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.

Remote ophthalmology with a smartphone adapter handled by nurses for the diagnosis of eye posterior pole pathologies during the COVID-19 pandemic.

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.

Branch Retinal Vein Occlusions as a Serious Complication of Covid 19 Infection

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.

Validation of portable slit lamp videos and anterior segment photographs as telemedicine modalities

Purpose : The COVID-19 pandemic has highlighted the need for telemedicine across all specialties. Though its utilization has increased since the start of the pandemic, ophthalmology has been reported to be among the specialties least likely to utilize telemedicine in practice. We evaluated the potential utility of portable slit lamp exam (SLE) videos and anterior segment photos as telemedicine modalities by comparing the findings from these modalities to those identified in-person in the clinic. Methods : Data was collected from 98 subjects at Rutgers Institute of Ophthalmology and Visual Science by non-ophthalmic trained staff, which included portable SLE videos and anterior segment photos, collected with Microclear digital hand-held slit lamp (Suzhou, China) and Canon non-mydriatic retinal camera CR-2 Plus AF (Tokyo, Japan), respectively. Analysis included anterior segment photos taken from 92 patients (183 eyes) and SLE videos taken from 91 patients (177 eyes), which were interpreted and compared to exam findings identified in-person in the clinic. Sample t-tests were used for statistical analysis. Results : Nuclear sclerotic cataract (NSC) had the most agreement between telemedicine interpretation and in-person exam (photo 93.8%, video 93.75%). Cortical cataract showed less agreement (photo 65.63%, video 45.16%) and posterior subcapsular cataract (PSC) showed the least agreement (photo 8.33%, video 0%) among cataract findings. Cornea findings were among those least likely to be identified (photo 12.5%, video 14.86%). Findings that showed statistically significant differences between photo and video included pinguecula (p=0.00032). PSC (p=0.044) and posterior capsule opacification (p=0.00098) showed statistically significant differences regarding identifying findings on telemedicine interpretation that were not documented in clinic. Conclusions : Portable SLE videos and anterior segment photos may have potential for utility as means of telemedicine, particularly for NSC. Portable SLE requires more training to display a full ophthalmic exam whereas photographs can easily be done by non-ophthalmic trained staff, displaying similar findings. Differences in exam findings may be attributed to lack of documentation when patients present to the clinic for more urgent concerns and lack of focus on slit lamp videos by non-ophthalmic trained staff. (Figure Presented).

Personal Protection Equipment and Slit-lamp Breath Shield in the Ophthalmology Office Setting

Purpose : COVID-19 pandemic has become a major global public health challenge. The ophthalmology office setting involves close encounters between the patient and the health care workers increasing risk of viral transmission. Use of PPE decreases risk of person-to-person viral transmission. The purpose of the study was to evaluate breath-induced air currents in subjects without a facemask, with a procedure mask, with an improvised face, and in the setting of slit-lamp examination. Methods : Breath-induced air currents were studied in healthy volunteers utilizing a vape pod system and videography during gentle and heavy breathing simulation. Video frames at 2 seconds after the initiation of expiration were captured and analyzed. Results : A total of 210 recordings were made for 7 settings. Without a face mask, the aerosol moved forwards and spread vertically and horizontally reaching a mean distance of 23.1 inches for gentle, and 36.1 inches for heavy breathing at 2 seconds (P< 0.001). Using PPE the airflow patterns included: a) procedure mask- forward 0 cases, upward 19 (63%) cases, side 28 (93%) cases, downward 22 (73%) cases, and backward 22 (73%) cases. Adding a tape at the upper border of the mask eliminated upward flow in all cases. b) Improvised face mask- forward 0 cases, upward 0 cases, side 30 (100%) cases, downward 30 (100%) cases, and backward 17 (57%) cases. In 14 (47%) cases trace of aerosol was detected adjacent to the front surface of the mask. Adding a second layer eliminated the trace of aerosol in all cases. In the setting of simulated slit-lamp examination without the breath shield, the aerosol reached the chin rest in 9 (60%) cases during gentle breathing and in all cases during heavy breathing. The breath shield was effective in blocking forward airflow in all cases. Conclusions : Use of a procedure mask by patients, while effective in blocking forward breath-induced airflow, redirects the flow upwards, potentially increasing the risk of contamination during an office procedure. An improvised facemask alters breath-induced air currents favorably and partially absorbs respiratory droplets.

