Assessing Corneal Endothelial Damage Using Terahertz Time-Domain Spectroscopy and Support Vector Machines.

The endothelial layer of the cornea plays a critical role in regulating its hydration by actively controlling fluid intake in the tissue via transporting the excess fluid out to the aqueous humor. A damaged corneal endothelial layer leads to perturbations in tissue hydration and edema, which can impact corneal transparency and visual acuity. We utilized a non-contact terahertz (THz) scanner designed for imaging spherical targets to discriminate between ex vivo corneal samples with intact and damaged endothelial layers. To create varying grades of corneal edema, the intraocular pressures of the whole porcine eye globe samples (n = 19) were increased to either 25, 35 or 45 mmHg for 4 h before returning to normal pressure levels at 15 mmHg for the remaining 4 h. Changes in tissue hydration were assessed by differences in spectral slopes between 0.4 and 0.8 THz. Our results indicate that the THz response of the corneal samples can vary according to the differences in the endothelial cell density, as determined by SEM imaging. We show that this spectroscopic difference is statistically significant and can be used to assess the intactness of the endothelial layer. These results demonstrate that THz can noninvasively assess the corneal endothelium and provide valuable complimentary information for the study and diagnosis of corneal diseases that perturb the tissue hydration.

Corneal reinnervation in patients with severe neurotrophic keratopathy secondary to herpes zoster ophthalmicus after treatment with autologous serum tear drops.

Purpose: To study potential corneal reinnervation and recovery of corneal sensation in patients with severe neurotrophic keratopathy (NK) secondary to herpes zoster ophthalmicus (HZO) after treatment with topical autologous serum tears (AST). Method: Four cases of HZO with severe NK were followed clinically and by serial laser in vivo confocal microscopy (IVCM, HRT3/RCM, Heidelberg Engineering) before and during treatment with 20% AST drops eight times a day. Two masked observers reviewed the IVCM images and assessed corneal nerve alterations. Results: At baseline, all patients had complete loss of corneal sensation. In addition, IVCM showed complete lack of the subbasal corneal nerve plexus in all patients. All four patients were refractory to conventional therapies and were treated with AST drops. All patients demonstrated significant nerve regeneration by IVCM within 3-7 months of treatment. The total nerve density increased to a mean ± SEM of 10,085.88±2,542.74 µm/mm2 at the last follow up. Corneal sensation measured by Cochet-Bonnet esthesiometry improved to a mean ± SEM of 3.50±1.30 cm. Interestingly, 3 of 4 patients developed stromal keratitis with ulceration within weeks of corneal reinnervation, which was reversed by adding topical steroids. Conclusion: Autologous serum tears are effective in restoring corneal subbasal nerves and sensation in patients with severe NK secondary to HZO. However, this group of patients may require concurrent topical immunomodulation and antiviral therapy while on AST to prevent stromal keratitis.

Telemedicine at a University Ophthalmology Practice During the Beginning of the COVID-19 Pandemic.

Purpose: The aim of the research was to evaluate the use of teleophthalmology at a university practice during the COVID-19 pandemic, specifically examining precision, effectiveness, and patient satisfaction. Patients and Methods: Telemedicine visits were offered to new and established patients requesting appointments with the Stony Brook University Department of Ophthalmology between March 30 and June 2, 2020. Records from these visits were reviewed for chief complaint, past medical and ocular history, diagnoses, treatment/management, and providers' sub-specialty. Precision was determined by comparing agreement between diagnoses of the telemedicine visit with those of the subsequent in-person visit. The decision to follow up in person was made by the physician and patient. Diagnostic precision as well as progression, improvement, or stability of patients' symptoms were determined by the physician's assessment at follow-up visits. Post-telemedicine visit satisfaction surveys were sent to all patients. Results: Telemedicine visits were offered to 783 patients, 520 (66.4%) of whom accepted. Of these 520 patients, 409 (78.7%) were established and 105 (20.2%) had in-person, follow-up visits. Overall, the diagnostic precision of the follow-up visits was 89.5%. Precision differed significantly across ophthalmologic subspecialties. Of the patients who had in-person follow-up visits, 56.8% remained stable, 32.4% improved, and 10.8% worsened. Established patients presented with more extensive ocular histories/procedures and experienced a higher percentage of worsening symptoms/disease stage compared to new patients. Oculoplastics/orbit was the most prevalent diagnostic subspecialty that worsened. Surveys were sent to all patients completing telemedicine visits, 15.0% of whom responded. Overall satisfaction was 91.9%, although only 23.0% of respondents preferred telemedicine to an in-office visit. Conclusion: Telehealth provides high levels of precision and patient satisfaction for a wide range of ophthalmologic visits, although most patients still prefer in-office examinations. Employing teleophthalmology for follow-up and emergency care may provide patients with an effective alternative during pandemic situations and beyond.

