DIAGNOSTIC PATTERNS OF AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To characterize prevalence estimates by race, age, sex, and comorbidity (diabetes and hypertension) within the Medicare beneficiary demographic. METHODS: In this US population-based retrospective cohort analysis, the Vision and Eye Health Surveillance System was analyzed for a 100% sample of Medicare Fee-For-Service beneficiary populations of Asians and non-Hispanic Whites between 2014 and 2018. Exclusionary criteria included beneficiaries younger than 40 years. Prevalence rate ratios, defined as prevalence rate for Asians divided by prevalence rate for non-Hispanic Whites, were calculated using multivariate negative binomial regression or Pearson-scaled Poisson regression, stratified by age, sex, and comorbidity. RESULTS: A total of 21,892,200 Medicare beneficiaries fulfilled the inclusionary criteria in 2018. Of the entire cohort, 3.2% of the beneficiaries (N = 714,500) were Asian. For beneficiaries aged 40 to 64 years, Asian male (prevalence rate ratios 1.73, 95% confidence interval 1.64-1.83, P < 0.0001) and female (prevalence rate ratios 1.34, 95% confidence interval 1.28-1.41, P < 0.0001) beneficiaries had an increased prevalence rate of all age-related macular degeneration relative to non-Hispanic Whites. Significant time-wise increases in prevalence rate ratios were observed within several age groups, sexes, and comorbidities (race-time interaction coefficients P < 0.05 ). CONCLUSION: This analysis highlights increased age-related macular degeneration prevalence estimates within the Asian American demographic relative to non-Hispanic Whites. Furthermore, specific Asian subpopulations are experiencing accelerated prevalence rates over time.

The effect of ocular rinse volume on surface irritation after povidone-iodine preparation for intravitreal injections: a randomized controlled trial.

PURPOSE: To evaluate whether the volume of wash out rinse after povidone iodine (PI) application for intravitreal injections (IVI) affects patients' ocular surface irritation. METHODS: This was a prospective, single-masked, randomized-controlled trial consisting of 142 subjects. A total of 51, 45, and 46 patients received 3-mL, 10-mL, and 15-mL of ocular rinse respectively. Reductions in the Ocular Surface Disease Index (OSDI) and the Standardized Patient Evaluation of Eye Dryness II (SPEED II) surveys, conducted before and at 24-72 h post-injection, were analyzed. RESULTS: There was no statistical difference in objective dry eye findings of Schirmer test (p-value = 0.788), tear break-up time (p-value = 0.403), Oxford fluorescein grade (p-value = 0.424) between the study groups prior to injections. Dry eye symptoms as measured by reductions in the OSDI and SPEEDII scores were not different between the study groups (p-value = 0.0690 and 0.6227, respectively). CONCLUSION: There is no difference in patients' ocular surface irritation between 3-mL, 10-mL, and 15-mL post injection rinse. Given the large number of IVIs performed, modification of practice patterns based on these findings could lead to significant reduction in global cost burden for IVIs.

Incidence and Clinical Characteristics of Postoperative Endophthalmitis After Ab-Interno Canaloplasty.

