Characteristics of endothelial corneal transplant rejection following immunisation with SARS-CoV-2 messenger RNA vaccine.

AIM: We report two cases of endothelial corneal allograft rejection following immunisation with SARS-CoV-2 messenger RNA (mRNA) vaccine BNT162b2 and describe the implications for management of transplant recipients postvaccination for COVID-19. METHODS: A 66-year-old woman with Fuchs endothelial corneal dystrophy (FECD) and a unilateral Descemet's membrane endothelial keratoplasty (DMEK) transplant received COVID-19 mRNA vaccine BNT162b2 14 days post-transplant. Seven days later, she presented with symptoms and signs of endothelial graft rejection. An 83-year-old woman with bilateral DMEK transplants for FECD 3 and 6 years earlier developed simultaneous acute endothelial rejection in both eyes, 3 weeks post second dose of COVID-19 mRNA vaccine BNT162b2. Rejection in both cases was treated successfully with topical corticosteroids. CONCLUSIONS: We believe this is the first report of temporal association between corneal transplant rejection following immunisation against COVID-19 and the first report of DMEK rejection following any immunisation. We hypothesise that the allogeneic response may have been initiated by the host antibody response following vaccination. Clinicians and patients should be aware of the potential of corneal graft rejection associated with vaccine administration and may wish to consider vaccination in advance of planned non-urgent keratoplasties. Patients should be counselled on the symptoms and signs that require urgent review to allow early treatment of any confirmed rejection episode.

COVID-19-related Ocular Hypertension Secondary to Anterior Uveitis as Part of a Multisystemic Inflammatory Syndrome.

It is the consensus of the medical community that ocular complications associated with Coronavirus Disease 2019 (COVID-19) are mild, self-limiting, and there are no reports to date of a sight-threatening event. We report a patient with a systemic inflammatory syndrome in the context of COVID-19, with ophthalmological (uveitis), dermatological (erythema and skin nodules), and cardiovascular (edema) manifestations. The anterior uveitis led to an increase in the intraocular pressure that failed to respond to clinical treatment and prompted a surgical intervention to save the vision. To the best of our knowledge, this is the first report of a COVID-19-related ocular hypertension. Timely surgical intervention was key to save the vision in the patient's only eye.

The Challenge of Managing Bilateral Acute Angle-closure Glaucoma in the Presence of Active SARS-CoV-2 Infection.

PURPOSE: To report a case of bilateral acute angle-closure glaucoma associated with hyponatremia in the setting of chlorthalidone use and SARS-CoV-2 infection, and to demonstrate the challenges of managing this patient given her infectious status. METHODS: This was a case report. CASE: A 65-year-old woman taking chlorthalidone for hypertension presented to the emergency room with headache, pain, and blurry vision in both eyes and was found to be in bilateral acute angle closure. On laboratory investigation, she was severely hyponatremic and also tested positive for SARS-CoV-2. B-scan ultrasound demonstrated an apparent supraciliary effusion in the right eye. Following stabilization of her intraocular pressures with medical management, she ultimately underwent cataract extraction with iridectomies and goniosynechiolysis in both eyes. CONCLUSIONS: We report a rare case of bilateral acute angle-closure glaucoma associated with hyponatremia. Chlorthalidone use and perhaps SARS-CoV-2 infection may have contributed to this electrolyte abnormality and unique clinical presentation. In addition, we discuss the challenges of managing this complex patient with active SARS-CoV-2 infection during the pandemic.

Risk of Airborne COVID-19 Transmission While Performing Humphrey Visual Field Testing.

PRECIS: Designing and demonstrating an experiment that shows the risk of airborne transmission of COVID-19 between patients having visual fields analyzed is low. PURPOSE: The aim was to investigate the possibility of airborne transmission of COVID-19 during Humphrey visual field testing in a real-world scenario. METHODS: A particle counter was placed within the bowl of Humphrey visual field analyzer (HFA) before and after turning on the machine to ascertain the effect of the air current produced by the ventilation system on aerosols. A second experiment was run where the particle counter was placed in the bowl and recorded particulates, in the air, as a 24-2 SITA standard was performed by a mock patient and then again immediately after the patient had moved away. We measured aerosol particle counts sized ≤0.3 µm, >0.3≤0.5 µm, >0.5≤1 µm, >1≤2.5 µm, >2.5≤5 µm, and >5≤10 µm. RESULTS: Particulates of all sizes were shown to be significantly reduced within the bowl after turning the machine on, demonstrating that the air current produced by the HFA pushes air out of the bowl and it cannot stagnate. There was no significant difference in measurement of aerosol while there was a patient performing the test and immediately after they had moved away, suggesting that aerosols breathed out by the patient are not able to remain in suspension in the bowl because of the ventilation current. CONCLUSION: There is no significant difference between aerosol count in the bowl of a HFA before, during and after testing. This suggests the risk of airborne transmission of COVID-19 is low between subsequent patients. This is in keeping with manufacturer's guidance on Humphrey visual field testing.

