Ocular Complications in the Prone Position in the Critical Care Setting: The COVID-19 Pandemic.

PURPOSE: Ocular complications are common in the critical care setting but are frequently missed due to the focus on life-saving organ support. The SARS-CoV-2 (COVID-19) pandemic has led to a surge in critical care capacity and prone positioning practices which may increase the risk of ocular complications. This article aims to review all ocular complications associated with prone positioning, with a focus on challenges posed by COVID-19. MATERIALS AND METHODS: A literature review using keywords of "intensive care", "critical care", "eye care", "ocular disorders", "ophthalmic complications," "coronavirus", "COVID-19," "prone" and "proning" was performed using the electronic databases of PUBMED, EMBASE and CINAHL. RESULTS: The effects of prone positioning on improving respiratory outcomes in critically unwell patients are well established; however, there is a lack of literature regarding the effects of prone positioning on ocular complications in the critical care setting. Sight-threatening ophthalmic disorders potentiated by proning include ocular surface disease, acute angle closure, ischemic optic neuropathy, orbital compartment syndrome and vascular occlusions. CONCLUSIONS: COVID-19 patients may be more susceptible to ocular complications with increased proning practices and increasing demand on critical care staff. This review outlines these ocular complications with a focus on preventative and treatment measures to avoid devastating visual outcomes for the patient.

Safety profile and surgical outcomes of early vitrectomy in eyes with unexplained fundus-obscuring vitreous haemorrhage.

OBJECTIVES: To investigate the safety profile and the surgical outcomes in a large cohort of subjects undergoing early vitrectomy for unexplained fundus-obscuring vitreous haemorrhage (FOVH). METHODS: Retrospective, single-centre case series of 186 consecutive eyes presenting between January 2018 and February 2020. Primary outcomes included change in best-corrected visual acuity (BCVA), rate of intra-operative retinal tears or retinal detachment (RD), baseline proliferative vitreoretinopathy (PVR), association of demographics with clinical outcomes, and rate of significant adverse events characterised by reoperation. RESULTS: Main final diagnosis was haemorrhagic posterior vitreous detachment (76%) and the overall risk of a retinal tear with or without RD found at the time of surgery was 69%. Vitrectomy was completed within 24 h in 94% of eyes. Rate of RD was 18%; all cases were macula-sparing with no PVR. Mean change in BCVA from baseline to final follow-up was -1.53 ± 0.69 LogMAR, p < 0.001. Time from presentation to surgery was significantly associated with final BCVA (p = 0.036, beta co-efficient 0.097). There was a significant association between presence of RD and age <60 y (OR 0.94, 95%CI [0.90-0.98], p = 0.003). 4.8% required repeated vitrectomy for post-operative RD (4), epiretinal membrane formation (3), removal of oil (1), and recurrent FOVH (1). None of these reoperations were induced by complications during the first surgery. CONCLUSION: There is a high rate of retinal breaks in cases with unexplained FOVH, and the risk of a concomitant RD is higher in younger subjects. Early vitrectomy within 24 h appears a safe first-line treatment and yields good clinical outcomes.

Predictive Factors for Magnetic Resonance Imaging Changes Suggestive of Demyelination in Adult Patients with Uveitis Scanned Prior to Commencing Adalimumab Therapy.

PURPOSE: To report the predictive clinical factors for abnormal magnetic resonance imaging (MRI) scans suggestive of demyelination by analysis of MRI's performed for adult non-infectious uveitic patients prior to commencing adalimumab therapy. METHODS: Retrospective case review of 240 patients was conducted in a single tertiary institution between November 2017 and March 2020. Aetiology of underlying disease, clinical characteristics, and MRI outcomes were analysed. RESULTS: The presence of bilateral idiopathic intermediate uveitis (IIU) (p = .0048) and neurological symptoms (p = .028) were highly predictive of an abnormal MRI strongly suggestive of demyelination (MRSSD); 5 out of 64 scans (7.8%) with these clinical characteristics had MRSSD. CONCLUSIONS: Tumor necrosis factor antagonist-induced demyelination is a concern in adalimumab use. We propose an MRI screening protocol to identify those at high risk of demyelination; positive results can be maximised by screening all patients with IIU and those with neurological symptoms.

A machine learning system to optimise triage in an adult ophthalmic emergency department: a model development and validation study.