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.

Distant Ocular Manifestations after New Coronavirus Infection

Purpose. Theoretically substantiate and practically identify ocular manifestations after the transferred SARS-CoV-2 virus. Patients and methods. For the study we were invited patients who had recovered from SARS-CoV-2 at the hospital of V.M. Buyanova, the age from 20 to 65 years old in period from 2020 to 2021. The total number of patients was 68 people. The patients had with them the results of PCR tests or ELISA tests, or an extract from the hospital confirmed COVID-19 case and also a clinical blood test and CT scan of the chest organs for the period of illness. Before the start of the study, the patients were asked to fill out a questionnaire “Questionnaire for patients who have had a new coronavirus infection” (Appendix 1). For a detailed study of this group of people, each underwent visometry, pneumotonometry, B-scan, a slit lamp study and also a slit lamp study with a 60D lens using 0.5 % Mydriacyl eye drops in the absence of contraindications and pupillography. Results. As a result of the work carried out, we concluded that the virus is capable of causing inflammation of the choroid of the eyeball, uveitis. Moreover, in our study, we identified patients with acquired intermittent divergent strabismus, anisocoria, ptosis, and accommodation disorder. And, in this regard, we came to the conclusion that the coronavirus belongs to the group of neurotropic, as it is able to affect the nervous tissue and cause the above clinical picture. In other words, the virus negatively affects the somatic and autonomic innervation of the oculomotor nerve. As a result of these lesions, we get the corresponding tetrad of symptoms: heterotropy, mydriasis, ptosis, accommodation paralysis. Conclusions. One of the extraordinary complications of coronavirus infection is damage effect to the fibers of the oculomotor nerve, the signs include: strabismus, mydriasis, ptosis and accommodation paralysis. Thus, this clinical picture is associated with the affinity of the virus to the nervous tissue. And as a result, this ability of the virus can probably infect various areas of the brain, which will lead to corresponding complications, not only from the oculomotor nerve, but also from other cranial nerves with the manifestation of the corresponding symptoms, which in theory can aggravate the patient's condition, causing deep disturbances of motor and sensory innervation.

Occurrence of Bacterial Conjunctivitis and Viral Conjunctivitis in Pakistan

Aim: To identify the prevalence of bacterial and viral conjunctivitis. Study design: Prospective study. Place and Duration of Study: Department of Ophthalmology, Pakistan Railways Hospital, Islamic International Medical College, Rawalpindi from 1st April 2021 to 30th September 2021. Methodology: Fifty conjunctivitis patients enrolled within age of 14-29 years. Clinical examination, slit lamp test and lab testing separated cases as viral or bacterial conjunctivitis. Polymerase chain reaction post culturing was sued in viral conjunctivitis cases while Kirby-Baur disc diffusion assay was sued in bacterial conjunctivitis confirmation. Results: There were 91.17% patients with viral conjunctivitis in age of 24-29 years and 62.5% patients with bacterial conjunctivitis within 14-18 years. The odds ratio value between the male and female gender showed a significant difference between both genders with 95% confidence interval with higher female frequency in both. Coronavirus cases were highest with 52.9% while cases of Micrococciwere highest as 37.5% with conjunctivitis. Conclusion: Viral conjunctivitis was more common in general cases due to recent covid-19 infection followed by Micrococci bacterial conjunctivitis.

Emerging complications of COVID-19 in a subset of Indian population: a pathological review with clinico-radiological case scenarios

Background: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was declared a pandemic by the World Health Organization on 11 March 2020 has been reported in most countries around the world since its origins in Wuhan, China. As of September 2021, there have been over 229 million cases of COVID-19 reported worldwide, with over 4.7 million COVID-19–associated deaths. Body: The devastating second wave of the COVID-19 pandemic in India has seen a rise in various extrapulmonary manifestations. One of key components in the pathogenesis of COVID-19 is downregulation of ACE-2, which is expressed on many organs and counterbalances the pro-inflammatory effects of ACE/angiotensin-II axis. This leads to influx of inflammatory cells into alveoli, increased vascular permeability and activation of prothrombotic mediators. Imaging findings such as ground glass opacities, interlobular septal thickening, vascular dilatation and pulmonary thrombosis correlate well with the pathogenesis. Conclusion: We hypothesize that the systemic complications of COVID-19 are caused by either direct viral invasion or effect of cytokine storm leading to inflammation and thrombosis or a combination of both. Gaining insights into pathobiology of SARS-CoV-2 will help understanding the various multisystemic manifestations of COVID-19. To date, only a few articles have been published that comprehensively describe the pathophysiology of COVID-19 along with its various multisystemic imaging manifestations.

