SHORT-TERM COMPUTER-ASSISTED QUANTIFICATION OF PLUS DISEASE AFTER TREATMENT OF TYPE 1 RETINOPATHY OF PREMATURITY WITH INTRAVITREAL BEVACIZUMAB OR RETINAL LASER PHOTOCOAGULATION.

PURPOSE: To compare objectively measured changes in plus disease after bevacizumab and laser for Type 1 retinopathy of prematurity. METHODS: ROPtool (a computer program) analyzed fundus images at baseline, 1 week, and subsequent examinations. RESULTS: Six infants (9 eyes) were treated with bevacizumab and 7 (12 eyes) with laser. One week after treatment, bevacizumab compared with laser resulted in a greater median percent change from pretreatment in tortuosity (-53.8 vs. -0.2%, P < 0.001) and overall plus disease (-20.1 vs. -3.1%, P < 0.001). Change in dilation did not differ (-3.5 vs. -5.5%, P = 0.48). After week 1, all median ROPtool parameters continued to decrease for both groups. At last follow-up (median 3, range: 2-10 weeks), both bevacizumab and laser significantly decreased tortuosity (-54.3 and -23.8%), dilation (-8.7 and -7.5%), and overall plus disease (-27.3 and -10.3%). CONCLUSION: Improvement in plus disease, in particular tortuosity, likely occurs more quickly after bevacizumab compared with laser, particularly at 1 week after treatment. These results guide clinical expectations for plus disease resolution after both treatment modalities.

Subepidermal Calcinosis in the Ocular Adnexa: A Systematic Review.

PURPOSE: To review the clinical and histopathologic findings associated with subepidermal calcinosis of the eyelids. METHODS: A systematic review of the literature on subepidermal calcinosis of the eyelids was performed. Cases included were idiopathic in nature and met the histologic criteria for subepidermal calcinosis with calcium deposits in the dermis of the skin. RESULTS: Twenty-one publications presenting 53 cases of subepidermal calcinosis involving the eyelids were published between 1970 and 2016. Males were affected more than females (67% vs. 33%), and 89% of patients were 21 years of age or younger. A total of 63% were non-Caucasian. Most cases involved a single lesion (82%), and lesions were most frequently located on the upper eyelid (63%). In 81% of cases, the lesion was less than 5 mm in diameter. When reported, the treatment of choice was complete surgical excision. CONCLUSIONS: Subepidermal calcinosis should be considered in the differential diagnosis of idiopathic lesions on the eyelid, particularly in young males with no history of systemic disease or laboratory abnormalities. These nodules usually present as painless, small, firm, mobile solitary cutaneous lesions with a predilection for the upper eyelid. Diagnosis is confirmed by histopathology, and treatment is with surgical excision.

Use of a Supplemental Oxygen Protocol to Suppress Progression of Retinopathy of Prematurity.

Purpose: To compare progression of retinopathy of prematurity (ROP) before and after institution of an oxygen therapy protocol to inhibit active proliferation and progression of ROP in premature infants. Methods: A retrospective cohort study was performed of premature infants undergoing ROP screening before (cohort A) and after (cohort B) implementation of an oxygen therapy protocol to inhibit further progression for those with stage 2 ROP or worse. Statistical analysis with χ2, Fisher's exact test, or Wilcoxon rank sum test was performed; and logistic regression models were created to determine the odds ratio of cohort B developing ROP progression beyond stage 2, compared to cohort A, adjusting for other risk factors for ROP. Results: In cohort A, without oxygen therapy protocol (2002-2007), 44% (54/122) of infants progressed beyond stage 2, compared to 23% (24/103) of infants after protocol implementation (cohort B, 2008-2012) (P = 0.001). No significant differences between cohort A and B were found for gestational age, birth weight, survival, sepsis, bronchopulmonary dysplasia, oxygen at discharge, or need for diuretics. Infants with stage 2 ROP in cohort B, with oxygen therapy protocol, had significantly decreased risk of ROP beyond stage 2 (odds ratio 0.37, 95% confidence interval 0.20-0.67; P = 0.0013), compared to cohort A, correcting for differences in birth weight and necrotizing enterocolitis. Conclusions: Progression from stage 2 to stage 3 ROP in premature infants was significantly decreased after implementation of an oxygen therapy protocol, without a corresponding increase in pulmonary morbidity. This study suggests that appropriate oxygen therapy may play a role in inhibiting progression of stage 2 ROP, potentially decreasing the risk of lifelong visual loss in this vulnerable population.

Description and validation of a structured simulation curriculum for strabismus surgery.

