Limited English Proficiency Is Associated With Diabetic Retinopathy in Patients Presenting for Cataract Surgery.

Purpose: To investigate the relationship between limited English proficiency (LEP) and diabetic retinopathy (DR) in patients presenting for cataract surgery. Methods: This is a retrospective observational study of patients who underwent cataract surgery between January 2014 and February 2020. Patients who self-identified as needing or preferring an interpreter were defined as having LEP. Differences in demographics, characteristics, and outcomes including history of type 2 diabetes (T2DM), DR, preoperative best corrected visual acuity (BCVA), macular edema, and anti-vascular endothelial growth factor injections were analyzed. Statistical comparisons were assessed using logistic regression with generalized estimating equations. Results: We included 13,590 eyes. Of these, 868 (6.4%) were from LEP patients. Patients with LEP were more likely to be Hispanic (P < 0.001), female sex (P = 0.008), or older age (P = 0.003) and have worse mean BCVA at presentation (P < 0.001). Patients with LEP had a significantly higher rate of T2DM (P < 0.001), macular edema (P = 0.033), and DR (18.1% vs. 5.8%, P < 0.001). Findings remained significant when controlling for age, sex, race/ethnicity, and type of health insurance. Patients with LEP and DR were more likely to have had later stages of DR (P = 0.023). Conclusions: Patients with LEP presenting for cataract surgery had a higher rate of DR and associated complications compared to patients with English proficiency. Further studies are needed to understand how language disparities influence health and what measures could be taken to improve healthcare in this vulnerable population. Translational Relevance: Our study highlights healthcare disparities within ophthalmology and emphasizes the importance of advocating for improved healthcare delivery for patients with LEP.

An intraocular solitary fibrous tumor/hemangiopericytoma with extrascleral extension: Case report and review of literature.

Purpose: To report a case of intraocular solitary fibrous tumor/hemangiopericytoma (SFT/HPC) complicated by extrascleral extension and to review the current literature regarding intraocular SFT/HPC. Observations: A twenty-two year old male presented with decreased vision in his left eye and was found to have a subretinal mass with extrascleral extension. He underwent enucleation of his left eye and histopathology confirmed a diagnosis of SFT/HPC. Conclusions and importance: To our knowledge, this is the seventh case of intraocular SFT/HPC ever reported and the first to report extrascleral extension. At the time of publication, there was no evidence of metastases. Extensive clinical, ophthalmic and radiographic imaging, and histopathologic data are presented to contribute to the current understanding of intraocular SFT/HPC.

RATES OF EXUDATIVE RECURRENCE FOR EYES WITH INACTIVATED WET AGE-RELATED MACULAR DEGENERATION ON 12-WEEK INTERVAL DOSING WITH BEVACIZUMAB THERAPY.

PURPOSE: To determine the recurrence rate of exudative age-related macular degeneration (wet AMD) in patients on 12-week dosing interval anti-vascular endothelial growth factor (anti-VEGF) bevacizumab therapy. METHODS: A retrospective chart review was performed on wet AMD patients treated with anti-VEGF therapy using a "treat-and-extend" methodology at one physician's practice site over 2 years (2012-2014). Charts were evaluated for visual acuity, anti-VEGF agent used, treatment interval, duration of treatment, trials off of anti-VEGF therapy, evidence of exudation, and wet AMD recurrence characteristics. RESULTS: Three hundred and twenty-one wet AMD patients were treated. Fifty-seven eyes were without active exudation by clinical examination or optical coherence tomography (OCT) and were maintained on repeating 12-week interval suppressive anti-VEGF therapy. Sixteen percent (8/49) showed exudation recurrence with an average 10% cumulative recurrence rate per year for eyes on bevacizumab. Eight eyes without active exudation were discontinued off of bevacizumab therapy. Sixty-three percent (5/8) demonstrated recurrence on average 4 months after stopping therapy. CONCLUSION: The findings in this study suggest that if a patient can be extended to 12-week interval bevacizumab therapy, there is on average a 10% chance of recurrence with each successive year. If anti-VEGF therapy is discontinued in these patients, there is an increased chance of recurrence by 4 months.

