Prevalence of Glaucoma in Cataract Patients - a Comparison between Pre-Covid and Post-Covid Periods

Objectives: Globally, cataract and glaucoma are the predominant causes of blindness. Screening glaucoma in patients referred for cataract surgery is a convenient tool for detecting glaucoma cases in rural population. The COVID period has adversely affected eye care as the routine screening and follow-ups at hospital were substantially reduced owing to pandemic restrictions. We aim to study the impact of COVID on detection of glaucoma in patients with cataract. Method(s): It was a retrospective study conducted to compare the prevalence of glaucoma in rural patients presenting with cataract pre- and post-COVID. Details of 975 consecutive patients each were taken prior to March 2020 (pre-COVID) and after October 2021 (post-COVID) from hospital database and patient case files. Result(s): The prevalence of glaucoma was higher during the pre-COVID time (3.8%) as compared to pre-COVID (3.8%), but the result was not statistically significant. In both the groups, primary open-angle glaucoma was the pre-dominant form of glaucoma, with prevalence being 1.5% and 2.2% in the pre-COVID and post-COVID groups, respectively. The mean intraocular pressure and mean VCDR values were higher in the post-COVID group as compared to the pre-COVID group, and the result was statistically significant. Conclusion(s): This was the first study to compare the prevalence of glaucoma in patients with cataract in rural population in the pre-COVID and post-COVID periods. In the aftermath of the pandemic, the present study emphasizes the role of screening and follow-ups in glaucoma management to prevent irreversible loss of vision.Copyright © 2023 The Authors.

Central Serous Chorioretinopathy Developed Following Covid-19 Vaccine

A 40-year-old male patient, an office worker, is a hospital staff. He applied with the complaint of sudden onset of blurred vision in the right eye. He stated that he had the first dose of inactivated covid vaccine (sinovac) 4 days ago in his story. In his examination, his vision was 0.5 in the right eye, 1.0 in the left eye, and his intraocular pressure was in both eyes. It was at the level of 15 mmHg. Biomicroscopically, the anterior segment looked natural. CSC was diagnosed in the FFA and OCT examinations.Treatment with oral acetazolamide (2x250 mg), topical nepafanac (4x1) was started. On the 13th day of the treatment, there was insufficient improvement in clinical findings, and oral acetazolamide was used. The dose was reduced (2x125 mg), oral epleronone (50 mg) was added. On the 70th day of the treatment, the vision in the right eye increased to full level in the control examination and it was observed that the retina returned to its normal appearance in the OCT examination.Copyright © 2023 Gazi Eye Foundation. All rights reserved.

Glaukomflecken: The classic and uncommon ocular sign after acute primary angle closure attack.

The widespread of upper respiratory tract symptoms caused by COVID-19 infections has increased the prescription and usage of antitussive and nasal decongestants. We presented a case of ocular acute primary angle closure attack with increased intraocular pressure after COVID-19 therapy. Glaukomflecken, the classic and uncommon ocular sign after acute primary angle closure attack, was demonstrated in this visual case discussion.

Simultaneous Primary Sinonasal Adenocarcinoma and Breast Adenocarcinoma: A Case Report