Telemedicine involves integration of modern telecommunications technology into medical practice. Over the years, it has demonstrated greater and more widespread utility for different medical specialties, including ophthalmology. As a response to the recent COVID-19 pandemic, the Stony Brook University Department of Ophthalmology provided an option of telemedicine for patients in lieu of in-person eye examinations. In this paper, Stony Brook ophthalmologists report on their experience with teleophthalmology, particularly regarding its utilization, accuracy, effectiveness, precision, and acceptability. The authors examined the records of 520 patients who had telemedicine encounters between March 30 and June 2, 2020. Precision was determined by comparing the initial and final diagnoses of all patients who had an in-person follow-up appointment following a telemedicine visit. Of 105 patients that followed up, precision was determined to be 89.5%. Precision was compared across ophthalmologic subspecialties and found to be statistically similar (p>0.05). Approximately a third of patients improved, while nearly 11% worsened. Established and oculoplastics patients were more significantly likely to worsen. Surverys were sent out to study patients to gauge their satisfaction with their telemedicine experience. Although satisfaction was nearly 92%, only 23% of patients preferred telemedicine to an in-person physician encounter. The authors conclude that teleophthalmology provides a high level of diagnostic precision and patient satisfaction; nevertheless, most patients prefer in-person physician encounters. Telemedicine may provide an effective alternative to in-person ophthalmology assessments, especially during a pandemic. There appears to be a lesser but potentially useful role for teleophthalmology in a non-pandemic setting.

A modified ultrasound-guided surgical technique for the management of the uveal effusion syndrome in patients with normal axial length and scleral thickness.

PURPOSE: The purpose of this study was to describe a modified surgical technique for the management of the uveal effusion syndrome (UES). METHODS: A consecutive interventional case series of six eyes with UES is reported. The diagnosis of the UES was based on detailed ophthalmic examination, fluorescein angiography, B-scan ultrasonography, biometry, and magnetic resonance imaging. All eyes underwent an ultrasound-guided placement of the sclerostomies subjacent to the area of maximal choroidal swelling using a scleral punch without scleral flaps or vortex vein decompression. RESULTS: All patients were men with a mean age of 53 years. The mean postoperative follow-up was 16.25 months. Five eyes had normal axial lengths (22.54-23.05 mm) by ultrasound and normal sclera thickness on magnetic resonance imaging. One eye had a shorter axial length (21.65 mm) and mild scleral thickening on magnetic resonance imaging. All six eyes had anterior peripheral choroidal swelling. Three eyes had associated serous retinal detachment, and three eyes had acute appositional angles. After surgery, five eyes had total resolution of the peripheral choroidal swelling and retinal detachment or normalization of the angle. One eye had partial resolution of the retinal detachment. Of the three eyes with retinal detachment, two eyes experienced improvement in visual acuity after surgery. No complications were noted. CONCLUSION: This modified ultrasound-guided surgical technique for sclerostomy placement seems to be effective in the management of the UES, including eyes with normal axial length and scleral thickness, a subset of the UES that has been previously reported not to respond to surgery.

Giant fornix syndrome: a case series.