Predictors for recovery of macular function after surgery for primary macula-off rhegmatogenous retinal detachment.

PURPOSE: To determine predictors of best-corrected postoperative visual acuity (VA) in patients who underwent surgical intervention for macula-off rhegmatogenous retinal detachment. MATERIALS AND METHODS: Primary macula-off retinal detachments from the University of Colorado Primary Rhegmatogenous Retinal Detachment Database (2012-2017) were reviewed. The primary outcome measure was a postoperative VA of 20/40 or better at least 6 months after surgery. Patient demographics, medical history, duration of central vision loss before surgery, examination findings, operative technique, and postoperative findings were analyzed as possible predictors of postoperative visual recovery to 20/40 or better. Chi-square or Fisher's exact test was used to compare categorical variables, and Wilcoxon rank sum test was used for continuous variables. A multivariable logistic regression analysis was used to determine the adjusted odds ratios and 95% confidence intervals for variables that were significant in the univariable analyses. Statistical significance was set at p < 0.05. RESULTS: One hundred thirty-one patients met inclusion criteria. Eighty-one (61.8%) patients achieved a postoperative VA of 20/40 or better 6 or more months after surgery. Patients with a single retinal break were more likely than patients with more than one break to reach a postoperative VA of 20/40 or better (76.9% vs. 55.4%, p = 0.021). Patients with a better preoperative logMAR VA had better postoperative VA (p = 0.021). Duration of central vision loss prior to surgical repair was not related to final postoperative VA in this particular study. CONCLUSION: Postoperative recovery of visual acuity to 20/40 or better was significantly more common in patients with a single retinal break as well as in patients with better preoperative visual acuity. Duration of central vision loss prior to surgical repair was not significantly associated with postoperative VA.

COLORADO AGE-RELATED MACULAR DEGENERATION REGISTRY: Design and Clinical Risk Factors of the Cohort.

PURPOSE: To study new and existing risk factors related to age-related macular degeneration (AMD) phenotypes in a Colorado cohort. METHODS: Age-related macular degeneration was categorized into early, intermediate, or advanced forms. Controls (n = 180) were patients with cataract and no AMD. Demographic and clinical data were gathered by patient interview and verified by chart review. Image data were reviewed by vitreoretinal specialists. Statistical analysis included univariable and multivariate logistic regression analysis (P < 0.05). RESULTS: Among the 456 patients with AMD, 157 (34.4%), 80 (17.6%), and 219 (48.0%) had the early/intermediate, geographic atrophy, and neovascular forms of the disease, respectively. Adjusted for age, African-American race was associated with a reduced risk of early/intermediate (adjusted odds ratio [AOR] = 0.08, confidence interval [CI] = 0.01-0.67) and neovascular AMD (AOR = 0.15, CI = 0.03-0.72). A family history of AMD was a risk factor for early/intermediate (AOR = 4.08, CI = 2.30-7.25), geographic atrophy (AOR = 8.62, CI = 3.77-19.7), and neovascular AMD (AOR = 3.76, CI = 2.16-6.56). A history of asthma was related to the early/intermediate form of AMD (AOR = 2.34, CI = 1.22-4.46). CONCLUSION: Studying AMD in specific populations may reveal novel risk factors such as our finding of a relationship between asthma history and AMD.

Association of Cancer Immunotherapy With Acute Macular Neuroretinopathy and Diffuse Retinal Venulitis.