Sinonasal cancer accounts for roughly only 3% of upper respiratory tract malignancies and generally presents as a primary malignancy. Although extremely rare, the sinonasal cavity is also a known location for metastasis, with 8% of these cases originating from primary breast cancer. When attempting to differentiate primary disease from metastasis, immunohistochemical analyses play a crucial role in reaching the correct diagnosis. To date, there are a handful of reports describing metastasis involving the paranasal sinuses but even fewer reporting primary sinonasal cancer with coexisting primary malignancy. Here we present a case of primary sinonasal adenocarcinoma in the setting of a long-standing history of breast cancer. The patient, a 73-year-old female, was diagnosed with T1cN1aM0, progesterone receptor positive and estrogen receptor negative ductal carcinoma in situ of the left breast in November 2019. She subsequently underwent bilateral mastectomy and treated with 3 cycles of chemotherapy and anastrozole, which were both discontinued due to intolerance. Of note, in March 2019, MRI of the head incidentally found a 3 x 2 cm mass in right nasal cavity extending into ethmoid sinus. One year later, she presented with mild right sided nasal obstruction and drainage, and biopsy revealed squamous and respiratory mucosa with chronic inflammation. The patient elected to cancel initial surgical resection of the mass due to the COVID-19 pandemic. The patient returned in March 2022 with complaints of eye pressure, double vision, headaches, and worsening nasal obstruction. PET/CT scan was negative for distant metastasis but demonstrated increased uptake in sinus cavity. MRI showed a larger 5 x 3.7 cm mass impressing on medial inferior margins of orbit. Imaging also suggested evidence of dehiscence of lamina and irregular neo-osteogenesis of the skull base. She underwent approach and resection of the mass with histology demonstrating a well differentiated, low grade non-intestinal mucinous adenocarcinoma. Immunohistochemistry was positive for pankeratin and CK7, favoring a primary sinonasal origin. It was estrogen receptor negative and negative for GATA3, a sensitive and fairly specific stain in mammary carcinoma. Adjuvant radiation was recommended postoperatively, however the patient declined this therapy. This case highlights the role of immunohistochemistry to discriminate a new primary cancer from metastasis in patients with a history of breast cancer. Clinically, patients with sinonasal metastasis can present with symptoms ranging from unilateral nasal obstruction, facial pain, diplopia, and decreased vision. On imaging, suspicion of malignancy is raised when there is evidence of destruction of bony boundaries and invasion of surrounding tissues such as the orbit and anterior skull base, as found in our patient. Notably, metastasis to the paranasal sinuses can mimic a primary cancer of the nasal cavity, with both tumors showing epithelial differentiation. However, primary tumors often show neoplastic changes in the overlying respiratory epithelium and do not express estrogen receptor, progesterone receptor, or HER2 positivity, which are known to be correlated with breast cancer. In this setting, GATA3 and estrogen receptor negativity allowed us to diagnose primary nasal cancer more confidently. Therefore, clinicians should be aware of metastatic disease and expand immunohistochemistry panels when appropriate.

The causal relationship between COVID-19 and increased intraocular pressure: A bidirectional two-sample Mendelian randomization study.

Background: Coronavirus disease 2019 (COVID-19) has brought great challenges to the global public health system and huge economic burdens to society, the causal effect of COVID-19 and intraocular pressure was blank. Objective: This study aimed to explore the causal association between coronavirus disease (COVID-19) susceptibility, severity and criticality and intraocular pressure (IOP) by bidirectional Mendelian randomization (MR) analysis. Materials and methods: Genetic associations with COVID-19 susceptibility, severity and criticality were obtained from the COVID-19 Host Genetics Initiative. Genetic associations with IOP were obtained from GWAS summary data. The standard inverse variance weighted (IVW) method was used in the primary assessment of this causality. Other methods were also implemented in supplementary analyses. Finally, sensitivity analysis was performed to evaluate the reliability and stability of the results. Results: The results showed that COVID-19 susceptibility had null effect on IOP (ß = 0.131; Se = 0.211; P = 0.533) as assessed by the IVW method. Moreover, the results revealed that COVID-19 severity, specifically, hospitalization due to COVID-19, had a positive effect on IOP with nominal significance (ß = 0.228; Se = 0.116; P = 0.049). However, there were null effect of COVID-19 criticality on IOP (ß = 0.078; Se = 0.065; P = 0.227). Sensitivity analysis showed that all the results were reliable and stable. The reverse MR analysis revealed that there was null effect of IOP on COVID-19. Conclusions: We demonstrated that hospitalization due to COVID-19 might increase IOP; therefore, greater attention should be given to monitoring IOP in inpatients with COVID-19.

Retrospective Analysis of CSR Patient in Pre and Post COVID Era

Background: A retrospective analysis of CSCR patient to ascertain the link between noble corona virus and CSCR disorder. Explosion of covid 19 cases inflated the use of steroid as well as stress in the patients leading to increase CSCR cases in post covid era. Aim: To determine the risk factors in covid 19 patients leading to the development of CSR. Materials and Methods: A Retrospective Observational study was done in a tertiary care center from February 2019-January 2021 including all CSR cases and categorizing them into two groups. One pre covid CSR group with patients of CSR diagnosed between February 2019-January 2020 and Post covid CSR group with newly diagnosed CSR cases between February 2020-January 2021. Results: The pre-covid group had 194 patients with 132 males and 62 females ageing between 24-40 years. Post covid group had 290 patients with 170 males and 120 females ageing between 21-48 years. B/L disease increased from 2 cases to 13 cases after covid. OCT thickness ranged 290-370 m in the pre covid group in comparison post covid group ranged 319-450 m. Mean steroid intake in post covid group was 41%. Conclusion: The outbreak of covid 19 with an increase in stress and irrational use of corticosteroid are major causes of increment in cases of CSR in post covid patients.