A Novel Procedure for the Management of Severe Hyphema after Glaucoma Filtering Surgery: Air-Blood Exchange under a Slit-Lamp Biomicroscopy.

Background and Objectives: This study introduces a novel office-based procedure involving air-blood exchange under a slit-lamp microscope for treatment of severe hyphema after filtering surgery. Materials and Methods: This retrospective study enrolled 17 patients (17 eyes) with a diagnosis of primary open-angle glaucoma with severe hyphema (≥4-mm height) after filtering surgery. All patients were treated with air-blood exchange under a slit-lamp using room air (12 patients) or 12% perfluoropropane (C3F8; five patients). Results: The procedures were successful in all 17 patients; they exhibited clear visual axes without complications during follow-up. In the room air group, the mean visual acuity (VA) and hyphema height significantly improved from 1.70 ± 1.07 LogMAR and 5.75 ± 1.14 mm before the procedure to 0.67 ± 0.18 LogMAR and 2.83 ± 0.54 mm after the procedure (p = 0.004; p < 0.001). In the C3F8 group, the mean VA showed a trend, though not significant, for improvement from 1.70 ± 1.10 LogMAR to 0.70 ± 0.19 LogMAR (p = 0.08); the mean hyphema height showed a trend for improvement from 5.40 ± 0.96 mm to 3.30 ± 0.45 mm. Compared with the C3F8 group, the room air group showed the same efficacy with a shorter VA recovery time. Conclusions: "Air-blood exchange under a slit-lamp using room air" is a convenient, rapid, inexpensive, and effective treatment option for severe hyphema after filtering surgery, and may reduce the risk of failure of filtering surgery.

Slit-lamp measurement of anterior chamber depth and its agreement with anterior segment optical coherence tomography and Lenstar LS 900 in pseudoexfoliation and normal eyes.

PURPOSE: There is a considerable lack of awareness of slit-lamp measurement of anterior chamber depth (ACD) by the Redmond Smith method (SACD) in present day-to-day clinical practice, which may provide rapid assessment in pseudoexfoliation (PXF) when assessing for angle closure and planning for cataract surgery. This assumes importance not only in outreach clinics but also in the ongoing pandemic caused by the highly contagious novel coronavirus, where social distancing is advocated to contain the spread. We aimed to compare the axial ACD in PXF and normal patients by SACD, and its agreement with the anterior segment optical coherence tomography (ASOCT) and LenstarLS-900. METHODS: A prospective comparative observational study was done at a tertiary eye care hospital. A PXF group and a normal group of controls were recruited. All eyes were phakic with normal cornea. Any eye with previous intraocular/refractive surgery and cause of other secondary or uncontrolled glaucoma was excluded. SACD was measured clinically via slit-lamp method and also via ASOCT and Lenstar; agreement between the methodologies was plotted. RESULTS: Fifty patients were recruited in each group. Mean age was 66.82 ± 4.88 years in PXF patients and 65 ± 5.46 years in controls (P = 0.2). ACD was found to be greater in controls compared with the PXF patients; this difference was statistically significant (P < 0.001) across all methodologies. A good agreement with narrow 95% limits of agreement was found between these methodologies. CONCLUSION: Redmond Smith slit-lamp methodology of estimating the axial ACD is recommended as a rapid, quantifiable, noncontact screening technique during routine examination, especially in primary outreach centers, and is also advantageous during the ongoing pandemic by reducing expendable investigations.

A novel approach to anterior segment imaging with smartphones in the COVID-19 era.