Importance: Checkpoint inhibition in cancer immunotherapy related to T-cell-driven mechanisms of action associated with acute macular neuroretinopathy (AMN) and diffuse retinal venulitis, an adverse event not previously described, is reported here. Objective: To describe 2 patients who developed ophthalmologic events after treatment with the programmed death 1 axis inhibitor, atezolizumab. Design, Setting, and Participants: Retrospective review of 2 patients treated with atezolizumab for metastatic breast cancer and colon cancer, respectively, who presented with AMN and diffuse retinal venulitis conducted at 2 tertiary medical centers. Main Outcomes and Measures: Multimodal imaging including near infrared, optical coherence tomography, and fluorescein angiography were used to characterize retinal vascular abnormalities. Results: Based on optical coherence tomography and multimodal imaging findings, the clinical diagnosis of AMN associated with diffuse retinal venulitis was made in these 2 patients receiving atezolizumab. Conclusions and Relevance: While only 2 cases of patients receiving the programmed death ligand 1 inhibitor atezolizumab who experienced AMN and diffuse retinal venulitis are described here, these findings suggest that patients receiving programmed death 1 axis inhibitor therapies may need to be monitored for unexpected immune-related ocular toxicity including abnormalities of the microvasculature and large retinal vessels. Further studies might investigate the potential mechanisms of retinal vascular changes associated with these therapies.

CONCURRENT ENDOPHTHALMITIS AND ANTERIOR SEGMENT ISCHEMIA AFTER STRABISMUS SURGERY.

BACKGROUND/PURPOSE: To report a case of simultaneous endophthalmitis and anterior segment ischemia (ASI) that occurred in a patient after strabismus surgery. This is the first known case of both complications occurring at the same time. METHODS: Case report. RESULTS: A 60-year-old woman presented with eye pain and loss of vision 6 days after uncomplicated strabismus surgery for thyroid eye disease. On examination, she had corneal edema, anterior segment fibrin, an atonic iris, and no view to the posterior segment. On fluorescein angiography of the anterior segment, a large portion of the iris was nonperfused. Posterior segment ultrasound showed dense vitritis and a choroidal abscess. Intraoperative cultures grew methicillin-resistant Staphylococcus aureus. CONCLUSIONS: Endophthalmitis and anterior segment ischemia are both exceedingly rare complications of strabismus surgery. It is possible that each one occurred independently, but more likely one process potentiated the other. One possible mechanism is inflammation-induced thrombosis.

The Relationship of Novel Plasma Proteins in the Early Neonatal Period With Retinopathy of Prematurity.

PURPOSE: Retinopathy of prematurity (ROP) is a vision-threatening disease associated with abnormal retinal vascular development. Proteins from the insulin-like growth factor pathway are related to ROP. However, there is a paucity of research on the role of other proteins in ROP. The aim of this study was to identify plasma proteins related to clinically significant ROP. METHODS: We measured 1121 plasma proteins in the early neonatal period in infants at risk for ROP using an aptamer-based proteomic technology. The primary aim of the study was to compare plasma protein concentrations in infants who did (n = 12) and did not (n = 23) subsequently develop clinically significant ROP using logistic regression. As a secondary aim, we examined patterns in the proteins across categories of clinically significant, low-grade, and no ROP groups. RESULTS: Lower levels of 16 proteins were associated with an increased risk of clinically significant ROP. In this group, superoxide dismutase (Mn), mitochondrial (MnSOD), and chordin-like protein 1 (CRDL1) were highly ranked. Other proteins in this group included: C-C motif chemokine 14 (HCC-1), prolactin, insulin-like growth factor-binding protein 7 (IGFBP-7), and eotaxin. Higher levels of 12 proteins were associated with a higher risk for ROP. Fibroblast growth factor 19 (FGF-19) was the top-ranked protein target followed by hepatocyte growth factor-like protein (MSP), luteinizing hormone (LH), cystatin M, plasminogen, and proprotein convertase subtilisin/kexin type 9 (PCSK9). We also noted different patterns in the trend of concentrations of proteins across the clinically significant, low-grade, and no ROP groups. CONCLUSIONS: We discovered plasma proteins with novel associations with clinically significant ROP (MnSOD, CRDL1, PCSK9), proteins with links to established ROP signaling pathways (IGFBP-7), and proteins such as MnSOD that may be a target for future therapeutic interventions.

Performance characteristics of a straight versus bent 25-gauge vitrector.