PURPOSE: To describe the demographics, characteristics, and treatment of giant fornix syndrome, a rare cause of chronic purulent conjunctivitis in the elderly. METHODS: Retrospective chart review of five patients with giant fornix syndrome evaluated by the Cornea Service, Oculoplastics and Orbital Surgery Service and the Department of Pathology at the Wills Eye Institute. RESULTS: The median age of the 5 female patients was 75 years (mean 80, range 70-95). The median duration of eye symptoms before presentation was 2 years (mean 2.4, range 1-4). Before referral, the chronic conjunctivitis was treated with topical antibiotics in all 5 cases and with additional dacryocystorhinostomy in one case. The right eye was affected in 2 cases, and the left eye was affected in the other 3 cases. Floppy eyelids were present in 2 cases. The superior fornix was involved in 4 cases, and the inferior fornix was involved in one case. Pseudomembranes and superficial punctate keratitis (SPK) were seen in 3 cases. Diagnosis of giant fornix syndrome was made in all 5 cases. Conjunctival culture grew methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and S. aureus in singular cases. Case 1 was treated with topical moxifloxacin, Case 2 was treated with topical vancomycin and repair of the upper eyelid, Case 3 was treated with topical besifloxacin, and Case 4 was treated with dacryocystorhinostomy and topical vancomycin. Case 5 was treated with reconstruction of the left upper eyelid. The median duration of follow up was 4 months (mean 21.6, range 1-84). CONCLUSIONS: Giant fornix syndrome can lead to chronic relapsing conjunctivitis in the elderly. Deep conjunctival fornices in affected patients can be a site for prolonged sequestration of bacteria causing recurrent infections. Removing the infected debris from the superior fornix and reconstruction of the upper eyelid may prevent the recurrent chronic persistent infection.

Corneal changes in ectrodactyly-ectodermal dysplasia-cleft lip and palate syndrome: case series and literature review.

The aim of this study is to describe the corneal changes in three unrelated patients with ectrodactyly-ectodermal dysplasia-cleft lip and palate (EEC) syndrome and review the literature on the possible etiology and clinical presentation of similar cases. Case 1 is an 18-year-old female with cleft lip and palate, syndactyly, and bilateral corneal pannus superiorly and inferiorly. She was initially diagnosed and treated as herpes simplex virus keratitis. Case 2 is a 3-year-old female born with cleft lip and palate, absent radial digits in both hands, and bilateral lacrimal stenosis. She developed progressive stromal scarring and neovascularization in both eyes. Her cornea perforated after developing infectious ulceration. Case 3 is a 49-year-old male with cleft palate, claw-hand deformities, absent meibomian glands and lacrimal duct, right ankyloblepharon, and a superior wedge-shaped opacity in the left cornea. The clinical findings demonstrated the different spectrum of keratopathy seen in patients with EEC. All patients were treated medically and without any surgical intervention. Limbal stem cell deficiency (LSCD) is presumed to be the cause in all three cases. Corneal changes in EEC can have variable presentation. LSCD seems to be the etiology of such keratopathy. Recurrent infection from lacrimal drainage obstruction and tear film instability are other risk factors for disease severity and progression.

Comparison of Comorbid Associations and Ocular Complications in Herpes Simplex and Zoster Keratitis.

A retrospective chart review examined adult patients with herpes simplex (HSV) and zoster (HZO) keratitis at a single institution. Patients who suffered a poor outcome (defined as visually significant corneal scarring, neurotrophic keratitis, secondary glaucoma, or requiring corneal surgery) were identified and each outcome type was analyzed in relation to age, sex, diabetes mellitus, immunosuppression, and a prior history of ≥2 ocular procedures.Advanced age, diabetes mellitus, and a prior history of ≥2 ocular procedures may be risk factors for poor outcomes in HSV, but not HZO, keratitis. In HSV, older age and DM were specifically associated with visually significant corneal scarring, while older age and male sex were associated with secondary glaucoma. Future prospective studies are warranted to determine the ideal management (including prophylaxis) in patients with these characteristics.

Non-contact terahertz spectroscopic measurement of the intraocular pressure through corneal hydration mapping.

