Consecutive central and branch retinal vein occlusions in the same eye of a young healthy COVID-19 patient: A unique case report.

Purpose: To report a case of consecutive central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO) in the same eye correlated with coronavirus disease (COVID-19) of the otherwise healthy patient. Observations: A 39-year-old woman with the diagnosis of COVID-19 infection for two weeks presented with a nonischemic central retinal vein occlusion (CRVO) in her right eye. The patient was on low-dose aspirin for anticoagulant prophylaxis (100 mg/day) for a week when the CRVO occurred. She had no history of any systemic risk factors for retinal vein occlusion (RVO) and her systemic evaluation failed to identify an etiology for her unilateral CRVO. While she was on monthly follow-up with no additional treatment, she experienced sudden visual acuity decrease in the same eye four months after the first RVO incident and one month after the cessation of aspirin intake. Her best corrected visual acuity (BCVA) was decreased from 20/25+ to 20/63. Her fundoscopic examination revealed increased intraretinal hemorrhages, dilated tortuous veins in the upper hemifield and macular edema. The central macular thickness measurement by optic coherence tomography was increased from 234 µm to 700 µm. The patient refused to undergo a fundus fluorescein angiography. After the diagnosis of the branch retinal vein occlusion with cystoid macular edema was done, the aspirin prophylaxis was restarted, and she received three intravitreal antivascular endothelial growth factor one month apart for her macular edema. Her BCVA improved to 20/20, and macular edema disappeared without any recurrence during the 6-month follow-up. Conclusions and importance: To the best of our knowledge, this unique case is the first report of consecutive RVOs in the same eye of a healthy young patient associated with COVID-19. As our case report demonstrated, close follow-up and timely initiation of appropriate treatment could give rise to complete resolution of RVO.

The Repeatability, Reproducibility, and Correlation of the Schirmer Test: A Comparison of Open versus Closed Eye.

PURPOSE: To compare the repeatability and reproducibility of the Schirmer test (ST) without anesthesia when the eyes are open (STo) and closed (STc) in previously undiagnosed patients with suggestive symptoms of dry eye. METHODS: In a comparative, observational series case study, 31 patients were included in the study. STo and STc were alternately applied for a total of six times. The ST was applied two times with the eyes open (S1) and closed (S2), respectively, by a single ophthalmologist. Then the ST was repeated four times with the eyes open (S3, S5) and closed (S4, S6), respectively, by a single nurse. RESULTS: S1, S3, and S5 were 23.4, 23.7, and 23.3 mm, respectively. S2, S4, and S6 were 14.7, 15.6, and 16.6 mm, respectively. STc scores were found to be statistically lower than the STo's in general (right: t = 2.033, p = 0.048; left: t = 3.474, p = 0.004). There was no statistically significant difference in the scores of the three tests with open eyes: S1, S3, and S5 (p = 0.462). There was also no statistically significant difference in the scores of the three tests with closed eyes: S2, S4, and S6 (p = 0.05). CONCLUSIONS: Our study suggests that although administering the ST with the patient's eyes open produces higher readings than STc in patients with suggestive symptoms of dry eye, there was an acceptable reliability among tests performed open and closed. Moreover, intraexaminer reliability was higher than interexaminer reliability for both with the eyes open and closed.

Macular Thickness and Microvasculature Loss in Glaucoma Suspect Eyes.