BACKGROUND AND OBJECTIVE: During vitrectomy in phakic patients, lens damage can occur while shaving the peripheral vitreous. Modifying the vitrector with a slight bend can diminish this risk. MATERIALS AND METHODS: To assess whether the bent vitrector performs to standard, the cutting and aspiration functionality of a straight and bent cutter was tested on both the vitreous from an enucleated porcine eye and balanced salt solution. Data were analyzed using a paired two-tailed t-test for comparison of two small sample means. RESULTS: The average time for removal of vitreous was 19.32 seconds with the straight cutter and 19.26 seconds for the bent cutter. There was no statistically significant difference between the removal rates (P = .87). The average time for aspiration of balanced salt solution was 14.3 seconds with the straight tip and 14.16 seconds with the bent tip. There was no statistically significant difference between the aspiration rates (P = .55). CONCLUSION: Both unmodified and bent vitrectors demonstrate an equally efficient rate of removal of vitreous and balanced salt solution in vitro.

Current knowledge and trends in age-related macular degeneration: genetics, epidemiology, and prevention.

PURPOSE: To address the most dynamic and current issues concerning human genetics, risk factors, pharmacoeconomics, and prevention regarding age-related macular degeneration. METHODS: An online review of the database Pubmed and Ovid was performed, searching for the key words: age-related macular degeneration, AMD, pharmacoeconomics, risk factors, VEGF, prevention, genetics and their compound phrases. The search was limited to articles published since 1985 to date. All returned articles were carefully screened and their references were manually reviewed for additional relevant data. The webpage www.clinicaltrials.gov was also accessed in search of relevant research trials. RESULTS: A total of 366 articles were reviewed, including 64 additional articles extracted from the references and 25 webpages and online databases from different institutions. At the end, only 244 references were included in this review. CONCLUSION: Age-related macular degeneration is a complex multifactorial disease that has an uneven manifestation around the world but with one common denominator, it is increasing and spreading. The economic burden that this disease poses in developed nations will increase in the coming years. Effective preventive therapies need to be developed in the near future.

Reversal of paracentral occlusive retinopathy in a case of sickle cell disease using exchange transfusion.

Paracentral occlusive retinopathy is an uncommon manifestation of sickle cell disease. If macular ischemia is not reversed, permanent vision loss can result. The authors report the successful use of exchange transfusion to treat unilateral paracentral occlusive retinopathy secondary to sickle cell disease in a 23-year-old man with hemoglobin SS disease. Initial presentation demonstrated arteriolar occlusion, perivenous hemorrhages, vessel tortuosity, and areas of retinal ischemia. Visual acuity was count fingers, and the patient noted a paracentral scotoma. Following transfusion, there was restoration of arteriolar flow as documented with fluorescein angiogram, and visual acuity returned to 20/20.

Intraocular Microsurgical Forceps (20, 23, and 25 gauge) Membrane Peeling Forces Assessment.

Background. To assess the peeling forces exerted by different calibers of microsurgical forceps on an experimental model of epiretinal membrane. Methods. A model of epiretinal membrane was constructed using thin cellulose paper and heptanes-isopropyl alcohol 1% mixture. The model was mounted on a force censoring device. Subsequently, flaps were created with three different microsurgical forceps of different calibers. We recorded the number of attempts, the duration of the event, and the pushing and the pulling forces during the peeling. The results were compared by a one-way ANOVA and a Fisher unprotected least significant difference test with an alpha value of 0.05 for statistically significance. Results. There was a statistical significant difference on the pulling and pushing forces between the 25 gauge (13.79 mN; -13.27 mN) and the 23 (6.63 mN; -5.76 mN) and 20 (5.02 mN; -5.30 mN) gauge, being greater in the first (P < 0.001). There were no differences in the duration of all events, meaning that all the forces were measured within the same period of time. Conclusions. The 25 gauge microsurgical forceps exerted the greatest mechanical stress over our simulated epiretinal membrane model and required more attempts to create a surgical suitable flap. The clinical implication of this finding is still to be determined.

Fluorescein angiogram findings in a case of cutis marmorata telangiectatica congenita.