Provision of Reading Glasses During Underserved Community-Based Tele-Ophthalmology Screenings

Purpose : The most common cause of blurry vision in the United States is refractive error. Despite being a correctable condition, over 8.2 million people are estimated to have their refractive error go undiagnosed or untreated. Minorities and low-income groups in particular have significantly increased odds of inadequate correction and double the rates of near-vision impairment. We aimed to address this gap in care through the provision of refractive glasses during community-based tele-ophthalmology screenings. Methods : Eight free eye screening events were held in Newark and West New York, NJ. Demographic information, intraocular pressure, visual acuity, auto-refraction, retinal imaging, and optical coherence tomography were obtained from each subject as part of a comprehensive tele-ophthalmology protocol. Reading glasses were provided as needed based on the recommendation of a certified telemedicine reader. Eligible recipients completed surveys on site regarding access to eye care. They were surveyed again by phone after one month to assess degree of satisfaction and vision improvement. Results : 38 subjects (mean age 53, 47% male) qualified for presbyopia correction and received reading glasses. 97% were Hispanic and 3% were African American. Of the 33 that returned surveys, 88% reported not seeing an eye doctor annually. The most common reason was lack of insurance or inability to pay (71%). Others included having no need to see an eye doctor (10%), disliking eye doctors (7%), not knowing the importance of regular eye exams (3%), and COVID-19 (3%). Of the 25 subjects that were reached for follow-up, 92% reported using the glasses daily. Those that did not reported the power was too strong or they did not feel they needed them. Subjects noted an average improvement in vision of 4.4 out of 5 and an average satisfaction of 4.7 out of 5 (Figure 1). Conclusions : Glasses distribution is an effective way to address refractive error in underserved communities. Given the gaps in knowledge and utilization of eye care identified in our study, there is an obvious need for continued outreach to these areas. Further studies will include larger populations and evaluate mobile refraction devices to increase ease and reach of glasses provision.

Automated Puff Tonometry in Comprehensive Community Based Screening for Vision Threatening Diseases during SARS-CoV-2

Purpose : Over 50% of individuals with vision-threatening disease (VTD) (e.g., diabetic retinopathy, glaucoma, macular degeneration) are unaware of their condition, and once diagnosed, 80% will not follow up for clinical care, especially since the onset of SARS-CoV-2 in 2020. Remote teleophthalmology with real-time robotic teleconsultation was implemented to include automated puff-tonometry (APT) as pre-triage to identify patients who require more detailed clinical assessment and treatment. Methods : 224 subjects (58% male) of average age 55 years were screened over 8 events. Following COVID-19 protocols screenings took place in New Jersey churches and health fairs featuring a high prevalence of African American and Hispanic subjects. Masked and self-reported vaccinated subjects underwent medical history, blood pressure, visual acuity (with pinhole), automated puff-tonometry (APT) for intraocular pressures (IOP), automated refraction, non-mydriatic retinal imaging, optical coherence tomography (OCT), and wearable visual field device (WVFD) testing. Face masks were fitted with surgical tape on the nose bridge to limit instrument fogging. To minimize equipment contact, all subjects were screened in the standing position, including APT and retinal imaging (Fig.1). Chi-square and t-tests were performed to assess factors associated with glaucoma referral. Subjects without IOP readings were excluded;significance was set at p<0.05. Results : 10.29% of measured eyes had an IOP>18 and underwent additional testing including OCT-B of the optic nerve head, nerve fiber layer, and ganglion cell complex. 31.43% of eyes with IOP>18 underwent teleconsultation with a glaucoma specialist, vs. 8.85% of eyes with IOP≤18 ((p<0.001), Table 1). The difference in mean age in subjects with glaucoma referral vs. without (57.42 vs. 51.61 years) was significant (p=0.008). Conclusions : APT was useful in supporting on-site OCT-B imaging and WVFD referral (37.67%, 8.52% of total subjects) that yielded 17.94% referral to on-site teleconsultation through a real-time telerobot. Future investigation will include larger and more diverse community-based populations.