PURPOSE: To characterize the change of ganglion cell complex (GCC) thickness and macular vessel density in glaucoma suspect eyes with ocular hypertension (OHT) or glaucomatous optic neuropathy (GON). DESIGN: Prospective, longitudinal study. PARTICIPANTS: Eight-three eyes (24 healthy, 30 OHT, and 29 GON) of 65 patients who underwent at least 3 visits were included from the Diagnostic Innovations in Glaucoma Study. The mean follow-up was at least 3 years. METHODS: OCT angiography (OCTA)-based vessel density and OCT-based structural thickness of the 3 × 3-mm1 GCC scan slab were evaluated at each visit. The rates of vessel density and thickness change were compared across diagnostic groups using a linear mixed-effects model. MAIN OUTCOME MEASURES: Change rates of macula GCC thickness and superficial vessel density. RESULTS: Significant mean rates of both GCC thinning and vessel density loss were detectable in OHT and GON groups. Of the individual suspect eyes, 49.1% showed significant loss (P < 0.05) with either vessel density or GCC thickness. Of the GON eyes, 31.0% showed both significant GCC loss and vessel density loss, 51.7% showed only significant GCC loss, whereas 17.2% showed only significant vessel density loss. Vessel density loss was faster than GCC thinning in half of the suspect eyes based on percent loss analysis. The age and scan quality-adjusted GCC thinning rates of the OHT group (-0.59 µm/year; P = 0.025) and GON group (-0.79 µm/year; P = 0.058) were faster than those of the healthy group (-0.11 µm/year), whereas the rate of vessel density loss was not significantly different among the diagnostic groups (all P > 0.2). Higher mean intraocular pressure during follow-up was associated with faster GCC thinning in the OHT group (P = 0.065) and GON groups (P = 0.015), but was not associated with the rate of vessel density decrease. CONCLUSIONS: Whereas the rate of GCC thinning was faster on average in suspect eyes than in healthy eyes, some suspect eyes showed significant loss of vessel density and faster vessel density loss than GCC thinning. OCT and OCTA are complementary and useful for evaluating eyes with OHT or GON.

The effect of topical bimatoprost on corneal clarity in primary open-angle glaucoma: a longitudinal prospective assessment.

PURPOSE: To study the effect of topical bimatoprost on the corneal optical density values using a dual Scheimpflug Placido analysis system. METHODS: This longitudinal case-control study included 18 patients with newly diagnosed primary open-angle glaucoma who received topical bimatoprost as a first-line treatment and 20 healthy individuals (age and sex-matched controls). Corneal densitometry data were obtained using the dual Scheimpflug analyzer at pre-treatment and 1st, 6th, 12th, 18th months of post-treatment. Repeated measures of ANOVA and Pearson correlation tests were used for statistical analysis. RESULTS: There were statistically significant differences between pre-treatment and post-treatment 1st and 6th months corneal densitometry values (p < 0.001, p = 0.007, respectively). However, there was no statistically significant difference between the post-treatment 12th and 18th months (p > 0.05). Corneal densitometry values decreased during the 1st month. Intraocular pressure (IOP) differences were statistically significant between baseline and 1 month after treatment (P < 0.001), however not statistically significant between the 1st and 6th, 6th and 12th, 12th and 18th months after treatment (p > 0.05, for all). Corneal densitometry was not correlated with IOP (r = - 0.037, p = 0.44). In the control group, there was no statistically significant difference between baseline and post-baseline 18th-month corneal densitometry measurements (p > 0.05). CONCLUSIONS: Topical bimatoprost administration might result in a decrease in corneal densitometry measurement. It is of clinical importance that topical bimatoprost administration can affect corneal transparency and cause a possible alteration in corneal properties.

Rates of Retinal Nerve Fiber Layer Thinning in Distinct Glaucomatous Optic Disc Phenotypes in Early Glaucoma.

PURPOSE: To compare spectral-domain optical coherence tomography (SDOCT) measured circumpapillary retinal nerve fiber layer (cpRNFL) among 4 glaucomatous optic disc phenotypes in early glaucoma. DESIGN: Clinical cohort study METHODS: In this study, 218 early glaucoma eyes that had at least 3 years of follow-up and a minimum of 4 SDOCT scans were recruited. The optic discs were classified into 4 types based on appearance: 76 generalized cup enlargement (GE), 53 focal ischemic (FI), 22 myopic glaucomatous (MY), and 67 senile sclerotic (SS). A linear mixed effects model was used to compare the rates of global and regional cpRNFL thinning among optic disc phenotypes. RESULTS: After adjusting for confounders, the SS group (mean [95% CI]: -1.01 [-1.30, -0.73] µm/y) had the fastest mean rate of global cpRNFL thinning followed by FI (-0.77 [-0.97, -0.57] µm/y), MY (0.59 [-0.81, -0.36] µm/y), and GE (-0.58 [-0.75, -0.40] µm/y) at P < .001. The inferior temporal sector had the fastest rate of cpRNFL thinning among the regional measurements except for the MY group (-0.68 [-1.10, -0.26] µm/y, P = .002). In the multivariable analysis, GE (P = .002) and MY (P = .010) phenotypes were associated with significantly slower global rates of cpRNFL thinning compared with the SS phenotype. CONCLUSIONS: Rates of cpRNFL thinning were different among the 4 glaucomatous optic disc phenotypes. Those patients with early glaucoma with SS phenotype have the fastest cpRNFL thinning. These patients may benefit from more frequent monitoring and the need to advance therapy if cpRNFL thinning is detected.

