corneal disease underwent combined temporary keratoprosthesis with penetrating keratoplasty combined with pars plana vitrectomy for retinal detachment repair with silicone oil tamponade. Visual and anatomical outcomes were reviewed retrospectively. Follow-up ranged from 12 months to 37 months. RESULTS: Preoperative visual acuity ranged from light perception to hand motion. All but one case had proliferative vitreoretinopathy present at the time of surgery. Postoperative visual acuity ranged from hand motion to light perception. At the most recent follow-up visit, all of the patients had attached retinas, no patients had phthisis bulbi, and all but one patient had a clear cornea. However, 3 of these cases (38%) required repeat retinal detachment repair and one of them also required repeat penetrating keratoplasty, which was performed at the time of retinal repair. CONCLUSION: Combined full-thickness penetrating keratoplasty and retinal detachment repair has good anatomical outcomes and is an efficient way to treat complex anterior and posterior segment abnormality. Although postoperative visual function is limited; almost all patients were agreeable to repeat surgery if they were presented with the choice again.

Scleral rupture during retinal detachment repair with primary scleral buckle and cryoretinopexy in a patient with microspherophakia.

Purpose: The purpose of this report is to describe a case of a patient with microspherophakia (MSP) who had a scleral rupture during a retinal detachment (RD) repair with primary scleral buckle and cryoretinopexy. Observations: A 48-year-old woman with MSP presented with six days of expanding loss of vision and photopsias. Examination revealed a superior retinal detachment involving the macula associated with two superior retinal tears. The patient underwent successful placement of a segmental buckle. During cryoretinopexy treatment of the tears, a 4 mm full-thickness scleral rupture occurred. The sclera was immediately closed with interrupted 8-0 nylon sutures and reinforced with a processed pericardium allograft. Subsequent combined phacoemulsification with capsulectomy, zonulectomy, and pars plana vitrectomy with retinal reattachment was performed nine days post buckle placement. Conclusions and importance: This case illustrates that a patient with MSP, even observed in the absence of a genetic syndrome or familial condition, may be at increased risk of scleral rupture during RD repair. Though future investigations are necessary to confirm this association, surgeons should take a conservative approach by having a high clinical suspicion for compromised scleral integrity in patients with MSP and proceeding with caution in procedures that may pose a risk of scleral rupture. A pericardium allograft can be an effective adjunct for scleral rupture repair.

Characterization of Choriocapillaris and Choroidal Abnormalities in Alport Syndrome.

Purpose: To analyze the characteristics of the choriocapillaris and the choroid in patients with Alport syndrome (AS) and investigate their clinical and demographic associations. Methods: Multicenter, cross-sectional study. Forty-two eyes with AS were consecutively enrolled. A cohort of 33 healthy eyes was included as controls. Demographics and medical history were collected for each participant. Each eye underwent 3 × 3 swept-source optical coherence tomography angiography (PLEX Elite 9000 2.0; Carl Zeiss Meditec, Dublin, CA, USA) and spectral-domain OCT (Spectralis HRA2; Heidelberg Engineering, Heidelberg, Germany). Choriocapillaris flow deficit (FD) number, mean FD size, total FD area, FD density, subfoveal choroidal thickness (CT), total CT, and choroidal vascularity index (CVI) were compared between AS and control eyes. Factors associated with the FD density and the CVI in AS were explored with multivariable linear mixed models. Results: There was high intragroup variability in choriocapillaris and choroidal measurements in patients with AS. Choriocapillaris FD in patients with AS were more numerous compared to controls (P = 0.02). FD density in eyes with AS increased with older age (estimate = 0.31% for each year; 95% confidence interval [CI], 0.06-0.57; P = 0.02) and was higher in patients with a history of kidney transplant (estimate = 9.66% in case of positive history; 95% CI, 3.52-15.8; P = 0.006). The CVI was lower in eyes with dot maculopathy (estimate = -3.30% if present; 95% CI, -6.38 to -0.21; P = 0.04) and anterior lenticonus (estimate = -6.50% if present; 95% CI, -10.99 to -2.00; P = 0.006). Conclusions: Patients with AS with kidney involvement requiring transplant may present with more severe choriocapillaris impairment. Lower choroidal vascularity was found in the presence of other ocular structural abnormalities. Translational Relevance: An increased load of choriocapillaris flow deficits on optical coherence tomography angiography was found in patients with Alport syndrome who also had severe kidney disease requiring transplant.