Introduction: Postoperative endophthalmitis (POE) is a rare but devastating complication of ophthalmic surgeries. Microinvasive glaucoma surgery (MIGS) procedures have become increasingly utilized for the surgical reduction of intraocular pressure (IOP). Ab-interno canaloplasty (ABiC) is a popular MIGS procedure, but POE rates and clinical effects following ABiC have not been studied. Methods: This study conducted a retrospective review of all consecutive cases of either standalone ABiC or combined ABiC with phacoemulsification performed at a tertiary care academic referral center from 2015 to 2021. Exclusion criteria included a history of incisional glaucoma surgery, retinal surgery, or additional concurrent microinvasive glaucoma surgery (MIGS) at the time of ABiC. The rates of POE after ABiC were calculated with 95% confidence intervals (CI) based on the Clopper-Pearson exact method. Results: Of 3256 cases of ABiC, one case (0.03%, 1/3256, 95% CI: 0.00-0.17%) of post-ABiC endophthalmitis was identified. The rate of POE in standalone ABiC was 0.00% (0/1332 cases, 95% CI: 0.00-0.28%), whereas the rate in combined ABiC with phacoemulsification was 0.05% (1/1924 cases, 95% CI: 0.00-0.29%). Additionally, the rate of POE following stand-alone cataract surgery, 0.10%, 11/11,470 cases, 95% CI: 0.05-0.17%), total cataract surgeries, 0.06% (17/28,013 cases, 95% CI: 0.04-0.10%), total MIGs, excluding ABiC, surgeries, 0.08%, (3/3845 cases, 95% CI: 0.02-0.23%) portray non-inferiority of ABiC in the risk of POE. The case of ABiC-POE presented four days after surgery and required a vitreous tap with intraocular injection of antibiotics and pars plana vitrectomy. No causative organism was identified. A final 1-year follow-up revealed a corrected distance visual acuity of 20/40 and stable glaucoma. Conclusion: The rate of POE after ABiC (1 per 3256 cases) is statistically non-inferior to the reported incidence of POE after other MIGS and incisional glaucoma surgeries.

The effect of punctal plugs in reducing ocular surface irritation after povidone-iodine preparation of intravitreal injection-a randomized trial.

PURPOSE: To evaluate the utility of dissolvable collagen punctal plugs (CPP) in reducing ocular surface irritation after intravitreal injections (IVI). METHODS: Sixty-four subjects in the experimental group received CPP after intravitreal injections. Sixty-two controls did not receive CPP. Reductions in the Ocular Surface Disease Index© (OSDI) and Standardized Patient Evaluation of Eye Dryness II (SPEED II) scores were analysed. RESULTS: Dry eye symptoms, as measured by reductions from the pre- to post-injection OSDI (p = 0.137) and SPEED II (p = 0.381) scores, did not significantly differ between the two groups. In sub-group analysis, patients with objective findings of dry eyes had significant improvement in their symptoms (p = 0.046) with CPP. The effect of CPP is not significant in those without dry eyes (p = 0.27). CONCLUSION: CPPs were not effective in reducing post-injection ocular irritation in patients with no or only mild dry eye symptoms. CPPs improved patients' post-injection comfort levels in those who had moderate-to-severe symptoms and objective findings of dry eye. Though costly CPP could be considered in selective patients. A standardized eye rinse could be a simple, efficacious, and cost-effective way to reduce post-injection ocular irritation; however, more studies are needed.

Migration of a Dexamethasone Intravitreal Implant to the Anterior Chamber in a Patient with a Intra-Scleral Haptic Fixated Intraocular Lens.

PURPOSE: To report a case of posterior to anterior migration of a dexamethasone (Ozurdex) implant in a case of scleral-fixated intraocular lens (SFIOL) via Yamane technique. METHODS/PATIENTS: Single case report. RESULTS: Dexamethasone implant was successfully removed in the operating room. The patient had improved confrontational visual field and did not develop corneal edema nor intraocular pressure elevation. CONCLUSION: In the presence of a stable SFIOL via Yamane technique, posterior chamber implants may migrate to the anterior chamber. Clinicians may wish to exercise additional caution in injecting posterior chamber steroid implants in this patient population.

ENDOPHTHALMITIS AFTER TRANSCONJUNCTIVAL PARS PLANA VITRECTOMY: A 6-year Experience Without Prophylactic Intraoperative Subconjunctival Antibiotics.