Cutis marmorata telangiectatica congenita is a well-characterized cutaneous vascular disorder with variable and rare ocular involvement. It has been reported in association with glaucoma, bilateral congenital retinal detachments, bilateral tractional retinal detachments secondary to proliferative vitreoretinopathy, and retinoblastoma. This case demonstrates novel findings of bilateral peripheral retinal vascular abnormalities and retinal nonperfusion on fluorescein angiography without retinal detachment that have not previously been described in cutis marmorata telangiectatica congenita. Laser photocoagulation was applied to areas of retinal nonperfusion with stability in the retinal pathology at follow-up examination 3 months later.

Current knowledge and trends in age-related macular degeneration: today's and future treatments.

PURPOSE: To address the most dynamic and current issues concerning today's treatment options and promising research efforts regarding treatment for age-related macular degeneration. This review is aimed to serve as a practical reference for more in-depth reviews on the subject. METHODS: An online review of the database PubMed and Ovid were performed, searching for the key words age-related macular degeneration, AMD, VEGF, treatment, PDT, steroids, bevacizumab, ranibizumab, VEGF-trap, radiation, combined therapy, as well as their compound phrases. The search was limited to articles published since 1985. All returned articles were carefully screened, and their references were manually reviewed for additional relevant data. The web page www.clinicaltrials.gov was also accessed in search of relevant research trials. RESULTS: A total of 363 articles were reviewed, including 64 additional articles extracted from the references. At the end, only 160 references were included in this review. CONCLUSION: Treatment for age-related macular degeneration is a very dynamic research field. While current treatments are mainly aimed at blocking vascular endothelial growth factor, future treatments seek to prevent vision loss because of scarring. Promising efforts have been made to address the dry form of the disease, which has lacked effective treatment.

Treatment of intractable posterior uveitis in pediatric patients with the fluocinolone acetonide intravitreal implant (Retisert).

PURPOSE: To evaluate the efficacy and safety of the fluocinolone acetonide intravitreal implant in pediatric patients with intractable noninfectious posterior uveitis. METHODS: A retrospective chart review was performed on all patients aged <18 years on whom a fluocinolone implant was used to treat intractable posterior uveitis at our institution. Conventional treatment with topical and systemic steroids and/or systemic steroid-sparing agents failed in all patients before proceeding with an implant. Each implant contained 0.59 mg of fluocinolone acetonide. Implants were placed in the inferonasal quadrant through a pars plana incision and sutured in place with 8-0 proline suture. Postoperatively, patients were followed for improvement in Snellen visual acuity, control of inflammation, and development of complications such as infection or uncontrolled intraocular pressure in the eyes. RESULTS: The study included six eyes of four patients. Mean age at implant placement was 9.2 years (range, 6-13 years). Four eyes were pseudophakic at the time of surgery; one eye had pars plana lensectomy at the time of surgery. Mean follow-up duration was 698 days (range, 376-1,189 days). Postoperative visual acuity improved by ≥3 lines in 3 eyes. Four eyes had postoperative intraocular spikes ≥30 mmHg, with 2 eyes having ≥40 mmHg. Two of these patients required glaucoma shunting procedures postoperatively for intraocular pressure control. Inflammation was well controlled postoperatively in all six eyes with all eyes successfully weaned off of topical steroids. The single phakic eye developed a visually significant cataract 18 months postoperatively requiring cataract extraction. There were no cases of postoperative infection. There were no postoperative complications of surgical technique including no instances of wound leakage or implant dislocation. CONCLUSION: The fluocinolone implant can be used effectively for control of posterior inflammation in pediatric patients. As in adults, concerns for development of cataract and secondary glaucoma remain. No other safety concerns were evident in this pilot study.

Thermal deformation of chandelier endoillumination probes exposed to uveal tissue and blood.

PURPOSE: The purpose of this study was to evaluate the characteristics and thermal properties of a chandelier endoillumination probe under conditions that may induce thermal damage. METHODS: Experimental evaluation of a surgical ophthalmic instrument under ex vivo conditions. RESULTS: A 27-gauge dual-tip chandelier endoillumination probe was exposed to air, saline, porcine uveal tissue, and human blood using a Xenon light source at 100% intensity. No alteration of probe tip morphology was observed in air or saline at 10-minute exposure. After exposure to uveal tissue and blood, thermal melting of the probe tip was noted at 10 minutes. Beam focus and intensity were observed to diminish in the probe tips that underwent thermal melting. A thermal imaging device was used to demonstrate increased thermal intensity from the probe tip that had been covered with uveal tissue compared with a control tip in air. CONCLUSION: Thermal melting of a chandelier fiber probe has been reported only once previously in the literature after exposure to porcine Tenon capsular tissue. We report two separate conditions that may induce thermal damage to a fiber optic probe including encapsulation of uveal tissue at the probe tip and exposure to blood. Vitreoretinal surgeons should be aware of this potential complication.