Community Based Eye Screenings Using Retinal and OCT-B Combination Imaging in Glaucoma During COVID-19

Purpose : Retinal imaging is the gold standard in tele-ophthalmology. Limitations in twodimensional imaging can lead to poor triage or unnecessary clinical referrals, especially during COVID-19. Combined retinal imaging with Optical Coherence Tomography-B scan (OCT-B) in detecting vision threatening diseases (VTDs) such as glaucoma in communitybased screenings adds a third dimension to subject data. Methods : A non-mydriatic Topcon 3D Maestro1 imaging system was deployed in this pilot study to screen 120 subjects (43.3% male, mean age 55.1) in community-based screenings. Measurements of vertical cup-to-disc ratio (VCDR), nerve fiber layer (NFL) thickness and macular and ganglion cell layer (GCL) thickness were collected along with color retinal images by the Maestro1. Visual acuity and intraocular pressures (IOP) were obtained as part of the screening protocol. Four types of OCTs were acquired: 78.33% 3D Wide, 13.33% 3D Macula, 5.83% 3D Disc, and 2.51% 5-Line Cross. An on-site certified reader (CR) interpreted results and provided consultation follow-up to a remote ophthalmic subspecialist. Results : Of 222 eyes, OCT-B confirmed follow-up in 86.94%. 88.3% of subjects had referable eye pathology: 23.33% to general or specialty eye clinic and 65% to telemedicine. CR glaucoma referral based on OCT-B scan, VCDR and NFL defects was compared to OCT-B referral based on VCDR ≥0.65. Cohen's kappa was 0.546 with 30% disagreement. Compared to CR, OCT-B generated VCDR had a 91.1% specificity and 42.3% sensitivity in detecting glaucoma. VCDR, IOP, NFL, and GCL measurements were significantly correlated with CR glaucoma referral (p<0.05). Only VCDR, NFL, and GCL were significantly correlated with Maestro 1 glaucoma referral (p<0.05). Conclusions : OCT-B images provide valuable added diagnostic information about referrals in glaucoma. Its ability to capture greater depth of information about the eye, such as NFL and GCL measurements, compared to traditional two-dimensional retinal photography, warrants consideration for OCT-B as a replacement for non-mydriatic retinal photography as the gold standard in ophthalmic diagnostics. Further studies can investigate the utility trend analysis of OCT-B in predicting VTD's progression over time.

Telemedicine Assisted Postoperative Care Following Microincision Vitrectomy Surgery

Purpose : Microincision vitrectomy surgery (MIVS) studies have shown low complication rates. In the setting of the COVID-19 pandemic and rural satellite clinics, we investigated the role of telemedicine as an alternative to postoperative visit (POV) regimens after uncomplicated MIVS. Methods : This IRB approved, prospective single-site, and single-surgeon study included patients without any history of glaucoma, ocular trauma, or severe systemic or ocular disease who underwent uncomplicated MIVS for any indication between January-August 2021. Prophylactic topical pressure-lowering drops were prescribed if POV intraocular pressure (IOP) was ≥22 mmHg. POVs included the same day after surgery, week(s) 1, 2, 8, and 12. Patients were randomly assigned (1:1) into two arms: telemedicine (TM) or In-person (IP). Weeks 1 and 8 POV utilized protocol-based and questionnaire guided undilated exams performed by an ophthalmology fellow that were conducted either TM or IP, according to arm assignment. Any patients with concerning symptoms identified at these visits were scheduled for dilated exams with the surgeon. All patients underwent dilated exams performed by the surgeon on the same day after surgery, weeks 2 and 12. Primary endpoint was mean best corrected visual acuity (BCVA). Secondary endpoints included changes in intraocular pressure (IOP), retinal nerve fiber layer thickness, and number of additional visits. Statistical analysis included Mann Whitney U and chi-square tests. Results : Fifty-two eyes from 50 patients (33 female, 17 male;p-value=0.02) with mean ages of 68.4±6.8 years underwent 55 total surgeries with 25 or 27G MIVS platforms. Forty-seven patients have completed all POVs. Mean preop BCVA logMAR was 0.53±0.55 and 0.40±0.45, and at 12 weeks, they were 0.39±0.45 and 0.26±0.33 for the TM and IP groups, respectively. No significant between-group differences were found for primary or secondary outcomes. All cases of abnormal IOP resolved by the following POV with pressure lowering drops. Concerning symptoms were identified in five patients requiring additional visits, revealing two cases of worsening macular edema (1 TM and 1 IP) and one case each of cataract progression (TM), vitreous hemorrhage (IP), and macular hole recurrence (TM). No complications presented at the TM or IP visits. Conclusions : Telemedicine-assisted POV regimens may be a safe and convenient alternative for patients undergoing uncomplicated MIVS.