Elevated intraocular pressure (IOP) results in endothelial layer damage that can induce corneal hydration perturbations. We investigated the potential of terahertz spectroscopy in measuring the IOP levels through mapping corneal water content. We controlled the IOP levels in ex vivo rabbit and porcine eye samples while monitoring the change in corneal hydration using a terahertz time-domain spectroscopy (THz-TDS) scanner. Our results showed a statistically significant increase in the THz reflectivity between 0.4 and 0.6 THz corresponding to the increase in the IOP. Endothelial layer damage was confirmed using scanning electron microscopy (SEM) of the corneal biopsy samples. Our empirical results indicate that the THz-TDS can be used to track IOP levels through the changes in corneal hydration.

Sinus opacification associated with exacerbation of thyroid eye disease.

PURPOSE: To describe the association of sinus opacification with exacerbation of thyroid eye disease. Three cases followed orbital decompression performed when disease was quiescent and one case occurred without prior orbital or sinus surgery. DESIGN: Retrospective observational case series. METHODS: Four patients' charts were retrospectively reviewed. RESULTS: Three patients with thyroid eye disease (TED), whose ophthalmopathy was stable after orbital decompression surgery, experienced recurrence of TED signs and symptoms after development of sinus inflammation. The fourth patient with TED did not have orbital surgery but presented with unilateral ophthalmopathy and ipsilateral sinus opacification. CONCLUSION: Paranasal sinus disease can exacerbate TED, possibly through a nonspecific inflammatory response. Minimizing inflammation proximal to the orbit may afford some protection against progression of the orbital process occurring in TED.

Observational Clinical Studies of Human Lens Transparency Using the Vision Index Pen.

PURPOSE: Preventing or delaying the onset of presbyopia and cataract formation remains a challenge. The goal of this study was to establish the utility of the Vision Index Pen (VIP), designed to measure in vivo dynamic light scattering (DLS) from the crystalline lens, in the detection of early cataract or loss of accommodation and to show reproducibility through trials at two independent sites. The gradual loss of transparency of the lens was characterized by the lens crystallin aggregation index (LCX) derived from measured DLS data. METHODS: Volunteers in different age groups participated in two independently operated observational clinical studies. All subjects underwent a detailed eye exam and VIP measurement of the intensity correlation of the backscattered light from the lens. RESULTS: LCX values extracted from DLS data show strong correlation with the aging lens, ranging from 20 at the age of 20 years to over 150 at 60 years. Quantitatively significant changes in the LCX value occur from 35 years to 55 years. LCX values were found to correlate with the loss of accommodation (correlation of -0.563 with P < 0.001) and with published data regarding the change in relative lens resistance with age. CONCLUSIONS: Results from two independent observational clinical trials have confirmed the repeatability and reproducibility of the VIP diagnostic device as a viable clinical tool for tracking localized macromolecular changes taking place in the aging lens. Detection of early changes in the crystalline lens can be useful in developing patient-specific prediction models, which can be used to screen patients who may benefit from early therapeutic interventions for delaying the onset of presbyopia and cataract growth. TRANSLATIONAL RELEVANCE: The VIP diagnostic device provides in vivo access to the human lens, enabling characterization of the unfolding and decomposition of long-lived macromolecules.

Refractive outcomes of phacoemulsification after pars plana vitrectomy using traditional and new intraocular lens calculation formulas.

PURPOSE: To evaluate refractive outcomes of cataract surgery in previously vitrectomized eyes and compare the accuracy of intraocular lens (IOL) calculation formulas in this population. SETTING: Stony Brook University Hospital, Stony Brook, New York, USA. DESIGN: Retrospective case series. METHODS: All electronic medical records of patients who had phacoemulsification from 2013 to 2017 were reviewed. Patients who had previously had pars plana vitrectomy in the same eye were selected. Patients with a history of refractive surgery, silicone oil in the eye, or other factors preventing accurate IOL power calculation were excluded. RESULTS: The mean postoperative spherical equivalent was -0.16 diopter (D) ± 0.81 (SD) (n = 61). The mean prediction errors were 0.30 ± 0.82 D, -0.09 ± 0.76 D, 0.23 ± 0.76 D, 0.25 ± 0.81 D, 0.04 ± 0.85 D, 0.30 ± 0.82 D, 0.33 ± 0.79 D, and 0.45 ± 0.80 D with the Holladay 1, Wang/Koch (WKA) adjusted Holladay 1 (n = 14), Holladay 2 (n = 48), SRK/T, WKA SRK/T (n = 14), Hill-Radial Basis Function (n = 50), and Ladas formulas, respectively. The formula with the highest percentage of predictions within ±0.50 D of the postoperative outcome was the Holladay 2 (60.42%). Statistically significant differences between the predicted and actual refractive outcomes were found with all formulas (P < .05) except the WKA Holladay and WKA SRK/T. Intraclass correlation showed low repeatability (<0.50) for all formulas. CONCLUSIONS: Refractive outcomes after cataract extraction in vitrectomized patients can be variable and more hyperopic than the predicted outcomes using traditional and newer IOL calculation methods. Thus, predicting refractive outcomes in this population is challenging, and patients should be counseled accordingly.