PURPOSE: To report a novel, telemedicine-friendly, smartphone-based, wireless anterior segment device with instant photo-documentation ability in the COVID-19 era. METHODS: Anterior Imaging Module (AIM) was constructed based on a 50/50 beam splitter design, to match the magnification drum optics of slit-lamps with a three-step or higher level of magnification. The design fills the smartphone sensor fully at the lowest magnification and matches the fixed focus of the slit-lamp. It comes with a smartphone for instant photo-documentation, an in-built software application for data-management and secure HIPAA compliant cloud storage, and a Bluetooth trigger for a one-tap image capture. The construction of the device is explained, and the optical resolution measured using U.S. air-force resolution test. AIM's performance was characterized with traceability to internationally relevant performance standards for digital slit-lamps after image quality assessment through a pilot study. RESULTS: Clinically useful anterior segment images were obtained with both diffuse and slit illumination at different magnification settings with the highest magnification (40X) resolution of 359 lines per cm and the lowest magnification (16X) resolution of 113 lines per cm. CONCLUSION: AIM is a novel, wireless, telemedicine-enabled design that digitizes existing, analog slit lamps with at least three-step magnification. The settings ensure the focus is determined purely by the position of the slit-lamp. Hence, the image viewed and captured on the smartphone is exactly what the clinician sees through the eyepiece. This helps in maintaining distance from the patient in the ongoing COVID-19 pandemic, as well.

Evaluation of Nasopharyngeal and Conjunctival Swab Samples of Hospitalised Patients with Confirmed COVID-19.

PURPOSE: To evaluate the results of conjunctival and nasopharyngeal swab tests in patients with confirmed COVID-19. METHODS: This prospective study included 45 patients who were hospitalized for confirmed COVID-19. Nasopharyngeal swab samples were obtained from the patients before hospitalization. Only one eye of each patient was randomly selected for-conjunctival sampling. All participants underwent a complete slit-lamp examination. Conjunctival and nasopharyngeal swab samples were analyzed by reversetranscriptase-polymerase-chain reaction (RT-PCR). RESULTS: Twenty seven (60%) of the patients were male and 18 (40%) were female. Conjunctival swab was positive in only one (2.22%) patient. None of the COVID-19 patients showed ocular changes and symptoms. There were no abnormalities of the ocular surface, anterior chamber or posterior segment at slit-lamp examination. CONCLUSIONS: The RT-PCR was not high positive in the conjunctiva as in nasopharyngeal swabs. Ocular changes were not common in COVID-19 patients.

Slit lamp examination during COVID-19: Where should the protective barrier be?

PURPOSE: The aim of this study was to describe a poly-vinyl chloride air condition (PVC AC) curtain shield placed at the intervening space between the chin rest and the illuminating and optical arm of the slit lamp microscope (distal barrier) instead of the present position at the oculars (proximal barrier) to guard against severe acute respiratory syndrome Coronavirus 2. This experimental study was done to validate and compare the protection offered by the conventional breath shields and the one described by us in a simulated environment. METHODS: In this experimental study, 12 puffs of fine mist were sprayed over a period of 1 minute using "magenta-colored dye" and "cyan-colored dye" for analyzing proximal barrier and distal barrier respectively. To access the amount of contamination of the slit lamp, caused by sprayed "magenta" and "cyan" colored dye, we covered the entire slit lamp with appropriately sized white-colored cotton sheet. The stained sheets were individually photographed and then the images were first cropped, then color threshold adjusted and then converted to binary and finally fraction of surface area stained was calculated using the ImageJ software. (Pn Surface Area magenta fraction (%) during analysis of "proximal barrier" and Pn Surface Area cyan fraction (%) during the analysis of "distal barrier", where Pn refers to various parts of slit lamp. RESULTS: The entire surface area of the cloth covering the slit lamp was 9912.45 cm2. The surface area of the cloth which was stained when using the "proximal barrier" was 567.50 cm2 whereas when using the "distal barrier" was 222.93 cm2. When using proximal barrier, 97.71% of the staining was present on the slit lamp base, viewing arm, illumination arm and the pivot of the slit lamp. While using the distal breath shield no parts of the viewing arm, illumination arm, the pivot or the mechanical base with joystick were stained. CONCLUSION: The novel PVC AC curtain shield provides better barrier against the simulated contaminated stream of patient's breath directed towards the working parts of the slit lamp as compared to conventional slit lamp oculars mounted breath shields.

Safe Slit-lamp Shield: Maintaining a balance between ergonomics and safety.

Since the emergence of COVID pandemic, health workers have been facing major challenges every day. Ophthalmology practice has encountered countless modifications in the practice pattern not to jeopardize patient care and at the same time maintain all safety measures to reduce transmission. One such modification we made was the Safe Slit-Lamp Shield (SSS) which has been found to be extremely protective in differentiation to other available shield. Although SSS has a larger surface area when compared to already available shields, it won't compromise the comfort of the clinician at the same time gives satisfactory protection.