Robotic Telepresence Consults in Underserved Community-Based Vision Threatening Disease Screenings During COVID-19

Purpose : Vision Threatening Diseases (VTDs) (age-related macular degeneration, cataracts, diabetic retinopathy, glaucoma) affect 36 million individuals in the United States. 50% are unaware they have a VTD, disproportionally affecting minorities and lowincome groups with less access to eye care. While screening programs in underserved communities result in early detection, less than half of subjects with findings follow up with a specialist. This number is four times lower during COVID-19. Methods : Robotic Telepresence (RT) was implemented in this pilot study during COVID19 to increase real-time access to specialist care. 58 subjects (age 56, 45% male) underwent a non-mydriatic screening protocol over five screenings. They were divided into three groups for consult: In Person (IP) followed by RT (N = 21), RT followed by IP (N = 19), and IP only (N = 18). IP consult was done by an on-site certified reader. RT consult was done by an off-site glaucoma or retina specialist with access to blood pressure, visual acuity, intraocular pressure, 45° retinal images, and ocular coherence tomography Bscans via cloud-based software. Video connection for RT was established via HIPAAcompliant mobile hotspot. Subject demographics and preferences were collected afterwards via survey. Results : Of 40 RT consults, 26 were second opinion for VTD suspect and 14 were wellness encounters. 24 reported their last eye care visit >3 years ago or never. Following RT consult, 18 subjects received one or multiple VTD diagnosis and 3 with glaucoma were referred for pressure-lowering eye drops. In the group with IP consult first, preferences were 5% RT, 52% IP, and 43% none. In the group with RT consult first, preferences were 5% RT, 58% IP, and 37% none. There was no significant difference in number of questions asked, wait time, or encounter length between IP and RT consults. Conclusions : RT consults proved valuable in community-based VTD screenings, particularly during COVID-19 when access to eye care is further limited. Most subjects preferred IP. However subjects with VTD that face socioeconomic barriers benefit from immediate RT consult and management directives from remote subspecialists. Further studies should incorporate consults from additional specialties (endocrinologists, general practitioners, social workers) and include telehealth CPT code for reimbursement.

Effectiveness and Safety of Resident-Performed Simultaneous Bilateral Selective Laser Trabeculoplasty in Patients With Open-Angle Glaucoma

Purpose : While its pathophysiology is not fully understood, there are a number of genetic and clinical risk factors associated with glaucoma;the primary risk factor is elevated intraocular pressure (IOP). Laser trabeculoplasty is a widely-used treatment method for glaucoma because it effectively reduces IOP without bearing the greater risks of invasive surgery. Selective laser trabeculoplasty (SLT) is a core competency skill that ophthalmology residents learn;however, competency in SLT is not well-defined, as experience in glaucoma procedures is variable by program. SLT is typically performed one eye at a time. During the COVID-19 pandemic, in-office visits were minimized and surgeries were limited to only the most vision-threatening at the University of Chicago. Bilateral SLT on the same day was used to keep IOP controlled during this period, while patients could not be monitored as frequently and surgeries were postponed. The goal of this study is to assess the effectiveness and safety of same-day bilateral resident-performed SLT in comparison to reported statistics of attending-performed SLT in the literature. Methods : A retrospective chart review of patients who underwent simultaneous bilateral SLT between January 2019-May 2021 was performed to quantify the effectiveness and safety of the procedure compared to published rates in the literature. Specifically, we examined the intraocular pressure (IOP) at the visits before and after the SLT procedure, type of glaucoma diagnosis, Age, Sex, and complications (IOP elevation, iritis, macular edema). Results : Preliminary data included a total of 51 patients (of which 32 were female) and 108 eyes (3 patients underwent SLT twice). Average age was 66. Average IOP was 18.7 mmHg (SD 5.0) on visit prior to SLT and 17.6 (SD 6.5) on day of SLT with the average IOP decreasing to 15.9 (SD 5.0) and 15.7 (SD 4.5) on the first and second follow-up. There were 2 patients in whom we documented IOP spikes on the visit after SLT was performed, one of whom had documented compliance issues on multiple visits. No macular edema or iritis was noted. Conclusions : We found a similar rate of decrease in IOP after bilateral SLT by residents compared to prior studies by attending physicians with very few complications. Resident-performed simultaneous bilateral SLT appears to be an effective and safe option for IOP-lowering.

