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Introduction: The use of smartphones to provide specialist ophthalmology services is becoming a more commonly used method to support patients with eye pathologies. During the COVID-19 pandemic, demand for telehealth services such as tele-ophthalmology, is increasing rapidly.Methods: In 2019, the agreement between diagnostic tests was investigated by comparing the diagnostic performance for eye posterior pole pathologies of the images obtained by a smartphone coupled to a medical device known as open retinoscope (OR), handled by a nurse and subsequently assessed by an ophthalmologist versus the images obtained by an ophthalmologist using a slit lamp associated to a 76 diopter indirect ophthalmic lens (Volk Super FieldVR ) (SL-IOL) at the outpatient department of a hospital. The OR used in this study worked with a 28 diopter indirect lens.Results: An examination of 151 dilated eyes (79 adult patients, mean age of 66.7 years, 59.5% women) was conducted. Sensitivity was 98.9%, specificity was 89.8%, the positive predictive value was 93.8% and the negative predictive value was 98.2%. The kappa index between both tests was 0.90 (95% CI: 0.83-0.97) in basic diagnosis, 0.81 (95% CI: 0.74-0.89) in syndromic diagnosis (13 categories) and 0.70 (95% CI: 0.62-0.77) in advanced diagnosis (23 categories).Discussion: Images obtained by a nurse using a smartphone coupled to the OR and subsequently assessed by an ophthalmologist showed a high diagnostic performance for eye posterior pole pathologies, which could pave the way for remote ophthalmology systems for this patient group.
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BACKGROUND: Branch retinal vein occlusion (BRVO) has an incidence of 0.5-1.2%. COVID-19 is associated with both venous and arterial thromboembolisms due to excessive inflammation, hypoxia, immobilization, and diffuse intravascular coagulation. AIM: The present study aims to describe our experience with BRVO in Egyptian COVID-19 patients. PATIENTS AND METHODS: The present retrospective study included 17 polymerase chain reaction (PCR)-proven COVID-19 patients with BRVO. Data obtained from the studied patients included detailed history taking. In addition, patients were diagnosed with BRVO based on a comprehensive ophthalmic evaluation, including logMAR Best-corrected visual acuity assessment, slit-lamp bio-microscopy, fundoscopy, fundus fluorescein angiography, and optical coherence tomography macular assessment. RESULT(S): The present study included 17 PCR-proven COVID-19 patients with BRVO. They comprised 9 males (52.9%) and 8 females (47.1%) with an age of 52.8 +/- 13.3 years. Fundus examination revealed BRVO as superior temporal in 9 patients (52.9%), inferior temporal in 5 patients (29.4%), superior nasal in 2 patients (11.8%), and inferior nasal in 1 patient (5.9%). The reported retinal thickness was 355.7 +/- 41.7 microm. In addition, fundus fluorescein angiography identified ischemic changes in 2 patients (11.8%). CONCLUSION(S): BRVO is a rare severe complication of COVID-19 infection. In patients with proven or suspected infection with a diminution of vision, there should be high suspicion of BRVO and prompt full-scale ophthalmological examination to exclude the condition. Copyright © 2022 Sanaa Ahmed Mohamed, Marwa Byomy, Eman El Sayed Mohamed El Sayed, Mostafa Osman Hussein, Marwa M. Abdulrehim, Ahmed Gomaa Elmahdy.