Home Monitoring for Glaucoma: Current Applications and Future Directions.

Technological advances provide a number of options for glaucoma monitoring outside the office setting, including home-based tonometry and perimetry. This has the potential to revolutionize management of this chronic disease, improve access to care, and enhance patient engagement. Here, we provide an overview of existing technologies for home-based glaucoma monitoring. We also discuss areas for future research and the potential applications of these technologies to telemedicine, which has been brought to the forefront during the ongoing COVID-19 pandemic.

Intraocular Pressure Telemetry for Managing Glaucoma during the COVID-19 Pandemic.

PURPOSE: To evaluate in glaucoma patients the feasibility and use of remote monitoring of intraocular pressure (IOP) with an implanted telemetry sensor during the coronavirus disease 2019 (COVID-19) lockdown. DESIGN: Cross-sectional study. PARTICIPANTS: Patients previously implanted with a telemetric IOP sensor (Eyemate; Implandata GmbH) were included. METHODS: Intraocular pressure measurements acquired by the patients during the lockdown were collected by physicians who were located remotely. A questionnaire was sent to 10 participating study centers to evaluate the clinical impact of remote monitoring of IOP via the IOP sensor system. MAIN OUTCOME MEASURES: Number of patients who obtained home IOP measurements. RESULTS: Data were available from all centers and from 37 eyes of 37 patients (16 patients with a sulcus-based sensor and 21 patients with a suprachoroidal sensor). Thirty-four patients obtained IOP measurements during the lockdown. Mean age of the patients was 69.3 ± 9.6 years, and 48.6% were women. A total of 8415 IOP measurements from 370 measurement days were obtained. Based on remote IOP measurements, treatment was changed in 5 patients. In another 5 patients, treatment change was considered when physicians received the IOP measurements after the lockdown. Nine of the 10 study centers judged remote IOP measurements to have a clinical impact. CONCLUSIONS: These results show the feasibility of patient-acquired measurement of IOP in conjunction with remote IOP monitoring by physicians with an implantable sensor. The data obtained impacted clinical decision making, including adjustment of ocular hypotensive therapy and avoiding unnecessary office visits during the COVID-19 pandemic.

Effect of Intraocular Pressure on Aerosol Density Generated by Noncontact Tonometer Measurement.

PRECIS: Aerosols generated by a noncontact tonometer (NCT) were quantified. There was a positive correlation between aerosols and intraocular pressure (IOP), and the concentration of aerosols beside the air jet port was the highest. PURPOSE: To investigate the effects of IOP on the aerosol density generated during the use of an NCT and provide references and suggestions for daily protection of ophthalmic medical staff during the coronavirus disease-19 (COVID-19) outbreak. OBJECTIVE AND METHODS: This cross-sectional clinical trial included 214 eyes of 140 patients from a hospital in Wenzhou city, Zhejiang Province. All subjects' IOPs were measured by an NCT (39 eyes with low IOP, 90 eyes with normal IOP, 37 eyes with moderately high IOP, and 48 eyes with very high IOP) between March 7 and June 17, 2020. The density of particulate matter (PM) 2.5 and PM10 generated during the process of IOP measurement with an NCT was analyzed. IOP values were recorded simultaneously. The aerosols generated during different IOP measurements were plotted in scatter plots. RESULTS: PM2.5 was generated more at the air jet port of the tonometer during the process of IOP measurement (H=2.731, P=0.019). Larger quantities of PM2.5 and PM10 were generated when the IOP was higher, and these differences were statistically significant (PM2.5: H=119.476, P<0.001; PM10: H=160.801, P<0.001). Linear correlation analysis with one variable demonstrated that IOP had significantly positive correlations with PM2.5 (r=0.756, P<0.001) and PM10 (r=0.864, P<0.001). CONCLUSIONS: Aerosols can be generated while using an NCT to measure IOP, and aerosols and IOP are positively correlated. Patients with moderately high IOP or very high IOP tend to generate more aerosols during the IOP measurement. The concentration of aerosols beside the air jet port was the highest.