COVID-19 Associated Optic Neuritis

Purpose : While severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is well known for its respiratory complications, ocular manifestations are emerging. This case report describes a patient with bilateral optic neuritis associated with coronavirus disease 2019 (COVID-19). Methods : A 46-year-old male presented with two weeks of pain with eye movement immediately after testing positive for COVID-19 and four days of bilateral blurry vision. Data including history, ocular examination, Humphrey visual field testing (HVF), magnetic resonance imaging (MRI), and serological testing was collected. Results : Visual acuity (VA) was 20/100 in the right eye (OD) and 20/70 in the left eye (OS) with pinhole VA of 20/40 in each eye. Pupil exam, intraocular pressures, and confrontational visual fields were normal. Ocular motility was full, however the patient endorsed pain with eye movement in all directions. The right optic nerve had blurred disc margins while the left optic nerve was unremarkable on exam. Color vision was decreased to 13/15 by Ishihara testing in each eye. MRI of the brain and orbits revealed bilateral thickening and T2 hyperintensity and hyperenhancement of the intercanalicular and intraorbital optic nerves with sparing of the nerve sheath and no demyelinating lesions (Figure 1). Bilateral central scotomas were seen on HVF (Figure 2). At this point, the patient's clinical picture was concerning for optic neuritis associated with COVID-19. A complete blood count, comprehensive metabolic panel, myelin-oligodendrocyte glycoprotein antibody, and aquaporin 4 antibody were unremarkable. Testing for tuberculosis, sarcoidosis, syphilis, thyroid disease, and rheumatologic and autoimmune disorders was normal. The patient was treated with corticosteroids. Within three to six weeks, the patient's symptoms and abnormal exam findings resolved. Conclusions : Infectious pathogens and their subsequent inflammation can cause optic neuritis. It is postulated that T cells release inflammatory mediators and cytokines that cross the blood brain barrier and lead to destruction of myelin, neuronal cell death, axonal degeneration, and vision loss. SARS-CoV-2 could cause a similar inflammatory response leading to optic neuritis and is important to consider in cases without a clear etiology.

Glaucoma Care Practice Changes Triggered by the COVID-19 Pandemic: A Qualitative Study

Purpose : The COVID-19 pandemic led to changes in glaucoma care to ensure patient and provider safety. In this qualitative interview study, we aimed to identify changes perceived as improvements in care that have persisted, even following vaccine rollout and uptrending patient volumes after the pandemic's initial surges. Methods : From July-December 2021, 20 of 45 (44%) NYC glaucoma specialists contacted were interviewed through semi-structured interviews, utilizing a 15 question guide while allowing for exploration of new topics. Interviews were audio-recorded, transcribed, and thematically analyzed with NVivo qualitative software. Results : Thematic saturation was reached after 15 transcripts. Participants included 12 women and 8 men from 9 institutions, in practice for 6-41 years. When asked to rate the change their practice experienced during the pandemic's first surge on a scale of 1 to 5 (5 being the most change), physicians reported a 4.26 ± 0.94. Certain changes have persisted [Figure 1]. Almost all physicians reported that infection prevention protocols (e.g. hand washing, mask donning) remain and may persist after the pandemic subsides. 9 [45%] reported that increasing the follow-up window for stable patients (e.g. from every 4 months to 6 months) was also a persistent change. While practices initially switched to disposable tools (e.g. tonometer tips, gonioscopy lenses), 9 of 17 [53%] physicians who reported on disposable tools have continued their usage. While disposable tool usage has declined since the first wave [p value=0.003;Figure 2], physicians who continued their usage shared positive views on safety and efficiency. 8 [47%] discontinued their usage, reporting negative sentiments around inaccuracy and waste. Telemedicine was not a persistent change, with only 1 provider continuing to use telemedicine. Reported rationale for discontinuation was the inability to collect data such as intraocular pressure, visual field testing and ophthalmoscopy. Conclusions : COVID-19 continues to impact glaucoma care. Persistent practice changes include infection prevention, extended follow-up windows and disposable tool usage, while telemedicine has largely been discontinued. As glaucoma care continues to evolve, these changes have lasting implications for continuity of care, patient safety and care delivery.

Can SLT safely delay surgery in presurgical primary open angle glaucoma?

