Clinician-Driven Reanalysis of Exome Sequencing Data From Patients With Inherited Retinal Diseases.

Importance: Despite advances in next-generation sequencing (NGS), a significant proportion of patients with inherited retinal disease (IRD) remain undiagnosed after initial genetic testing. Exome sequencing (ES) reanalysis in the clinical setting has been suggested as one method for improving diagnosis of IRD. Objective: To investigate the association of clinician-led reanalysis of ES data, which incorporates updated clinical information and comprehensive bioinformatic analysis, with the diagnostic yield in a cohort of patients with IRDs in Korea. Design, Setting, and Participants: This was a multicenter prospective cohort study involving 264 unrelated patients with IRDs, conducted in Korea between March 2018 and February 2020. Comprehensive ophthalmologic examinations and ES analyses were performed, and ES data were reanalyzed by an IRD specialist for single nucleotide variants, copy number variants, mobile element insertions, and mitochondrial variants. Data were analyzed from March to July 2023. Main Outcomes and Measures: Diagnostic rate of conventional bioinformatic analysis and clinician-driven ES reanalysis. Results: A total of 264 participants (151 [57.2%] male; mean [SD] age at genetic testing, 33.6 [18.9] years) were enrolled, including 129 patients (48.9%) with retinitis pigmentosa and 26 patients (9.8%) with Stargardt disease or macular dystrophy. Initial bioinformatic analysis diagnosed 166 patients (62.9%). Clinician-driven reanalysis identified the molecular cause of diseases in an additional 22 patients, corresponding to an 8.3-percentage point increase in diagnostic rate. Key factors associated with new molecular diagnoses included clinical phenotype updates (4 patients) and detection of previously overlooked variation, such as structural variants (9 patients), mitochondrial variants (3 patients), filtered or not captured variants (4 patients), and noncanonical splicing variants (2 patients). Among the 22 patients, variants in 7 patients (31.8%) were observed in the initial analysis but not reported to patients, while those in the remaining 15 patients (68.2%) were newly detected by the ES reanalysis. Conclusions and Relevance: In this cohort study, clinician-centered reanalysis of ES data was associated with improved molecular diagnostic yields in patients with IRD. This approach is important for uncovering missed genetic causes of retinal disease.

Non-Arteritic Ischemic Optic Neuropathy Following COVID-19 Vaccination in Korea: A Case Series.

BACKGROUND: To report the clinical manifestations of non-arteritic anterior ischemic optic neuropathy (NAION) cases after coronavirus disease 2019 (COVID-19) vaccination in Korea. METHODS: This multicenter retrospective study included patients diagnosed with NAION within 42 days of COVID-19 vaccination. We collected data on vaccinations, demographic features, presence of vascular risk factors, ocular findings, and visual outcomes of patients with NAION. RESULTS: The study included 16 eyes of 14 patients (6 men, 8 women) with a mean age of 63.5 ± 9.1 (range, 43-77) years. The most common underlying disease was hypertension, accounting for 28.6% of patients with NAION. Seven patients (50.0%) had no vascular risk factors for NAION. The mean time from vaccination to onset was 13.8 ± 14.2 (range, 1-41) days. All 16 eyes had disc swelling at initial presentation, and 3 of them (18.8%) had peripapillary intraretinal and/or subretinal fluid with severe disc swelling. Peripapillary hemorrhage was found in 50% of the patients, and one (6.3%) patient had peripapillary cotton-wool spots. In eight fellow eyes for which we were able to review the fundus photographs, the horizontal cup/disc ratio was less than 0.25 in four eyes (50.0%). The mean visual acuity was logMAR 0.6 ± 0.7 at the initial presentation and logMAR 0.7 ± 0.8 at the final visit. CONCLUSION: Only 64% of patients with NAION after COVID-19 vaccination have known vascular and ocular risk factors relevant to ischemic optic neuropathy. This suggests that COVID-19 vaccination may increase the risk of NAION. However, overall clinical features and visual outcomes of the NAION patients after COVID-19 vaccination were similar to those of typical NAION.

Longitudinal metatranscriptomic sequencing of Southern California wastewater representing 16 million people from August 2020-21 reveals widespread transcription of antibiotic resistance genes.