Use of Telepresence Robots in Glaucoma Patient Education.

PRCIS: Telepresence robots (TR) present the versatility to effectively provide remote educational sessions for patients affected by glaucoma to improve disease knowledge. Given COVID-19's effect on clinical practice, TR can maintain social distancing when educating patients. PURPOSE: TR are devices that allow remote users to have a mobile presence anywhere. We compared the effect of an education session given by an in-person educator versus a TR on glaucoma knowledge and identified factors that impact patient education. METHODS: Eighty-five glaucoma patients were split into control, human, and TR groups. We measured glaucoma knowledge scores (KS) using the National Eye Institute's Eye-Q Test. Human and TR groups had the education session with a human or TR followed by the questionnaire. The control group was administered the questionnaire without an education session. Treatment regimen recall (RR) >90% was considered a success. We used linear regression and binary logistic regression to determine variables that affect KS and RR, respectively. RESULTS: Mean age was 58.3±2.8 years. 49% were female. Mean KS were 5.8±0.7 in the control group (n=31), 7.9±0.5 in the TR group (n=26), and 8.4±0.5 in the human group (n=28). Control participants had a lower mean KS than the human or TR groups (P<0.001). Having the education session (2.5, P<0.001), education greater than high school (0.8, P=0.016), and diabetes (-0.7, P=0.037) affected KS. Having diabetes (odds ratio=0.14, P=0.014) negatively affected RR. Having the education session may affect RR (odds ratio=5.47, P=0.07), warranting additional studies. CONCLUSIONS: Education sessions with a human and TR improved patients' glaucoma KS. TRs may serve as an alternative to in-person education sessions and allow educators to safely and effectively educate patients remotely to adhere to COVID-19 social distancing guidelines.

Drive-through Intraocular Pressure Checks During the COVID-19 Pandemic.

PRECIS: A drive-through clinic was created to obtain intraocular pressure measurements before a virtual visit with their provider, in order to provide care for patients in the Kellogg Glaucoma Clinic while minimizing risk of COVID-19 transmission. PURPOSE: The aim of this study was to establish a drive-through clinic model to provide glaucoma care for patients while minimizing the risk of COVID-19 transmission. PATIENTS AND METHODS: A drive-through clinic was created by adapting a 1-lane, 1-way driveway adjacent to the Kellogg Eye Center building entrance. Patients were physicianselected from the Glaucoma Clinic at Kellogg Eye Center as existing patients who required intraocular pressure (IOP) checks and therapeutic management and were chosen based on their ability to be managed with an IOP measurement primarily. The entrance was otherwise closed to the public, allowing staff to utilize an adjacent vestibule with glass walls and sliding doors as a staffroom. Patients were instructed to arrive within a 15-minute time window at which time they would drive through the lane and stop their cars under an awning over the driveway. Ophthalmic technicians wearing appropriate personal protective equipment then approached each car, confirmed patient information, and measured IOP. Once the data were recorded using a mobile workstation, the physician was able to complete each visit by discussing the findings and therapeutic plan with the patient, either in-person in real time or virtually by phone or video visit at a later time. RESULTS: A total of 241 visits were completed over 14 half day clinic sessions, with number of drive-through visits ranging from 5 to 45 per session. CONCLUSIONS: It is possible to institute a drive-through model of IOP checks for glaucoma patients which is efficient and minimizes the risk of exposure to COVID-19 for patients and staff.

Mask-induced Artifact Impacts Intraocular Pressure Measurement Using Goldmann Applanation Tonometry.