Superficial and Deep Macula Vessel Density in Healthy, Glaucoma Suspect, and Glaucoma Eyes.

PRECIS: Macular superficial capillary plexus (SCP) vessel density is more informative than deep capillary plexus (DCP) vessel density for the detection of glaucoma. PURPOSE: The purpose of this study was to characterize optical coherence tomography angiography macular SCP and projection-resolved DCP vessel densities and compare their diagnostic accuracies with ganglion cell complex (GCC) thickness in healthy, glaucoma suspect, and glaucoma eyes. MATERIALS AND METHODS: Sixty-eight eyes of 44 healthy subjects, 26 eyes of 16 preperimetric glaucoma suspects, and 161 eyes of 124 glaucoma patients from the Diagnostics Innovations in Glaucoma Study with good quality high-density 6×6 mm2 macula optical coherence tomography angiography images were included. The diagnostic accuracy of SCP vessel density, projection-resolved DCP vessel density and GCC thickness were compared among groups. RESULTS: Mean whole image vessel density (wiVD; % of area occupied by vessels containing flowing blood) in the SCP layer was highest in healthy eyes (49.7%), followed by glaucoma suspect eyes (46.0%), and glaucoma eyes (40.9%) (P<0.001). Mean wiVD in the DCP layer was similar in healthy (50.6%), glaucoma suspect (47.3%), and glaucoma eyes (45.7%) (P=0.925). Diagnostic accuracy of both GCC thickness and SCP wiVD was significantly higher than DCP wiVD for classifying healthy and glaucoma eyes [adjusted area under the receiver operating characteristic curve (95% confidence interval): GCC=0.86 (0.72, 0.94), SCP=0.80 (0.66, 0.91) and DCP=0.44 (0.30, 0.57)] (P<0.001). CONCLUSIONS: SCP vessel densities have better diagnostic accuracy for detecting glaucoma than DCP vessel densities. Although the diagnostic accuracy of the macula SCP is relatively modest, it is more informative than the DCP.

OCT Angiography Artifacts in Glaucoma.

PURPOSE: To determine the prevalence of different types of artifacts seen in OCT angiography (OCTA) images of healthy and glaucoma eyes and evaluate the characteristics associated with poor-quality images. DESIGN: Retrospective study. PARTICIPANTS: A total of 649 eyes of 368 healthy, glaucoma suspect, and glaucoma patients. METHODS: Angiovue (Optovue Inc) high-density (HD) and non-HD optic nerve head and macula OCTA images of participants were evaluated by 4 expert reviewers for the presence of different artifacts, including eye movement, defocus, shadow, decentration, segmentation error, blink, and Z offset in the superficial vascular layer. Each OCTA scan was designated to have good or poor quality based on the presence of artifacts. The association of demographic and ocular characteristics with the likelihood of obtaining poor-quality OCTA images was evaluated. MAIN OUTCOME MEASURES: The prevalence of OCTA artifacts and the factors associated with increased likelihood of capturing poor-quality OCTA images. RESULTS: A total of 5263 OCTA images were evaluated. Overall, 33.9% of the OCTA images had poor quality. The majority of images with acceptable quality scores (QS ≥ 4) had no artifacts (76.6%). Other images had 1 (13.6%) or 2 or more artifacts (9.8%). Older age (P < 0.001), male gender (P = 0.045), worse visual field mean deviation (P < 0.001), absence of eye tracking (P < 0.001), and macular scan area (P < 0.001) were associated with a higher likelihood of obtaining poor-quality images. In images with acceptable QS, the commercially available quality measures including QS and signal strength index had the area under the receiver operating characteristic curves of 0.65 (95% confidence interval [CI], 0.62-0.69) and 0.70 (95% CI, 0.68-0.73) to detect good-quality images, respectively. CONCLUSIONS: OCTA artifacts associated with poor-quality images are frequent, and their prevalence is affected by ocular and patient characteristics. One should not rely solely on the quantitative assessments that are provided automatically by OCTA instruments. A systematic scan review should be conducted to ensure appropriate interpretation of OCTA images. Given the high prevalence of poor-quality OCTA images, the images should be reacquired whenever an apparent and correctable artifact is present on a captured image.