Municipal wastewater provides a representative sample of human fecal waste across a catchment area and contains a wide diversity of microbes. Sequencing wastewater samples provides information about human-associated and medically important microbial populations, and may be useful to assay disease prevalence and antimicrobial resistance (AMR). Here, we present a study in which we used untargeted metatranscriptomic sequencing on RNA extracted from 275 sewage influent samples obtained from eight wastewater treatment plants (WTPs) representing approximately 16 million people in Southern California between August 2020 - August 2021. We characterized bacterial and viral transcripts, assessed metabolic pathway activity, and identified over 2,000 AMR genes/variants across all samples. Because we did not deplete ribosomal RNA, we have a unique window into AMR carried as ribosomal mutants. We show that AMR diversity varied between WTPs (as measured through PERMANOVA, P < 0.001) and that the relative abundance of many individual AMR genes/variants increased over time (as measured with MaAsLin2, Padj < 0.05). Similarly, we detected transcripts mapping to human pathogenic bacteria and viruses suggesting RNA sequencing is a powerful tool for wastewater-based epidemiology and that there are geographical signatures to microbial transcription. We captured the transcription of gene pathways common to bacterial cell processes, including central carbon metabolism, nucleotide synthesis/salvage, and amino acid biosynthesis. We also posit that due to the ubiquity of many viruses and bacteria in wastewater, new biological targets for microbial water quality assessment can be developed. To the best of our knowledge, our study provides the most complete longitudinal metatranscriptomic analysis of a large population's wastewater to date and demonstrates our ability to monitor the presence and activity of microbes in complex samples. By sequencing RNA, we can track the relative abundance of expressed AMR genes/variants and metabolic pathways, increasing our understanding of AMR activity across large human populations and sewer sheds.

Longitudinal metatranscriptomic sequencing of Southern California wastewater representing 16 million people from August 2020-21 reveals widespread transcription of antibiotic resistance genes.

Municipal wastewater provides a representative sample of human fecal waste across a catchment area and contains a wide diversity of microbes. Sequencing wastewater samples provides information about human-associated and medically-important microbial populations, and may be useful to assay disease prevalence and antimicrobial resistance (AMR). Here, we present a study in which we used untargeted metatranscriptomic sequencing on RNA extracted from 275 sewage influent samples obtained from eight wastewater treatment plants (WTPs) representing approximately 16 million people in Southern California between August 2020 - August 2021. We characterized bacterial and viral transcripts, assessed metabolic pathway activity, and identified over 2,000 AMR genes/variants across all samples. Because we did not deplete ribosomal RNA, we have a unique window into AMR carried as ribosomal mutants. We show that AMR diversity varied between WTPs and that the relative abundance of many individual AMR genes/variants increased over time and may be connected to antibiotic use during the COVID-19 pandemic. Similarly, we detected transcripts mapping to human pathogenic bacteria and viruses suggesting RNA sequencing is a powerful tool for wastewater-based epidemiology and that there are geographical signatures to microbial transcription. We captured the transcription of gene pathways common to bacterial cell processes, including central carbon metabolism, nucleotide synthesis/salvage, and amino acid biosynthesis. We also posit that due to the ubiquity of many viruses and bacteria in wastewater, new biological targets for microbial water quality assessment can be developed. To the best of our knowledge, our study provides the most complete longitudinal metatranscriptomic analysis of a large population's wastewater to date and demonstrates our ability to monitor the presence and activity of microbes in complex samples. By sequencing RNA, we can track the relative abundance of expressed AMR genes/variants and metabolic pathways, increasing our understanding of AMR activity across large human populations and sewer sheds.

Acquired Esotropia in an Adolescent Wearing Orthokeratology Lenses.

Orthokeratology is a procedure involving the use of reverse-geometry lenses to temporarily correct refractive errors. Switching from spectacles to orthokeratology lenses may influence binocular visual function and accommodation. This is the first report of orthokeratology lens-associated acquired esotropia, a form of distance esotropia, in an adolescent with myopic anisometropia. [J Pediatr Ophthalmol Strabismus. 2022;59(1):e7-e10.].

Progressive Myelinated Retinal Nerve Fibers in Children With Craniosynostosis.

The authors found the changes of myelinated retinal nerve fibers in one pair of identical twins with nonsyndromic craniosynostosis and two patients with Crouzon syndrome, who were at risk for impaired lamina cribrosa barrier function. This is the first report of progressive and presumed acquired myelinated retinal nerve fibers in craniosynostosis. [J Pediatr Ophthalmol Strabismus. 2021;58(6):e40-e43.].