PURPOSE: To describe and validate a Web-based structured simulation curriculum of strabismus surgery for residents in training using noncadaveric eye models. METHODS: A pre- and posttest of cognitive skills, objective wet laboratory structured assessment of technique, and summative global evaluation form were implemented as part of a systematic ophthalmology wet lab (OWL) curriculum. Strabismus techniques were taught using a structured simulation method on noncadaveric models of eyes. Likert scale questionnaires were administered to assess the comfort level with strabismus surgery of residents before and after participation in the wet laboratory. Statistical analysis was performed using the paired t test. RESULTS: Seven residents participated in the curriculum. Average test scores improved from 65% to 91% (P = 0.0002). Resident comfort level improved from an average score (assessed by Likert scale of 1-5) with standard deviation of 2.6 ± 1.0 to 4.3 ± 0.5 for passing scleral sutures (P = 0.0008), of 2.6 ± 0.5 to 4.3 ± 0.5 for isolating and suturing muscles (P = 0.00004), and of 2.7 ± 1.0 to 4.6 ± 0.5 for comfort with naming instruments (P = 0.0007). CONCLUSIONS: In this study of 7 residents, knowledge and comfort level with strabismus surgery statistically improved with a structured simulation curriculum.

Cataract surgery in children with uveitis: retrospective analysis of intraocular lens implantation with anterior optic capture.

PURPOSE: To present experience with cataract extraction in 9 eyes of 7 pediatric patients with chronic uveitis and compare the technique of anterior optic capture in 5 eyes that underwent cataract extraction without optic capture of the intraocular lens (IOL) or were left aphakic. METHODS: A retrospective review of pediatric patients with chronic uveitis undergoing cataract surgery was performed, examining the preoperative and postoperative visual acuity, immunosuppressive therapy, surgical technique, complications, subsequent procedures, and need for escalation of systemic immunosuppressive therapy. The technique of anterior optic capture is described in detail. RESULTS: Of the 9 eyes, 5 underwent cataract extraction with IOL placement with the haptics in the capsular bag and optic prolapsed through the anterior capsulorhexis. One eye underwent cataract extraction with IOL implantation in the bag. Three eyes had lensectomy without IOL placement. The eyes with anterior optic capture had no adverse outcomes and uveitis flares were controlled with topical medications and systemic immunosuppressants; the eye with IOL placement without optic capture had recurrent membranes and uveitis flares, necessitating increased systemic immunosuppression. All eyes achieved best-corrected visual acuity of 20/60 or better by 6 months following surgery and 20/30 or better at the most recent follow-up. CONCLUSIONS: The technique of cataract extraction with IOL placement and anterior prolapse of the optic through the anterior capsulorhexis shows promise to be a safe and viable option for pediatric patients with chronic uveitis treated with systemic immunotherapy.

Metastatic B-cell lymphoma masquerading as infectious retinitis and vasculitis.

Intraocular lymphoma is a rare ocular malignancy that may occur in the retina or the uvea. Retina or vitreoretinal lymphoma accounts for the majority of cases and is often secondary to diffuse large B-cell lymphoma. In the present study, a 66-year-old Caucasian male with a history of Waldenstrom's macroglobulinemia with diffuse large B-cell lymphoma, presented with blurred vision in the left eye one month following cycle 4 of an R-CHOP regimen. At the time of onset, the patient was being treated for bacterial pneumonia. Visual acuity was 20/25 in his right eye (OD) and 20/30 in the left (OS). Ophthalmologic examination showed intraretinal white infiltrates associated with hemorrhage in the superotemporal midperiphery of the retina and vitritis OS. Initial diagnostic considerations included infectious (cytomegalovirus retinitis, syphilis, toxoplasmosis, tuberculosis), inflammatory (retinal vasculitis associated with autoimmune disease or hypercoagulable states) or malignant (intraocular lymphoma) diseases. The patient did not respond to intravitreal injection of foscarnet and oral valgancyclovir. Systemic work-up and aqueous fluid biopsy were inconclusive. Diagnostic vitrectomy yielded inconclusive results and the patient continued to have progressive loss of vision. A repeat diagnostic vitrectomy with retinal and subretinal biopsy confirmed large B cells consistent with metastatic B-cell lymphoma. A concomitant PET/CT scan was performed that revealed bilateral new pulmonary nodules resulting in additional chemotherapy. Our case shows the diagnostic dilemmas in patients with systemic lymphoma and the possible role of concurrent systemic restaging in patients with ocular complaints, even when in systemic remission.