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Background: Mucormycosis is an invasive fungal illness associated strongly with COVID-19 and found lethal in many cases. Rhino-orbital-cerebral mucormycosis (ROCM) is the most common mucormycosis infection. The worldwide disease concern for ROCM has grown recently following the spike in incidence during the COVID-19 pandemic. This study shows the clinical characteristics and therapeutic outcomes of patients with ROCM. Material(s) and Method(s): A retrospective observational study on 77 patients with ROCM was performed between March 2021 and June 2021 at a tertiary care hospital. This study only included patients who were microbiologically tested and conformed for ROCM. Numerous clinal diagnosis tests were performed to examine vision, paralysis of the eye muscles, eyeball protrusion, orbital swelling, extra-ocular movements, fundus examination, and extent of orbital involvement on MRI. Result(s): This study of 77 patients, showed a higher ratio of male patients (74.04%) for ROCM cases. The average age of all patients was 49.14 years, and 62 (80.52%) were detected for COVID in the past. These patients were hospitalised for a minimum of 1 day to a maximum of 127 days, with an average of 40.48 days. Type 2 diabetes was found in 40 (52%) cases, while hypertension was the second most common comorbid condition observed in 21 (27.27%) cases. Amphotericin B injection was the preferred therapeutic drug shown in this study for 44 patients out of 56 who used any medication. Exenteration was also shown as a possible therapy that was performed on 53.25% of patients. Conclusion(s): ROCM is more prevalent in diabetic male patients of 50 years of age infected by SARS-CoV2 who have had a later bacterial or fungal illness exacerbated by SARS-CoV2. Amphotericin B injection and exenteration could be the best possible therapeutic solution for treating ROCM. Copyright © 2022 Authors. All rights reserved.
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Purpose : In the COVID-19 era, tele-retinal technologies are rising to the forefront of contactless ophthalmic care. Point-of-care Optical Coherence Tomography (OCT) and fundus photography remotely analyzed by an off-site retina specialist (tele-R) must be validated for screening retinal disorders. This study assesses the feasibility of tele-R as a screening tool for diabetic retinopathy (DR) in an outpatient clinical setting. Methods : A retrospective study was conducted on 16 patients (32 eyes, 28 with DR, and 4 controls) presenting to the retina clinic (RC) of an urban academic medical center. Automated OCT-B and 45 fundus photographs of the posterior pole were taken using a Topcon Maestro 3D OCT-1 unit, and 3D topographical maps of the macula were generated. Images were transmitted to a remote retina specialist (blinded to patient history and demographics) who assessed severity of DR and diabetic macular edema (DME). Primary outcomes included grading of DR and DME with fundus and OCT-B images, respectively, using the International Clinical Diabetic Retinopathy classification scale. The secondary outcome was identifying the severity grade of DME using the 3D macular map. Concordance was tested between diagnoses obtained from tele-R assessment and in-person examination by the retina specialist (gold standard) using Cohen's Kappa statistic (κ). Eyes that could not be assessed were removed from analysis. Results : 30 of 32 eyes with sufficient data for analysis were included. The average age was 57.9 (±11.2) years. 37% of patients were male, 69% were Hispanic, and 94% had Type 2 diabetes. The κ±standard error (SE) for DR severity was 0.738±0.099 (p<0.001), for DME severity was 0.588±0.122 (p<0.001), and for presence of DME was 0.727±0.122 (p<0.001). The retina specialist was able to grade the DME severity in only 10/14 (71%) eyes using the 3D macular map alone, but in 93% (13/14) eyes with OCT-B images. Conclusions : Tele-R is a reliable modality for diagnosis of DR severity;there was substantial agreement on identifying DR severity using tele-R vs in-person examination. There was substantial agreement in discerning DME using tele-R vs in-person while only moderate agreement on determining the severity of DME, which suggests that tele-R may useful in identifying presence of DME but not determining the severity of edema.
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Purpose : In recent years, innovations in tele-ophthalmology have shown promise in providing quality ophthalmic care to patients in low-access settings and high-risk environments such as the COVID-19 pandemic. Emergency departments and urgent centers may benefit from tele-ophthalmology applications;the tele-images can be sent to the covering ophthalmologist or, to another ED for evaluation of images prior to transferring the patient. In this study, we aimed to assess the ability of resident physicians to identify features of posterior-pole retinal pathology using teleophthalmology. Methods : Retrospective study on 16 patients (32 eyes;30 with retinal pathology and 2 controls) who presented to a retina clinic at an academic medical center. Automated OCT-B images with 3D topographic maps and fundus photographs of the posterior pole using a Topcon Maestro 3D OCT-1 unit were taken. Images were transmitted remotely to a resident physician who attempted to identify retina pathology using fundus photography and OCT. The same images were consequently evaluated by a retina specialist for grading. We then tested the concordance between diagnoses rendered via tele-OCT by the resident physician and the gold standard clinical examination (performed by the retina specialist) using Cohen's Kappa statistic (κ). Results : An overall average of 79.9% concordance for 69 potential findings was obtained between the retina attending's diagnosis with clinical examination and the resident physician's diagnosis using tele-OCT/fundus images based on Cohen's Kappa statistic (κ). The concordance was lower in eyes with vitreous hemorrhage most likely due to the inferior quality fundus and OCT-B images. The resident exam also identified the presence of any macular pathology in all 30 eyes with macular pathology and correctly identified the controls, indicating 100% sensitivity for identifying abnormal findings using tele OCT/fundus images. Conclusions : This study verifies the utility of resident screening of tele-OCT fundus and OCT-B images to identify retinal pathology. Tele-ophthalmology likely has a useful role in triaging retinal pathology whose outcomes could be affected by timely intervention. Many unnecessary emergency transfers may be avoided if the on-call ophthalmology residents are able to review the fundus and OCT images before hand.