Photographic Assessment of Intermittent Exotropia Using a Translucent Cover.

PURPOSE: To evaluate the validity of the photographic assessment with a translucent cover that is clinically available for the evaluation of intermittent exotropia. METHODS: Photographs of 270 patients who cooperated for the prism and alternate cover test (PACT) were reviewed. Full-face images were obtained with a digital camera while a translucent cover was placed in front of either eye. The change in distance from the medial canthus to the nasal limbus with occlusion was measured and the photographic angle was estimated by three independent ophthalmologists based on representative photographs. These two measurements were correlated with the angle measured using the PACT, and clinical features related to the discrepancy between the photographic angle and the angle measured with the PACT were determined. RESULTS: Patients with intermittent exotropia of 27.0 ± 6.1 prism diopters (PD) showed a 4.5 ± 3.3 mm exodrift and an estimated angle of 29.0 ± 4.3 PD on the photographs with occlusion. The exodrift distance and photographic angle were positively correlated with the angle of PACT (r = 0.256, P < .001 and r = 0.546, P < .001, respectively). Of the 47 patients with a discrepancy of greater than 8 PD, 38 patients (80.9%) were regarded as having a photographic angle that was larger than the angle of PACT, which was more common in older patients, in those with a small distance angle, and when taking off the spectacles. CONCLUSIONS: Photographs with a translucent cover can reveal the latent components of intermittent exotropia. However, the photographic angle might differ from the real angle, particularly in older patients with a small angle and with the spectacles off. [J Pediatr Ophthalmol Strabismus. 2021;58(5):331-338.].

Myopic Progression in Girls with Gonadotrophin-Releasing Hormone Agonist Treatment for Central Precocious Puberty.

We sought to determine whether the myopic progression of patients with central precocious puberty (CPP) who were undergoing treatment differed from that of their healthy peers with normal pubertal onset and progression. Eighteen girls with CPP and 14 age-matched controls who underwent regular ophthalmic examinations for at least 1 year were included. All the CPP patients received a 3.75 mg leuprolide acetate depot subcutaneously every 28 days. The spherical equivalent (SE) and axial length (AL) for myopia progression and the pubertal parameters (height, body weight, body mass index, Tanner stage, and bone age) were compared between the two groups. Of 32 subjects with a mean age of 8.6 ± 0.7 years, the SEs and ALs did not differ at baseline between the two groups, which had similar weight and similar body mass index. After 1 year, both the CPP patients and controls showed myopic progression, with an average myopic shift of -0.73 ± 0.48 diopters (D) and AL elongation with a mean change of 0.44 ± 0.61 mm. The SE and AL changes over 1 year were greater in the controls than those in the CPP patients, which was not statistically significant (-0.85 ± 0.55 D vs. -0.64 ± 0.41 D and 0.55 ± 0.89 mm vs. 0.35 ± 0.22 mm, respectively). The change in AL correlated significantly with the change in the height (ß = 0.691, p = 0.039). In this 1-year study, the CPP patients with treatments trended to show less myopic progression than the controls.

Ocular biometric features of pediatric patients with fibroblast growth factor receptor-related syndromic craniosynostosis.

Ametropia is reported as a common ophthalmic manifestation in craniosynostosis. We retrospectively compared childhood refractive error and ocular biometric features of fibroblast growth factor receptor (FGFR)-related syndromic craniosynostosis patients with those of non-syndromic craniosynostosis and control subjects. Thirty-six eyes (18 patients) with FGFR-related syndromic craniosynostosis, 76 eyes (38 patients) with non-syndromic craniosynostosis, and 114 eyes (57 patients) of intermittent exotropes were included in the analysis. Mean age at examination was 7.82 ± 2.51 (range, 4-16) years and mean spherical equivalent was -0.09 ± 1.46 Diopter. Mean age and refractive error were not different between groups, but syndromic craniosynostosis patients had significantly longer axial length, lower corneal power, and lower lens power than other groups (p < 0.01, p < 0.01, and p < 0.01, respectively). Axial length was positively correlated and keratometry and lens power were negatively correlated with age in non-syndromic craniosynostosis and controls, while these correlations between age and ocular biometric parameters were not present in the FGFR-related syndromic craniosynostosis. In conclusion, ocular biometric parameters in FGFR-related syndromic craniosynostosis differed from those of non-syndromic craniosynostosis and age-matched controls, and did not show the relations with age, suggesting this cohort may have abnormal refractive growth.