Comparison of Peripapillary Capillary Density in Glaucoma Patients of African and European Descent.

PURPOSE: To evaluate racial differences in optic nerve head peripapillary capillary density measured by OCT angiography (OCTA) in patients with open-angle glaucoma. DESIGN: Observational, cross-sectional study. PARTICIPANTS: Two hundred eighty-four eyes of 195 glaucoma patients and 108 eyes of 58 healthy participants from the Diagnostic Innovations in Glaucoma Study. METHODS: Global and sectoral circumpapillary capillary density (cpCD) loss in participants of European descent (ED) and African descent (AD) were compared. Areas under the receiver operating characteristic curve (AUROCs) were used to evaluate diagnostic accuracy of cpCD and global circumpapillary retinal nerve fiber layer (cpRNFL) thickness in the 2 groups after adjusting for confounders. MAIN OUTCOME MEASURES: Peripapillary capillary density and cpRNFL thickness measurements and their estimated loss. RESULTS: Participants of AD and ED with glaucoma were of similar age and glaucoma severity. After adjusting for age, disc area, and other confounders, significantly lower cpCD was found in ED eyes compared with AD eyes in mild glaucoma (mean, 42.2% [95% confidence interval (CI), 41.2%-43.2%] and 46.5% [95% CI, 44.8%-48.1%], respectively; adjusted difference, 4.4 [95% CI, 2.6-6.2]; P < 0.001) and moderate to advanced glaucoma (mean, 34.7% and 38.5%, respectively; adjusted difference, 4.8 [95% CI, 1.6-8.1]; P = 0.005). Although capillary density loss was greater in all sectors in ED compared with AD participants, a similar sectoral pattern of density loss was observed in both racial groups. Lower mean deviation and older age were associated with lower cpCD in both races in multivariate models. The adjusted AUROC for discriminating between healthy and glaucomatous eyes for cpCD was higher for ED (0.95) compared with AD (0.68) patients (P < 0.001). Sensitivity at 95% specificity in AD participants was lower than in ED participants for cpCD (0.32 [95% CI, 0.11-0.64] vs. 0.83 [95% CI, 0.69-0.93], respectively; P < 0.001). CONCLUSIONS: Although peripapillary capillary density parameters showed good diagnostic accuracy for detecting glaucoma in ED patients, their diagnostic accuracy was only modest in AD patients. Diagnostic performance of cpCD is race dependent, and clinicians should be aware that it has poorer performance in AD patients.

Central Visual Field Defects in Patients with Distinct Glaucomatous Optic Disc Phenotypes.

PURPOSE: To investigate central visual field (VF) defects among 4 phenotypes of glaucomatous optic discs. DESIGN: Cross-sectional study. METHODS: Optic disc phenotypes were determined in eyes with definite or suspected glaucoma that had a 24-2 VF with mean deviation (MD) better than -12 dB and a 10-2 VF. 10-2 VFs were classified as abnormal based on a cluster criterion. Additionally, the average of the total deviation values at each 10-2 test point was compared by optic disc phenotype. RESULTS: The following 4 glaucomatous optic disc phenotypes were identified in 448 eyes of 309 patients: focal ischemic (FI) (n = 121); generalized cup enlargement (GE) (n = 109); myopic glaucoma (MY) (n = 66); and senile sclerotic (SS) (n = 152). Although 24-2 VF MD values were similar among optic disc phenotypes, GE eyes had higher 10-2 VF MD (P = .004), as well as lower 24-2 VF pattern standard deviations (PSD) (P < .001) and VF 10-2 PSD (P < .001) than the other phenotypes. The prevalence of an abnormal VF 10-2 was highest in FI eyes (78.5%) and lowest in GE eyes (50.5%) (P < .001). In glaucoma suspects, the prevalence of an abnormal 10-2 VF was highest in the MY eyes (31.2%) and FI eyes (23.5%) and lowest in GE eyes (8.6%). In mild glaucoma, the prevalence of abnormal 10-2 VF test results was highest in FI eyes (79.2%) and lowest in GE eyes (44.4%) (P = .013). CONCLUSIONS: The severity and prevalence of central VF loss varied among different glaucomatous optic disc phenotypes. Glaucomatous eyes with FI and MY optic disc phenotypes are more likely to have 10-2 VF loss, particularly in early disease, and especially may benefit from testing with both 10-2 and 24-2 VF tests.