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Purpose : Dry age-related macular degeneration (AMD) is a leading contributor to visual impairment across the globe. No current treatment exists to improve visual function or reduce disease progression outside of vitamin supplementation and lifestyle changes. LIGHTSITE III is evaluating multiwavelength photobiomodulation (PBM) therapy using the LumiThera Valeda® Light Delivery System in dry AMD Methods : LIGHTSITE III (NCT04065490) is a prospective, double-masked, randomized, sham-controlled, parallel group, multi-center study to assess the safety and efficacy of PBM in dry AMD. Target enrollment was approximately 96 subjects (144 eyes). Subjects are treated with six series of PBM/Sham treatments (3x per week for 3 weeks) delivered over a 24-month period with a 13-month efficacy analysis of data. PBM therapy consists of low-level light exposure to selected tissues resulting in positive effects on mitochondrial output and improvement in cellular activity. Valeda is used to deliver multiwavelength PBM treatment using 590, 660 and 850 nm of light. Subjects are assessed for clinical and safety outcomes (i.e., best-corrected visual acuity (BCVA), low- luminance BCVA, contrast sensitivity, reading speed, color vision, VFQ-25 and perimetry). Independent OCT, FAF and color fundus imaging outcomes at selected timepoints are analyzed by a masked imaging reading center Results : A total of 148 eyes from 100 subjects with dry AMD have been enrolled and randomized in a 2:1 design (PBM:Sham). The majority of subjects are female (68%) and Caucasian (99%). The average age at enrollment was 75 years and mean time since dry AMD diagnosis is 4.9 years. COVID-19 interference has been minimal and not significantly impacted subject enrollment or retention. Clinical and anatomical outcome data from the interim analysis conducted at Month 13 is presented. Results from the 21-month time point are expected at end of 2022 Conclusions : LIGHTSITE III provides the largest, randomized controlled trial evaluating the effects of PBM in dry AMD subjects. PBM therapy may offer a new treatment strategy with a unique mechanism and modality for patients with dry AMD.
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Purpose : The COVID-19 pandemic exposed the need for increased mobilization of teleophthalmology resources. Artificial intelligence (AI) may serve as a tool to assist physicians in triaging highest need patients if the AI's assessment of disease is comparable to the physician's assessment. This study assesses the ability of AI software to diagnose diabetic retinopathy (DR) as compared to Tele-ophthalmology and in-person examination by a retina specialist. Methods : Records of forty patients (average age 55.1±10.9 years) presenting to an urban retina clinic were reviewed retrospectively for factors including demographics, retinal photos taken by Canon CR-2 Plus AF Retinal Imaging camera (Tokyo, Japan), and diagnosis of DR based on the International Clinical Diabetic Retinopathy (ICDR) classification scale during an in-person clinic visit in which a fundus exam was performed. Retinal photos were graded by AI software, EyeArt (EyeNuk, CA), as Normal, Mild DR, or More than Mild DR. Retinal images were also graded remotely by a retina specialist using the ICDR classification scale via TeamViewer software (Tele). Agreement between Tele, AI, and inperson DR diagnosis was assessed using Cohen's Kappa (κ) coefficient using IBM® SPSS® Statistics software. Results : Among 80 eyes, 33 were diagnosed in-person with no DR, 5 with mild nonproliferative DR (NPDR), 9 with moderate NPDR, 3 with severe NPDR, 7 with proliferative diabetic retinopathy (PDR), and 23 with regressed PDR. Eleven and 26 eyes could not be graded by Tele or AI, respectively. κ±SE for in-Person diagnosis vs Tele was 0.859±0.058 (p<.001), in-person vs AI was 0.751±0.082 (p<.001), and Tele vs AI was 0.883±0.063 (p<.001). Conclusions : AI is a reliable tool for screening patients for DR and referring them for physician evaluation since AI had a substantial rate of agreement with the in-person diagnosis and near perfect agreement with Tele. Tele grading was in near perfect agreement with the in-person diagnosis, showing that Tele is a reliable option for a physician to remotely screen patients that may be ungradable by AI. However, improvements are needed due to the high number of images that are ungradable via Tele and AI. Further studies should assess ways to reduce the number of ungradable images via Tele and AI and create a trend analysis for multiple visits for a given patient.