Reducing the Costs of an Eye Care Adherence Program for Underserved Children Referred Through Inner-City Vision Screenings.

PURPOSE: We previously reported costs and outcomes of the Children's Eye Care Adherence Program (CECAP1), a social worker intervention designed to improve adherence to eye care for underserved children in urban Philadelphia. Using cost findings from CECAP1, we revised the intervention to reduce costs. The aim of this study was to evaluate costs and effectiveness of the revised intervention (CECAP2). DESIGN: Retrospective cohort study. METHODS: Records of children needing ophthalmic follow-up after 2 community-based vision screening programs were reviewed. We modified CECAP1 to prioritize children more likely to visit, decreased phone calls and scheduling attempts, better documented children already followed by other doctors, and constricted our geographic catchment area for better accessibility. Cost was calculated using time spent executing CECAP2 by our salaried social worker. Effectiveness was defined as the percentage of patients completing at least 1 follow-up visit within the recommended time frame. RESULTS: Of 462 children referred to CECAP2 from our in-school and on-campus screening programs, 242 (52.4%) completed subsequent recommended eye examinations, a proportion identical to our prior report (52.3%). Social worker time per patient was 0.8 hours; a significant reduction from the previous 2.6 hours (P < .01). Cost per patient was $32.73; a significant reduction compared to the previous $77.20 (P < .01). CONCLUSIONS: Programmatic changes to reduce social worker intervention time and target potential patients by likelihood to attend along with constriction of the catchment area led to reduced costs by more than 50%, without impairing CECAP effectiveness.

Block-building performance test using a virtual reality head-mounted display in children with intermittent exotropia.

PURPOSE: To determine whether childhood intermittent exotropia (IXT) affects distance divergence and performance in block-building tasks within a virtual reality (VR) environment. METHODS: Thirty-nine children with IXT, aged 6-12 years, who underwent muscle surgery and 37 normal controls were enrolled. Children were instructed to watch the target moving away and perform a block-building task while fitted with a VR head-mounted display equipped with eye- and hand-movement tracking systems. The change in inter-ocular distance with binocular distance viewing, time to stack five cube blocks of different sizes in order, and distance disparities between the largest and farthest cubes were assessed. All children were evaluated at baseline and 3-month time points. RESULTS: The patients with IXT exhibited a larger distance divergence than did controls (p = 0.024), which was associated with greater distance angle of deviation and poorer distance control (r = 0.350, p = 0.001 and r = 0.349, p = 0.004). At baseline, the patients with IXT showed larger distance disparities in the block-building task than did controls in terms of the horizontal, vertical, and 3-dimensional (3-D) measurements (all ps < 0.050). Larger horizontal disparity was associated with greater distance angle of deviation (r = 0.383, p = 0.037). Three months after surgery, the horizontal and 3-D disparities in the patients with IXT improved significantly and were not comparably different compared with controls. CONCLUSIONS: These preliminary findings suggest that VR-based block-building task may be useful in testing possible deficits in visuo-motor skills associated with childhood IXT.

Sternocleidomastoid muscle asymmetry in unilateral congenital superior oblique palsy.

BACKGROUND: To determine whether there is an asymmetry in bilateral sternocleidomastoid muscle (SCM) thickness in patients with unilateral congenital superior oblique palsy (SOP) and its association with surgical results. METHODS: The medical records of 186 patients with head tilt secondary to unilateral SOP, who were evaluated for the status of the SCM with neck ultrasound or magnetic resonance imaging, were reviewed. The SCM asymmetry index was calculated as a bilateral difference in the maximal muscle thickness divided by each tilted-side SCM thickness. The presence of SCM asymmetry, defined as an index of >10%, and its relationship to residual torticollis ≥5° after SOP surgery were assessed. RESULTS: Of 186 patients with a median age of 1.2 years, SCM asymmetry was present in 102 (54.8%) patients (6.8 ± 1.9 mm for the SOP side vs. 6.6 ± 2.1 mm for the tilted side). The SCM asymmetry did not differ according to age, amount of head tilt or hypertropia. In the patients with SCM asymmetry, more patients (87.3%) underwent physiotherapy than those without asymmetry (61.9%) (P = 0.021). In 99 patients who underwent surgery for SOP, the resolution of torticollis was not significantly different between patients with and without SCM asymmetry (87.2% vs. 76.9%, P = 0.184). CONCLUSIONS: Nearly half of the patients with congenital SOP had SCM thickness asymmetry that was already determined at a young age. However, the surgical results did not differ significantly with respect to SCM asymmetry when physiotherapy was combined. Thus, SOP surgery can be considered despite preoperative SCM asymmetry.