Purpose : Selective laser trabeculoplasty (SLT) has been widely used as both a primary and adjunct treatment in glaucoma. Glaucoma surgery was significantly affected during the Covid-19 pandemic due to reduced theatre and clinic capacity. We looked at SLT as a temporary alternative to safely delay surgical intervention in presurgical primary open angle glaucoma (POAG). Methods : This is a retrospective study that included 104 patients who had a diagnosis of POAG and received SLT treatment, with at least 1 year follow-up. Primary outcomes included: reduction in intraocular pressure (IOP), and number of glaucoma medications (NGM). The endpoint was defined as time to be listed for glaucoma surgery. All eyes that had progressive or advanced visual fields and were on 2 or more medications were included. Eyes with previous glaucoma filtration surgery or argon laser trabeculoplasty, diagnosed with normal tension glaucoma or that had significant angle closure disease (peripheral anterior synechiae >180) were excluded. Results : The mean patient age was 73.4 ± years. At baseline, the mean IOP and NGM were 20.5 ± 4.9 and 2.8 ± 0.9 mmHg, respectively. At 12 months, the mean IOP was 16.5 ± 3.3 mmHg and the NGM was 2.7 ± 1.0. The IOP reduction was 3.7 ± 5.8 mmHg (14.5%, p<0.01) at 12 months follow-up, 3.4 ± 4.7 mmHg (15.5%, p<0.01) at 24 months follow-up, 3.7 ± 5.2mmHg (15.2%, p<0.01) at 36 months follow-up and 2.5 ± 5.9 mmHg (10.1%, p=0.04) at 48 months follow-up. No surgical intervention was needed in 96% of eyes within the first year of SLT. There was no significant difference in the NGM pre- and post- SLT. Conclusions : With the current pandemic limiting the surgical capacities of eye hospitals, SLT can safely delay the need for glaucoma surgery for at least 1 year by reducing the IOP. This is particularly apparent in elderly patients or those poorly compliant to medical therapy. In addition, this could increase ophthalmology clinic capacity by reducing the number of post-operative follow ups.

A Cross-Sectional Study on the Effect of the COVID-19 Pandemic on Ocular Health at a Tertiary Care Department of Ophthalmology

Purpose : The COVID-19 pandemic caused disruptions in ophthalmic care, and may have negatively impacted some patients more than others. We performed a retrospective, cross-sectional study at our large, tertiary care ophthalmology referral center in the Midwest region of the United States in an attempt to identify patients at risk for worsening ocular health during the COVID-19 shutdowns. Methods : We completed retrospective Electronic Health Record data extraction of demographic and clinical outpatient encounter-level data for all patients examined in our department from March-May 2019, August-October 2019, March-May 2020 (peak COVID), and August-October 2020 (COVID recovery). Changes in mean logMAR visual acuity (logMAR VA), mean intraocular pressure (IOP), and mean number of procedures per encounter were tested and stratified by age (<18, 18-64, and 65+ years-old), and compared based on associated billing codes. Results : During peak COVID, there was a 73% decrease in the number of outpatient clinical encounters compared to the control time period in 2019 (6,976 vs. 26,068), and mean patient age was significantly lower during peak COVID (mean age 53.4, 95% CI 52.8- 54.0) compared with the other time periods. Documented best-corrected logMAR VA of the right and left eyes worsened for pediatric, adult, and elderly patient age groups;IOP of the right and left eyes worsened when evaluating all patients together;and the mean number of procedures performed per encounter increased by 74% comparing early 2019 to peak COVID months. The billing diagnoses associated with the worst ocular health outcomes during the COVID-related shutdowns include patients with anophthalmia of the fellow eye;infectious keratitis;open, chronic angle closure, and secondary causes of glaucoma;ocular inflammatory disorders;optic neuritis and ischemic optic neuropathies;and vitreoretinal disorders related to diabetes, macular degeneration, and vitreous or retinal hemorrhages. Conclusions : Patients seen during the COVID-19 pandemic were younger, had worsened logMAR VA, increased IOP, and underwent more procedures compared to the COVID-recovery and 2019 control months. Numerous billing diagnoses were associated with worse measures ocular health. Patients with these ocular disorders may need prioritization during future periods of reduced access ophthalmic care.

