Telemedicine screening for cytomegalovirus retinitis using digital fundus photography.

BACKGROUND: Screening for cytomegalovirus retinitis (CMVR) is important in patients with acquired immune deficiency syndrome and low CD4(+) counts. However, many human immunodeficiency virus (HIV) patients lack access to specialist ophthalmological care. Telemedicine screening is a cost-effective method for screening these patients. We aimed to report the use of composite nine-field digital fundus photography (DFP) images for CMVR screening. We report its sensitivity and specificity in detecting CMVR and the level of agreement with gold-standard binocular indirect ophthalmoscopy. MATERIALS AND METHODS: An audit was performed on our national CMVR screening program that screened all HIV patients referred to the Ophthalmology Department at Tan Tock Seng Hospital, Singapore. All patients underwent retinal screening with DFP. Images were categorized as CMVR-positive, CMVR-negative, suspicious, or unreadable by blinded retinal specialists. Patients subsequently underwent dilated gold-standard indirect ophthalmoscopy by a different retinal specialist. Diagnoses were categorized as CMVR-positive, CMVR-negative, or unreadable. Sensitivity and specificity of retinal findings on DFP and kappa values for level of agreement between the two screening methods were calculated. RESULTS: Three hundred seventy screenings on 188 patients were performed. Twenty-three eyes diagnosed with CMVR on indirect ophthalmoscopy were also identified on DFP (100% sensitivity). A 99.9% specificity was achieved. The fundus photograph of one eye without CMVR was read as CMVR-positive because of an artifact, accounting for a false-positive. Kappa values ranged from 0.739 to 0.987. CONCLUSIONS: DFP is a sensitive and specific method of screening HIV patients for CMVR and has a high level of agreement with indirect ophthalmoscopy.

Surgically-induced corneal changes following macular translocation with punctate retinotomies and chorioscleral infolding (limited macular translocation).

INTRODUCTION: To report the sequential changes in corneal topography and astigmatism following limited macular translocation. CLINICAL PICTURE AND TREATMENT: A 45-year-old-man who underwent limited macular translocation for idiopathic subfoveal choroidal neovascularisation in the right eye was evaluated by corneal topography and manifest refraction preoperatively and serially for 1 year postoperatively. OUTCOME: An increase in astigmatism with corneal steepening along meridians corresponding to the area of chorioscleral infolding was observed and this persisted for 1 year after surgery. Vector-analysed astigmatic change showed significant surgically induced astigmatism of 2.18 dioptres (D) X 52.9 degrees, 2.17 D X 57.8 degrees and 2.56 D X 59.1 degrees at 2, 5 and 12 months after surgery respectively. CONCLUSION: Surgically induced corneal changes are evident after limited macular translocation and may remain up to 1 year after surgery.

Neisseria meningitidis keratitis in adults: a case series.

INTRODUCTION: The aim of this case series is to describe the clinical course of 2 patients with Neisseria meningitidis corneal ulcers. CLINICAL PICTURE: A 49-year-old man (Patient 1) and a 22- year-old man (Patient 2) both experienced eye pain and were found to have corneal ulcers with surrounding infiltrate and ground-glass appearance. Gram-negative diplococci were seen in the first case. N. meningitidis was isolated in culture of corneal scrapings from both patients. TREATMENT: Patient 1 was treated with levofloxacin (0.5%) and cefazolin (50 mg/mL) eye drops hourly and intravenous ceftriaxone and oral rifampicin. Patient 2 was treated with cefazolin (50 mg/mL) and gentamicin (14 mg/mL) eye drops hourly, as well as intravenous ceftriaxone. OUTCOME: The corneal ulcers resolved with anterior stromal scarring and no impairment of vision. CONCLUSIONS: Corneal ulcers caused by N. meningitidis may respond well to treatment without permanent visual sequelae. However, in view of the potential ocular and systemic complications, it is important to investigate and treat patients with N. meningitidis infection aggressively.

A Cytomegalovirus Retinitis Screening Program: Evaluation of Enrollment Criteria for HIV Patients in Singapore.

PURPOSE: Identification of optimal enrollment criteria for a CMVR screening program suitable for a resource-limited environment. METHODS: A prospective audit was performed on newly diagnosed HIV patients referred for CMVR screening with any of the following four criteria: (1) visual symptoms, (2) low CD4(+) counts (<50 cells/µL), (3) AIDS-defining illnesses (ADI), and/or (4) opportunistic infections (OI). Odds ratios for each of the demographic factors and enrollment criteria were calculated. Sensitivities, specificities, and workload reduction for the various combinations were determined. RESULTS: A total of 348 screening visits for 176 HIV patients were performed. While individually only ADI was statistically significant for increased CMVR risk, the combination of CD4(+) counts <50 cells/µL with either ADI or visual symptoms or all 3 criteria were also statistically significant. Two enrollment criteria, ADI and ADI with CD4(+) <50 cells/µL, demonstrated good sensitivities, specificities, and workload reduction. CONCLUSION: We propose ADI and possibly CD4(+) counts <50 cells/µL as enrollment criteria for CMVR screening.

Evaluation of biofilm formation on nylon sutures removed from clinically noninfected eyes after cataract surgery.

PURPOSE: To determine the presence of bacterial biofilm on nylon sutures removed from clinically noninfected eyes after cataract surgery. SETTING: The Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore. METHODS: Sutures were removed from 10 eyes after cataract surgery at different time periods. Immediately after removal, the sutures were fixed and dehydrated. All sutures were viewed by scanning electron microscopy, and 6 were also viewed by transmission electron microscopy (TEM). RESULTS: There was no evidence of bacterial biofilm formation on the nylon sutures. Significant cellular debris was seen, mainly at the knots. Clusters of coccoid-shaped structures were visible; however, examination by TEM showed they were not bacteria. CONCLUSION: There was no evidence of biofilm formation on sutures removed after cataract surgery from clinically noninfected eyes.

Spontaneous resolution of corneal oedema after inadvertent 'descemetorhexis' during cataract surgery.

A 96-year-old lady underwent cataract surgery complicated by the loss of a 5.5 mm diameter area of Descemet's membrane (DM) centrally. Postoperatively, severe corneal oedema with folds in the remaining annular ring of DM were observed. The patient was managed conservatively and the corneal oedema gradually resolved over 5 months. Loss of DM can be managed conservatively with good visual outcome without the need for surgical intervention.