Range of forced cyclorotation in superior oblique palsy and V-pattern strabismus.

PURPOSE: To quantify a passive range of cyclorotation using a smartphone application and evaluate its associations with fundus torsion and rectus muscle cyclorotation in superior oblique palsy (SOP) and V-pattern strabismus. METHODS: Fifty-two patients showing overelevation in adduction (30 with congenital SOP and 22 with V-pattern strabismus) underwent forced cyclorotation on the photographs. A photograph of the globe was taken in maximally excyclorotated and incyclorotated positions after marking at the 6 and 12 o'clock limbus under general anaesthesia, and the rotational alignment of these markings was read using the toriCAM application. The degrees of forced cyclorotation were compared between the two groups. Disc-fovea angle on fundus photographs and rectus muscle cyclorotation in the coronal view on orbital computed tomography were correlated with the range of forced excyclorotation. RESULTS: The range of forced excyclorotation was greater in V-pattern strabismus than that in SOP (58.5° vs. 46.8°, p < 0.001), whereas the ranges of incyclorotation were similar between the two groups (39.0° vs. 39.0°, p = 0.543). Regression analysis revealed a significant increase in the range of excyclorotation with the degree of rectus muscle excyclorotation, after accounting for age and angle of hypertropia (r2 = 0.475, p = 0.001). The range of excyclorotation did not correlate with the amount of fundus extorsion and grade of overelevation in adduction. CONCLUSIONS: The range of excyclorotation was correlated with the rectus muscle excyclorotation in these populations, suggesting that the results from this forced cyclorotation test may reflect orbital alignment and oblique muscle status.

Anomalous extraocular muscles in Crouzon syndrome with V-pattern exotropia.

Strabismus associated with Crouzon syndrome is common and often complex. V-pattern strabismus is most commonly reported in this condition and is mainly thought to be due to an excyclorotation of the orbits and rectus muscle pulleys. We report two cases of children with Crouzon syndrome and V-pattern exotropia who had rectus muscle heterotopy on orbital imaging and were also found intraoperatively to have anomalous extraocular muscles. At the time of surgery, bifid insertion, misdirection, and fibrosis of extraocular muscles were noted. This highlights the various causes of V-pattern strabismus associated with Crouzon syndrome, including dysmorphic orbits and extraocular muscle anomalies.

Binocular discrepancy in lateral rectus muscle attachment in intermittent exotropia with eye dominance.

PURPOSE: To determine whether there is asymmetry in the lateral rectus (LR) muscle attachment between both eyes in patients with intermittent exotropia (IXT) with a non-dominant eye, but without amblyopia or anisometropia. METHODS: In total, 109 patients who underwent bilateral lateral rectus recession for IXT were included, 81 with and 28 without eye dominance. The limbus-insertion distance and tendon width of the LR muscle were measured intraoperatively using callipers. The insertion-equator distance (presumed arc of contact), area of contact (arc of contact × tendon width), and torque value (radius of globe × arc of contact) of the LR muscle were calculated based on intraoperative measurements and axial length measured using a partial interferometer. Parameters regarding LR muscle attachment were compared between fellow eyes and between groups. RESULTS: Mean measurements in all parameters related to LR muscle attachments other than tendon width were not different between the two eyes or between groups. The mean tendon width of the non-dominant eye was 9.2 ± 0.7 mm, narrower than the 9.4 ± 0.5 mm width in either eye of patients without dominance (p = 0.020). However, there was no difference in all parameters in 21 pairs of patients after matching. The proportion of patients who showed binocular discrepancies in attachment measurements beyond that attributable to potential measuring errors did not differ between the two groups. CONCLUSIONS: Structural parameters related to LR muscle attachments did not differ based on eye dominance, suggesting that the anatomic structure of LR muscle attachments is not responsible for eye dominance in IXT.