Post COVID-19 Vaccine Uveitis: A Case Series

Purpose : With the recent emergence and worldwide distribution of COVID-19 vaccines, many side effects may be underreported and possibly unknown. Cases of vaccine-associated uveitis have been linked to almost all vaccines administered in the past, however, there is scarcity of literature providing insight into post COVID-19 vaccine associated uveitis / episcleritis. By documenting patients presenting with uveitis / episcleritis after the administration of mRNA Pfizer and Moderna vaccines, this case series significantly advances our current understanding of potential COVID-19 vaccine ocular complications. Methods : Patients with ocular symptoms consistent with uveitis / episcleritis within 15 days of the administration of the Pfizer or Moderna COVID-19 vaccine were included in this study. Ocular assessment included a Snellen best-corrected visual acuity (BCVA) converted to logMAR, intraocular pressure (IOP) with Goldmann Applanation Tonometry, pupil check, anterior and dilated posterior segment assessment with slit-lamp, and optical coherence tomography (OCT) imaging. Patients were anonymized and demographics including sex, race, age, and other necessary clinical data were recorded. Results : A total of 9 patients (6 female and 3 males) with a mean age of 42.9 (range, 19-83) were included. 7 patients received a Pfizer vaccine and 2 received a Moderna vaccine. 5 patients presented with symptoms after their first dose, 2 after their second dose, and 1 after both doses. The mean time of ocular symptoms post vaccine was 6.15 days (range, 1-14) and the mean BCVA was 0.657. Patients were diagnosed with bilateral anterior granulomatous uveitis (case 1), unilateral nongranulomatous anterior uveitis (case 2, 6-9), bilateral nongranulomatous anterior uveitis (case 3-4), and episcleritis (case 5). Case 1 and 9 have been highlighted and summarized in figure 1 and 2, respectively. Conclusions : The pathogenesis of vaccine induced uveitis is not properly understood, however, the outcomes of this case series aids in establishing a temporal association between the Pfizer and Moderna COVID-19 vaccines and the onset of uveitis / episcleritis. As the rate of COVID-19 vaccinations increase globally, it is imperative for physicians to be aware of the possible association and presentation of these ocular findings and diagnoses to effectively treat patients.

Virtual Reality Visual Field Exam in Community Screenings During COVID-19

Purpose : 57.5 million people worldwide are affected by glaucoma. However, 50% of those with glaucoma are unaware, and 80% of those identified for follow-up in community screenings (CS) fail to do so. Current standards of visual field testing are usually limited to the clinic. As such, a wearable perimetry headset was used to perform Virtual Reality Visual Field Acuity (VRVFA) examination for suspected visual field loss in the community minimizing exposure to COVID-19 and the need for follow-up. Methods : 31 subjects from 4 CS were screened by an onsite certified telemedicine reader (CR) who considered family history, visual acuity, intraocular pressures, cup-to-disc ratio, nerve fiber layer defects, and ganglion cell complex captured by non-mydriatic photography and ocular coherence tomography (OCT-B). Cataracts were also graded. Supervised VRVFA testing with a multilingual Palmscan VF2000 Analyzer (Fig.1) was performed in 6 minutes on average. Eyes with fixation losses >20% or false positive/negative ratios >0.375 were excluded. Visual field index (VFI), mean deviation (MD), pattern standard deviation (PSD), and mean sensitivity (MS) from VRVFA were compared to CR glaucoma referral and cataract grading. Descriptive statistics, independent samples t-tests, and Mood's median tests were performed. Subjects with positive findings underwent same-day robotic glaucoma specialist telepresence evaluation. Results : 37 eyes from 31 subjects met inclusion criteria (mean age 51.42 ± 14.57 years, 56.76% male, 94.59% Hispanic). 7 (18.92%) eyes were referred for glaucoma evaluation. Glaucoma referrals had significantly different VFI (66.86% vs 86.40%, p=0.027), MD (-9.60 vs -4.04, p=0.031), and MS (19.94 vs 26.01, p=0.027) (Fig. 2). 30 (81.08%) eyes were 0-1+ in cataract grading, 5 (13.51%) were 2-3+, and 2 (5.41%) were intra-ocular lenses (IOL);respectively, these subgroups were not significantly different in VFI (84.20% vs 92.80% vs 35.00%, p=0.147), MD (-4.70 vs -2.11 vs -18.41, p=0.147), PSD (3.52 vs 2.25 vs 9.69, p=0.053), or MS (25.38 vs 27.75 vs 9.91, p=0.147) (Fig. 2). Conclusions : VRVFA testing yielded valuable information on the extent of vision loss as a supportive screening tool for glaucoma congruent with referrals. Expanded testing is needed. Future studies may evaluate VRVFA utility in evaluating other peripheral vision threatening diseases.