Background: A substantial proportion of attendances to ophthalmic emergency departments are for non-urgent presentations. We developed and evaluated a machine learning system (DemDx Ophthalmology Triage System: DOTS) to optimise triage, with the aim of reducing inappropriate emergency attendances and streamlining case referral when necessary. Methods: DOTS was built using retrospective tabular data from 11,315 attendances between July 1st, 2021, to June 15th, 2022 at Moorfields Eye Hospital Emergency Department (MEH) in London, UK. Demographic and clinical features were used as inputs and a triage recommendation was given ("see immediately", "see within a week", or "see electively"). DOTS was validated temporally and compared with triage nurses' performance (1269 attendances at MEH) and validated externally (761 attendances at the Federal University of Minas Gerais - UFMG, Brazil). It was also tested for biases and robustness to variations in disease incidences. All attendances from patients aged at least 18 years with at least one confirmed diagnosis were included in the study. Findings: For identifying ophthalmic emergency attendances, on temporal validation, DOTS had a sensitivity of 94.5% [95% CI 92.3-96.1] and a specificity of 42.4% [38.8-46.1]. For comparison within the same dataset, triage nurses had a sensitivity of 96.4% [94.5-97.7] and a specificity of 25.1% [22.0-28.5]. On external validation at UFMG, DOTS had a sensitivity of 95.2% [92.5-97.0] and a specificity of 32.2% [27.4-37.0]. In simulated scenarios with varying disease incidences, the sensitivity was ≥92.2% and the specificity was ≥36.8%. No differences in sensitivity were found in subgroups of index of multiple deprivation, but the specificity was higher for Q2 when compared to Q4 (Q4 is less deprived than Q2). Interpretation: At MEH, DOTS had similar sensitivity to triage nurses in determining attendance priority; however, with a specificity of 17.3% higher, DOTS resulted in lower rates of patients triaged to be seen immediately at emergency. DOTS showed consistent performance in temporal and external validation, in social-demographic subgroups and was robust to varying relative disease incidences. Further trials are necessary to validate these findings. This system will be prospectively evaluated, considering human-computer interaction, in a clinical trial. Funding: The Artificial Intelligence in Health and Care Award (AI_AWARD01671) of the NHS AI Lab under National Institute for Health and Care Research (NIHR) and the Accelerated Access Collaborative (AAC).

An unusual presentation of thymoma: dysgeusia, ulcerative colitis, keratoconjunctivitis sicca, autoimmune retinopathy and myasthenia gravis.

A 41-year-old female presented with dysgeusia, dry eyes, nyctalopia with progressive visual field constriction (due to autoimmune retinopathy) and gastrointestinal symptoms (due to ulcerative colitis). She was subsequently admitted to intensive care with a myasthenic crisis, and CT of the thorax demonstrated a thymoma.Following thymectomy and adjuvant radiotherapy, she has remained in complete remission from her ulcerative colitis and myasthenia gravis, her retinopathy has stabilised and there has been no thymoma recurrence over a 10-year postoperative period. There was a brief relapse of her dysgeusia (causing weight loss) and dry eye symptoms 3 years after her surgery, which resolved 8 months later. While the association of thymomas with paraneoplastic syndromes (PNS) is well established, it is unusual to present with multiple PNS, and some of these have only been documented in sparse case reports to date. Thymectomy played a crucial role in improvement and stabilisation of her PNS.

Pharmacotherapeutic management of atopic keratoconjunctivitis.

INTRODUCTION: Atopic keratoconjunctivitis (AKC) is a form of allergic eye disease that can have sight threating implications. Prevalence is underestimated due to scarce published data and treatment is expanding as a result of limitations of current strategies. This article aims to provide an up-to-date overview of AKC and summarize current and upcoming management. AREAS COVERED: The authors provide history, immunopathogenesis, and summary of the clinical manifestations of AKC as well as presenting a review of the evidence in relation to treatment options including mast cell stabilizers, antihistamines, corticosteroids, and immunomodulatory drugs based on clinical trials. Future trends, drug targets, and novel delivery drug systems are also highlighted in this review. EXPERT OPINION: Previously established treatment strategies of AKC had relied on corticosteroids, but the side effects of long-term therapy resulted in the expansion into the use of immunomodulatory drugs such as tacrolimus and ciclosporin. However, these too provide limited success due to the suboptimal structural properties of the current molecules. The ideal molecule should generate maximum permeability across the multi-layered structure of the cornea, be able to be formulated into eye drops for ease of application with minimal dosing and for maximal clinical effect.