Capillary Density Measured by Optical Coherence Tomography Angiography in Glaucomatous Optic Disc Phenotypes.

PURPOSE: To compare optical coherence tomography angiography (OCTA)-measured capillary density of the optic disc among 4 glaucomatous optic disc phenotypes. DESIGN: Cross-sectional study. METHODS: Circumpapillary capillary density (cpCD) of 4 glaucomatous optic disc phenotypes in 193 eyes of 141 glaucoma patients and cpCD in 92 eyes of 55 healthy subjects from the Diagnostic Innovations in Glaucoma Study (DIGS) were compared. Areas under the receiver operating characteristic (AUROC) curves were used to evaluate diagnostic accuracy among groups after adjusting for confounders. RESULTS: Four glaucoma phenotypes were assessed: focal ischemic (n = 45), generalized cup enlargement (n = 60), myopic glaucoma (n = 38), and senile sclerotic (n = 50). Sex, mean ocular perfusion pressure, intraocular pressure, mean deviation, and the quality score did not differ among phenotypes. However, there were differences in age (P = .050), race (P = .039), axial length (P = .033), and retinal nerve fiber layer thickness (P < .001) among the groups. After adjusting for confounders, senile sclerotic discs had the lowest cpCD (37.1% [95% confidence interval, 35.3-38.8]), followed by focal ischemic (41.8% [40.0-43.6]), myopic glaucoma (42.1% [40-44.2]), and generalized cup enlargement (45.5% [44-47]) (P < .001) discs. The adjusted AUROC curves of cpCD for discriminating between healthy and glaucomatous eyes were highest in senile sclerotic eyes (0.928) and lowest in generalized cup enlargement eyes (0.704). CONCLUSIONS: OCTA-measured vessel density differs among optic disc phenotypes. Clinicians should be aware that the performance of OCTA for glaucoma diagnosis may be influenced by the optic disc phenotype.

Relationship of Corneal Hysteresis and Anterior Lamina Cribrosa Displacement in Glaucoma.

PURPOSE: To investigate the relationship between corneal hysteresis (CH) and anterior lamina cribrosa surface (ALCS) displacement over time in a cohort of patients with glaucoma. DESIGN: Prospective observational case series. METHODS: In this study, 147 eyes from 96 glaucoma or glaucoma suspect patients were followed for a mean of 3.5 years and 7.9 visits. Baseline CH measurements were obtained using the Ocular Response Analyzer (ORA; Reichert Ophthalmic Instruments Inc, Depew, New York, USA). The mean anterior lamina cribrosa surface depth (ALCSD) and choroidal thickness were by automated segmentation of spectral-domain optical coherence tomography (SD-OCT) scans. The rate of change of ALCSD was calculated using linear mixed effects models. Relationship between baseline CH and follow-up ALCSD rate of change was adjusted for confounding factors, including age, intraocular pressure (IOP), and choroidal thickness. RESULTS: The mean baseline CH was 9.4 mm Hg (95% confidence interval [CI] 9.1-9.7). Overall, the ALCS was displaced posteriorly at a rate of 0.78 µm/y (95% CI -1.82, 0.26). Seventeen eyes (11.5%) showed a significant posterior displacement of ALCS, whereas 22 eyes (15.0%) showed a significant anterior displacement of ALCS. The choroidal thickness thinned at a rate of -1.09 µm/y during the follow-up (P = .001). Multivariable mixed modeling showed that choroidal thinning, lower IOP change, and lower corneal hysteresis were significantly associated with posterior ALCS displacement over time (P = .034, P = .037, and P = .048). Each 1 mm lower CH was associated with 0.66 µm/y posterior displacement of the ALCS. CONCLUSIONS: Lower corneal hysteresis was significantly associated with posterior displacement of the anterior lamina cribrosa over time. These data provide additional support for lower corneal hysteresis being a risk factor for glaucoma progression.