PURPOSE: The coronavirus (COVID-19) pandemic has impacted ophthalmology practices significantly. American Academy of Ophthalmology and Center for Disease Control guidelines suggest mandatory masking of patients and physicians during outpatient visits. We have recently become aware of a mask-induced phenomenon, whereby the intraocular pressure (IOP) as measured by Goldmann applanation tonometry (GAT) is artificially elevated due to mechanical interference from the mask. CLINICAL PRESENTATION: A 37-year-old male with a history of primary open-angle glaucoma on triple therapy presented for a routine visit. CLINICAL FINDINGS: When measuring IOP by GAT the right eye measured 16 mm Hg, but the left eye measured 20 mm Hg. The patient's mask was noted to be touching the base of the sensor rod on the tonometer. This patient's IOP was falsely elevated due to the lateral edge of his mask touching the base of the applanation tonometer, changing the relationship between the bi-prism tip and the weighted balance below, and eliminating the weighted balance from the pressure measuring mechanism. The patient's mask was adjusted to ensure there was no touch and repeat measurement showed an IOP of 16 mm Hg in the left eye. CONCLUSION: Recognizing mask-induced alteration in IOP is essential as it could lead to unnecessary escalation of treatment. We recommend flattening the area of mask protrusion during applanation and ensuring that the sensor arm remains clear of the mask while the tonometer tip approaches the cornea, especially at the moment the mires become visible during corneal contact.

Visual Field Artifacts in Glaucoma With Face Mask Use During the COVID-19 Pandemic.

PURPOSE: The coronavirus (COVID-19) pandemic has changed how outpatient care is delivered in ophthalmology clinics, particularly with glaucoma care. This case series highlights the need for awareness of fogging and improper face mask fit as causes of standard automated perimetry artifacts in patients with ocular hypertension and glaucoma. CLINICAL PRESENTATIONS: Six patients with the diagnosis of ocular hypertension, glaucoma suspect, or glaucoma underwent standard automated perimetry (24-2 or 10-2 SITA, Humphrey Field Analyzer) while wearing ear-loop surgical face masks. Due to patient complaints of fogging during the testing, low test reliability, and unexpected results, the tests were repeated after taping securely the mask to the bridge of the nose. CLINICAL FINDINGS: Fogging may reduce visual field (VF) test reliability and induce artifacts that mimic glaucomatous defects. VF test reliability can be improved and artifacts minimized following mask taping. In 1 case there was worsening of VF defects after mask taping. This suggests that fogging may also disguise true VF defects. CONCLUSIONS: Fogging can result in unreliable VF testing with glaucoma-like artifacts. Secure taping of the face mask to the nose bridge may minimize this problem and reduce unnecessary additional testing and follow-up visits.

Quantitative High-speed Assessment of Droplet and Aerosol From an Eye After Impact With an Air-puff Amid COVID-19 Scenario.

PURPOSE: To quantify aerosol and droplets generated during noncontact tonometry (NCT) and assess the spread distance of the same. METHODOLOGY: This was an experimental study on healthy human volunteers (n=8 eyes). In an experimental setup, NCT was performed on eyes (n=8) of human volunteers under normal settings, with a single and 2 drops of lubricant. High-speed shadowgraphy, frontal lighting technique, and fluorescein analysis were used to detect the possible generation of any droplets and aerosols. Mathematical computation of the spread of the droplets was then performed. RESULTS: In a natural setting, there was no droplet or aerosol production. Minimal splatter along with droplet ejection was observed when 1 drop of lubricant was used before NCT. When 2 drops of lubricant were instilled, a significant amount of fluid ejection in the form of a sheet that broke up into multiple droplets was observed. Some of these droplets traversed back to the tonometer. Droplets ranging from 100 to 500 µm in diameter were measured. CONCLUSIONS: There was no droplet generation during NCT performed in a natural setting. However, NCT should be avoided in conditions with high-tear volume (natural or artificial) as it would lead to droplet spread and tactile contamination.

Intraocular Pressure Measurement in Patients Wearing Filtering Facepiece Masks.

Ophthalmological examination requires a strict contact between caregivers and patients. In the COVID-19 era, this may be a risk factor for virus spread, and the use of facial masks for all in-office ophthalmological procedures has been recommended. In this case-series, we report about some errors in intraocular pressure measurement, that may occur during the slit-lamp examination of patients wearing filtering facepiece masks and N95 respirators. This is mainly due to the greater dimensions of these masks in comparison with the surgical standard ones, and to the presence of a preshaped rigid nose area that may press against the Goldmann tonometer. Special care should be taken when measuring intraocular pressure in these cases.