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Purpose : COVID-19 vaccination has been accompanied by reports of inflammatory events. We aim to report the first case of bilateral persistent placoid maculopathy (PPM) following COVID-19 vaccination. Methods : Case report Results : A 58-year-old man presented with bilateral sudden painless decrease in vision approximately two weeks after the second dose of AstraZenaca® COVID-19 vaccine. Visual acuity (VA) at presentation was 1.00 LogMAR in the right eye (RE) and hand movement in the left eye (LE). He had no known medical or ophthalmic history, up until after his first AstraZenaca® COVID-19 vaccine dose, he was diagnosed with palmoplantar pustular psoriasis and was started on 60mg of oral Prednisolone. Fundus examination revealed bilateral well-delineated whitish plaque-like macular lesions involving the fovea, sparing the peripapillary region in the RE (Figure 1a & e). Multimodal imaging including fluorescein angiography, indocyanine-green angiography, fundus autofluorescence and optical coherence tomography were consistent with PPM (Figure 1 & 2). Infective and auto-immune screen were all negative apart from a positive MPO-ANCA, prompting a rheumatology review which subsequently excluded any systemic vasculitis. Patient was monitored closely and his VA improved and stabilised with tapering regime of oral Prednisolone. To prevent relapse of PPM, patient was commenced on Mycophenolate Mofetil as a long-term steroid sparing immunosuppression. Conclusions : Our case demonstrated a likely inflammatory or autoimmune response affecting choriocapillaris driven by the COVID-19 vaccine and there may be a correlation between the two. The patient in our case portrayed features classical of PPM, which is a selective autoimmune vasculitis causing microinfarcts on choriocapillaris, resulting in focal choroidal hypoperfusion after the COVID-19 vaccine. (Figure Presented).
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Purpose : To report the longterm safety and stability of two suprachoroidal retinal prosthesis trials (NCT01603576, NCT03406416), comprising of seven patients, with followup ranging from two to nine years. Methods : Three patients with retinitis pigmentosa were implanted with our prototype 24 channel suprachoroidal retinal prosthesis in May-August 2012. One patient had the entire device removed following the trial in 2014 for a medical reason unrelated to the device. The other two patients had the intraocular array left in situ and the percutaneous connector removed, as planned. Ocular followup has continued since that time, albeit interrupted due to the Covid 19 pandemic. Four patients with retinitis pigmentosa were implanted with our second generation 44 channel fully implantable device in February to August 2018. They continue to use the device in the home enviroment. Ocular assessments including clinical examination, colour fundus photographs and optical coherence tomography (OCT) have been used to assess stability of the devices and retinal health longitudinally in patients (P) 1-7. Results : Electrode to retina distance OCT measurements over two to nine years, calculated by comparing group means, showed an increase over time. (Wilcoxon, p=0.03) In the prototype trial, the increase appeared linked to fibrosis and stimulation, with no progression once devices were inactivated, in the second generation trial, it seemed primarily due to passive fibrosis. Retinal thickness OCT measurements showed a slow reduction in central retinal thickness, as expected, due to progression of dystrophic disease. (Wilcoxon, p=0.11) Device position compared to the optic nerve head (ONH) was calculated and three patients demonstrated some temporal movement. P1 position returned to baseline over seven years, P2 stabilised over three months and P6 had a temporary choroidal effusion event which settled spontaneously. Function of the four Generation two fully implantable devices remains stable. Conclusions : Using fundus photography and OCT measurements we demonstrate that retinal prostheses implanted in the suprachoroidal space for up to nine years are overall stable in position and cause mild progressive fibrosis in the suprachoroidal space. Longterm assessment of the changes in the retina are all consistent with the underlying retinal dystrophy. This provides further evidence of the safety of the suprachoroidal surgical approach for retinal prostheses.