A review of teaching methods and outcomes of resident phacoemulsification.

Cataract surgery with phacoemulsification is a challenging procedure for surgeons in training to learn to perform safely, efficiently, and effectively. We review the auxiliary learning tools outside the operating room that residency programs have incorporated into their curriculum to improve surgical skills, including wet laboratory and surgical simulators. We then discuss different methods of teaching cataract surgery in the operating room. Our goal is to define a learning curve for cataract surgery. We demonstrate that complication rates decline significantly after a resident performs an average of 70 cases. We summarize the reported incidence and risk factors for complications in resident-performed cataract surgery to help identify cases that require a higher level of skill to improve visual outcomes. We suggest that future studies include details on preoperative comorbidities, risk stratification, resident skill level, and frequency of takeover by attending.

Improved refractive outcomes of postgraduate year 4 cataract surgery after implementing a stepwise biometry lecture series reinforced by self-assessment at a teaching program.

PURPOSE: To determine whether a structured biometry course improves refractive outcomes of resident phacoemulsification. SETTING: Northeast Veterans Administration Hospital, Northport, New York, USA. DESIGN: Retrospective case study. METHODS: Phacoemulsification surgeries performed by residents before and after a biometry curriculum were reviewed. The inclusion criterion was phacoemulsification performed by residents. Patients with fewer than 3 months of follow-up were excluded. The main outcome measure-the mean absolute difference between the target and final refraction-was compared using a linear mixed model. RESULTS: Phacoemulsification surgeries performed by 4 residents before (n = 223) and by 4 residents after (n = 242) a biometry curriculum was implemented were reviewed. All measured preoperative factors were similar in both groups, including age, visual acuity, axial length, steep and flat keratometry values, astigmatism, anterior chamber depth, and lens thickness. Before the biometry course was instituted, 10% of patients had a mean absolute difference of less than 0.25 diopter (D); the percentage was 35% afterward. The mean absolute difference was less than 0.50 D in 40% before the curriculum was initiated and 70% after. The mean absolute difference was less than 1.00 D in 75% before the curriculum was initiated versus 94% after (all P < .05). The corrected distance visual acuities were similar in both groups, with 83% and 80%, respectively, having an acuity of at least 20/25 (P > .05). CONCLUSION: Residents' refractive predictions significantly improved after a formal biometry curriculum, showing that improvements in resident surgical outcomes are possible with structured curriculums reinforcing outcome measures. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

A 31-year-old man with bilateral blurry vision and floaters.

We report a case of bilateral multifocal retinochoroiditis and bilateral optic disc edema in a patient with cat-scratch disease from Bartonella henselae. The patient initially had negative serologic testing. Repeat testing showed a markedly increased IgG and IgM convalescent titer and the development of a branch retinal artery and vein occlusion. In patients for whom there is a high clinical suspicion of cat-scratch disease, a convalescent titer should be obtained 2-3 weeks following a negative initial result.

Trabeculectomy for traumatic hyphema in sickle cell trait.

A case report of a traumatic hyphema in a patient with sickle cell trait is presented. A review of the published literature in PubMed was performed and medical management strategies and surgical treatment indications for traumatic hyphema are discussed. We support the case for temporary trabeculectomy in patients with traumatic hyphema and sickle cell disease.