Comparison of long-acting bevacizumab formulations in the treatment of choroidal neovascularization in a rat model.

OBJECTIVE: The objective of this study was to compare the reduction in size of experimentally induced choroidal neovascularization (CNV) in rat eyes treated with bevacizumab, poly(ethylene-glycol) (PEG)-bevacizumab conjugate (b-PEG), and poly(lactic-co-glycolic acid) (PLGA)-encapsulated bevacizumab (b-PLGA). METHODS: Forty-eight eyes from 24 rats were divided into 4 groups of 12 eyes. In each group, 3 eyes were assigned to a treatment subgroup, each receiving a different injection-control, bevacizumab, b-PEG, and b-PLGA. In all eyes, laser photocoagulation was used to rupture Bruch's membrane. In group 1, laser was followed by injection, which was then followed by harvesting the rats to assess the CNV area. All 3 steps were separated by a 2-week interval. In groups 2, 3, and 4, injection preceded laser photocoagulation by a variable interval and all rats were harvested 2 weeks postlaser treatment. In group 2, laser and injection were separated by 2 weeks. In group 3, laser followed injection by 4 weeks. In group 4, laser followed injection by 6 weeks. The CNV area was measured for each subgroup and compared against its control. Pairwise comparisons were conducted to assess for statistically significant differences between subgroups. RESULTS: All subgroups in groups 1, 2, and 4 showed statistically significant reduction of CNV area (P<0.05). In group 3, the b-PEG and b-PLGA subgroups showed a 9.0% (P=0.384) and 20.3% (P=0.077) reduction in CNV area versus control, whereas there was no reduction in CNV area in the bevacizumab subgroup. However, this was not found to be statistically significant. In group 4, b-PEG was more effective than bevacizumab and b-PLGA. CONCLUSION: The reduction in CNV area in all treatment subgroups, with the exception of those in group 3, suggests successful creation of the 2 bevacizumab formulations while retaining its active antiangiogenic properties. Further studies varying in dosages and timing of injection and laser are needed to evaluate the formulations' long-acting efficacy.

Ischemic index and neovascularization in central retinal vein occlusion.

PURPOSE: To explore the association of angiographic nonperfusion with anterior segment and posterior segment neovascularization in central retinal vein occlusion (CRVO). METHODS: An imaging database at one institution was searched for the diagnosis of central retinal vein occlusion. Ultra wide field fluorescein angiograms were graded for image quality, the presence of retinal neovascularization, and the quantity of nonperfusion; an ischemic index (ISI) was calculated. Charts were reviewed to exclude eyes with previous treatment and to determine which eyes had anterior segment or posterior segment neovascularization on the day of the angiogram. Time from onset to presentation could not accurately be ascertained. RESULTS: In a 39-month period, there were 69 eyes that met inclusion criteria. The mean ISI was 25% (SD, 26%; range, 0-100%), and 15 eyes (21%) with neovascularization had a mean ISI of 75% (range, 47-100%) compared with eyes without neovascularization that had an ISI of 6% (range, 0-43%). Ischemic index significantly correlated to neovascularization, and eyes that had evidence of neovascularization had an ISI >45% (P < 0.0001). CONCLUSION: Ultra wide field fluorescein angiography provides visualization of nonperfusion in eyes with central retinal vein occlusion. Eyes with neovascularization on the day of the angiogram were found to have significantly larger areas of retinal nonperfusion compared with eyes without neovascularization. A prospective study is indicated to know if early treatment of peripheral retinal nonperfusion in CRVO improves outcomes.