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Purpose : During the Covid-19 era, understanding the benefits and limitations of tele-ophthalmology has become increasingly important. In this study, we aim to assess the accuracy of tele-ophthalmic diagnosis of diabetic retinopathy (DR) and diabetic macular edema (DME) when performed by resident physicians. Methods : Retrospective study on 16 patients (32 eyes;28 DR and 4 controls) who presented to a retina clinic at an academic medical center. Automated OCT-B images with 3D topographic maps and fundus photographs of the posterior pole using a Topcon Maestro 3D OCT-1 unit were taken. Images were transmitted remotely to a resident physician who assessed the severity of the DR and DME on the basis of the fundus photographs and OCT. The same images were transmitted to a retina specialist for grading. Primary outcomes included DR and DME grade as defined by the International Clinical Diabetic Retinopathy classification scale. We then tested the concordance between diagnoses rendered via tele-OCT by the resident compared to the retina attending's remote diagnosis and the gold standard retina specialist's clinical examination using Cohen's Kappa statistic (κ). Results : Agreement between ophthalmology residents and attendings on tele-OCT diagnosis of DR was substantial (78% concordance on presence and 75% on severity), while agreement on identifying and grading edema was moderate (60% concordance on DME presence and 52% concordance on overall DME severity). Detection of DR by residents via tele-retinal imaging is highly sensitive (100% sensitivity), while detection of DME is highly specific (79-95% specificity). Discordance between residents and attendings on DME grading may owe to differences in opinion regarding what constitutes mild edema versus no edema;however, both concordance and predictive accuracy increase when identifying patients with moderate to severe DME. Conclusions : This study provides proof of principle for the sensitivity and specificity for remote diagnosis of DR via tele-OCT fundus and OCT-B images. This technology may be useful in identifying patients at risk of severe vision loss and enable early detection of patients who need referral for prompt treatment. These findings may be particularly relevant to training programs looking to implement tele-retinal diabetic screening or using tele-OCT where prompt access to a retina specialist may not be possible.
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Introduction: Acute Interstitial Nephritis (AIN) is an important cause of Acute Kidney Injury (AKI), and infections are the second most common etiology, after the drugs. However, AIN following fungal infections is rare. We describe two cases of AIN, which on the investigation turn out to be candidemia following fungal infective endocarditis. Methods: CASE 1: A 65-year-old man with hypertension and diabetes without diabetic or hypertensive retinopathy and prior normal renal function, presented to us with vague abdominal pain with steadily creeping creatinine to 2mg/dl within 2 weeks, and urine showed no albuminuria and sediments. There was no history of any specific drug intake. His hematological and other parameters were normal. Blood and urine cultures were sterile. He underwent a renal biopsy which revealed acute interstitial nephritis (Figure 1). He was started on prednisolone at 1mg/kg/day for 1-week following which he had a rapidly worsening azotemia requiring hemodialysis. Steroids were stopped. Repeat blood cultures were sent which grew candida albicans resistant to flucytosine. Re-evaluation of the fundus revealed macular infarct in the right eye with vitreoretinitis in the left eye suggestive of endophthalmitis. PET CT showed increased FDG uptake in both kidneys suggestive of pyelonephritis. Trans-esophageal echocardiography (TEE) showed aortic valve vegetations. He was treated with antifungals for 3 months. He was dialysis-dependent for 2 weeks. He gradually regained normal renal function 3 weeks after starting anti-fungal agents. CASE 2: A 57-years-old man with diabetic, hypertensive, and no diabetic retinopathy had severe covid pneumonia in June 2021 requiring oxygen and tocilizumab 80 mg for 4 days, recovered with normal renal function. He presented to us 1 month later with unexplained non-oliguric severe AKI requiring dialysis, with bland urine sediments. Renal biopsy showed