Internuclear Ophthalmoplegia as the First Manifestation of Pediatric-Onset Multiple Sclerosis and Concurrent Lyme Disease.

BACKGROUND Internuclear ophthalmoplegia (INO) presents as a disruption of horizontal conjugate ocular movement and is an uncommon finding in the pediatric population. Its presence warrants a thorough evaluation to search for demyelinating, mass effect, inflammatory, or infectious etiologies. CASE REPORT A 15-year-old African American girl presented to the Emergency Department with acute horizontal binocular diplopia in left gaze. An ophthalmic examination revealed a right INO. She denied any fever, chills, or neck stiffness. Complete blood counts and a metabolic panel were unremarkable. Magnetic resonance imaging (MRI) of the brain and orbits revealed scattered pontine, periventricular, and subcortical white matter signal abnormalities within the left frontal lobe suggestive of active demyelination. MRI of the spinal column also demonstrated multiple areas of increased signal intensity from the C3 to C7-T1 region. Inflammatory and autoimmune studies were negative. However, her serum IgM and IgG studies were positive for Borrelia burgdorferi with negative CSF titers. Cerebrospinal fluid (CSF) analysis demonstrated mildly elevated glucose (82 mg/dL) and oligoclonal bands, but was otherwise unremarkable. She was started on intravenous methylprednisolone and ceftriaxone. She was subsequently diagnosed with pediatric-onset multiple sclerosis and started on disease-modifying therapy, with full resolution of diplopia and INO 2 weeks later. CONCLUSIONS We present a case of INO presenting as the first manifestation of multiple sclerosis in a pediatric patient with a concurrent infectious etiology. A thorough evaluation can lead to earlier identification and treatment of underlying diseases.

Corneal donor tissue preparation for Descemet's membrane endothelial keratoplasty.

Descemet's Membrane Endothelial Keratoplasty (DMEK) is a form of corneal transplantation in which only a single cell layer, the corneal endothelium, along with its basement membrane (Descemet's membrane) is introduced onto the recipient's posterior stroma(3). Unlike Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK), where additional donor stroma is introduced, no unnatural stroma-to-stroma interface is created. As a result, the natural anatomy of the cornea is preserved as much as possible allowing for improved recovery time and visual acuity(4). Endothelial Keratoplasty (EK) is the procedure of choice for treatment of endothelial dysfunction. The advantages of EK include rapid recovery of vision, preservation of ocular integrity and minimal refractive change due to use of a small, peripheral incision(1). DSAEK utilizes donor tissue prepared with partial thickness stroma and endothelium. The rapid success and utilization of this procedure can be attributed to availability of eye-bank prepared precut tissue. The benefits of eye-bank preparation of donor tissue include elimination of need for specialized equipment in the operating room and availability of back up donor tissue in case of tissue perforation during preparation. In addition, high volume preparation of donor tissue by eye-bank technicians may provide improved quality of donor tissue. DSAEK may have limited best corrected visual acuity due to creation of a stromal interface between the donor and recipient cornea. Elimination of this interface with transplantation of only donor Descemet's membrane and endothelium in DMEK may improve visual outcomes and reduce complications after EK(5). Similar to DSAEK, long term success and acceptance of DMEK is dependent on ease of availability of precut, eye-bank prepared donor tissue. Here we present a stepwise approach to donor tissue preparation which may reduce some barriers eye-banks face in providing DMEK grafts.