lymphocytic infiltrates in the interstitium suggestive of AIN (Figure 2). Blood cultures were sterile, but serum beta-D-glucan was elevated at 333 pg/ml. He was Initiated on 1mg/kg of prednisolone, on the presumption of drug-induced AIN. Simultaneously workup for systemic infection revealed mitral anterior leaflet endocarditis. He was initiated on anti-fungal therapy on the advice of an infectious disease specialist and the steroid was stopped. He continued to be dialysis-dependent after 6 weeks, despite anti-fungal agents. Results: [Formula presented] Conclusions: AIN contributes a significant proportion of cases in unexplained AKI. Prompt evaluation with a renal biopsy is warranted. Acute interstitial nephritis particularly due to candidemia can be oligosymptomatic as seen in our two cases. Since steroids have a significant role in treating early AIN, a dedicated search for underlying silent endocarditis and candidemia is advisable before initiating steroid therapy. Ophthalmic fundus evaluation, TEE, and repeat blood culture may be necessary to identify hidden candidemia. We recommend an evaluation to exclude fungal endocarditis in patients with AIN who present with minimal or no symptoms and no definitive cause for AIN is present. No conflict of interest
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Background/aim: Mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is a rare clinicoradiological syndrome that typically presents with central nervous system symptoms such as loss of consciousness, seizure, headache, and ophthalmoparesis. Materials and methods: Here, we highlight the characteristics of this syndrome together with the clinical and MRI findings of 6 pediatric patients with MERS. Results: Between January 2017 and October 2020, 6 patients with MERS (3 boys and 3 girls) presented to our center. The mean age was 122 ± 54.6 (min-max: 44-180) months. None of the patients had a chronic disease. In our study, infectious agents were detected in 4 patients (66.6%), while noninfectious causes (one seizure and the other hyponatremia) were detected in two patients. All of our cases were discharged without any sequelae after an average of 12.1 ± 7 (min–max: 4–20) days of hospitalization. In 1 patient (case 6), control MRI could not be performed, and the radiological recovery of our other patients was shown to be between 14 days and 2 months. Conclusion: MERS is an acute encephalopathy with good prognosis and should be considered by neurologists in differential diagnosis due to its variable clinical presentation and specific MRI findings.
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Background: In July 2020, in response to COVID-19 clinic restrictions, Liverpool Eye Clinic instituted an orthoptist-led clinic, with subsequent virtual retinal specialist reviews, to screen and monitor for chloroquine/hydroxychloroquine (CQ/HCQ) retinopathy. We discuss its implementation, uptake and issues. Standard: American Academy of Ophthalmology: Revised Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy. Methods: The screening protocol included collecting data on patients' demographics, CQ/HCQ retinopathy risk factors, visual acuity, dilated fundus examination, automated visual fields (HVF) and macular spectral domain optical coherence tomography (SD-OCT). Results were reviewed by a retinal VMO, with clinic review if abnormal. Records of patients seen in this clinic from inception to May 2021 were audited. Results: Forty-six patients (female: n = 35, 76.1%) were screened during this period. Twenty-six patients had CQ/HCQ retinopathy risk factors. All patients underwent baseline SD-OCT and 10-2 HVF with 24-2 HVF performed on those of Asian background (n = 19, 41.3%). Patients with pre-existing pathology or positive risk factors were appropriately referred for further ophthalmic review. Although orthoptists complied with examination protocols, issues included delays in retinal specialist review of SD-OCT and/or fundus photography, discoordination with scheduled main clinic follow up for other pathology, and non-attendance for dilated fundus examination if required at a second visit. Recommendations: Screening and monitoring for CQ/HCQ retinopathy can be effectively performed by an orthoptist with virtual ophthalmologist oversight. However, appropriate systems are needed to ensure that all examination results are reviewed, and abnormal results managed accordingly.