PURPOSE: This study aimed to investigate the incidence and risk factors of endophthalmitis after transconjunctival pars plana vitrectomy (PPV) without intraoperative subconjunctival antibiotics. DESIGN: Retrospective, consecutive case series at a single institution. METHODS: Consecutive cases of transconjunctival 25-gauge PPV without intraoperative subconjunctival antibiotics performed by three retina surgeons at a single surgical site at the Dean McGee Eye Institute from 2012 to 2018 were reviewed. RESULTS: Of 4,263 cases of PPV without intraoperative subconjunctival antibiotics, five cases (0.117%, 5/4,263) of post-PPV endophthalmitis were identified. Of these five cases, four cases (80%, 4/5) received combined cataract extraction or secondary intraocular lens implantation at the time of PPV. The incidence of endophthalmitis in isolated PPV was 0.027% (1/3,606 cases), whereas the incidence in combined PPV with anterior segment procedures was 0.608% (4/657 cases). Risk factors for endophthalmitis included diabetes mellitus, which was present in 80% of patients with endophthalmitis (4/5 cases). Causative organisms were identified in four of the five cases (80%), including Staphylococcus epidermidis (N = 3) and Propionibacterium acnes (N = 1). CONCLUSION: Performing transconjunctival PPV alone with standard preparation using povidone-iodine and postoperative topical antibiotics for 1 week without intraoperative subconjunctival antibiotics did not lead to an increase in incidence of postoperative endophthalmitis (1 per 3,606 cases).

Increased Glial Fibrillary Acid Protein and Vimentin in Vitreous Fluid as a Biomarker for Proliferative Vitreoretinopathy.

Purpose: Glial fibrillary acid protein (GFAP) and vimentin are type III intermediate filament proteins, ubiquitously expressed in retinal glial cells. Under retinal stress, both GFAP and vimentin are well-known sensitive markers for retinal gliosis. However, little is known about whether these proteins are released into the vitreous body in response to retinal gliosis or are related to the severity of retinal gliosis seen in proliferative vitreoretinopathy (PVR). Methods: Vitreous fluids were collected from 44 patients who underwent pars plana vitrectomy for macular hole (Group 1; n = 8), epiretinal membrane (Group 2; n = 8), or retinal detachment (RD) with various degrees of PVR (Group 3; n = 28). The severity of PVR was determined by cumulative scores using PVR classification. GFAP, vimentin, and total protein levels from the vitreous samples were measured. Results: Both GFAP and vimentin levels were significantly elevated in vitreous fluid from Group 3 (RD) compared with Groups 1 and 2 (P < 0.01). GFAP levels (ng/mL) were 12.4 ± 9.8, 17.5 ± 17.7, and 572.0 ± 11659.7, and vimentin levels (ng/mL) were 40.8 ± 61.9, 88.6 ± 86.8, and 3952.8 ± 8179.5 in Groups 1, 2, and 3, respectively. Total protein levels were not significantly different among the three groups. Elevated GFAP and vimentin levels in Group 3 were positively correlated with the areas of RD (P < 0.01, r = 0.53 in GFAP and P < 0.05, r = 0.46 in vimentin) and PVR scores (P < 0.05, r = 0.46 in GFAP and P < 0.00001, r = 0.76 in vimentin). Conclusions: Our data suggest that human vitreous GFAP and vimentin are protein biomarkers for PVR, and reactive gliosis may play a part in PVR formation.

Whole exome sequencing identification of novel candidate genes in patients with proliferative diabetic retinopathy.

Rare or novel gene variants in patients with proliferative diabetic retinopathy may contribute to disease development. We performed whole exome sequencing (WES) on patients at the phenotypic extremes of diabetic retinal complications: 57 patients diagnosed with proliferative diabetic retinopathy (PDR) as cases and 13 patients with no diabetic retinopathy despite at least 10years of type 2 diabetes as controls. Thirty-one out of the 57 cases and all 13 controls were from the African American Proliferative Diabetic Retinopathy Study (AA). The rest of the cases were of mixed ethnicities (ME). WES identified 721 candidate genes with rare or novel non-synonymous variants found in at least one case with PDR and not present in any controls. After filtering for genes with null alleles in greater than two cases, 28 candidate genes were identified in our ME cases and 16 genes were identified in our AA cases. Our analysis showed rare and novel variants within these genes that could contribute to the development of PDR, including rare non-synonymous variants in FAM132A, SLC5A9, ZNF600, and TMEM217. We also found previously unidentified variants in VEGFB and APOB. We found that VEGFB, VPS13B, PHF21A, NAT1, ZNF600, PKHD1L1 expression was reduced in human retinal endothelial cells (HRECs) cultured under high glucose conditions. In an exome sequence analysis of patients with PDR, we identified variants in genes that could contribute to pathogenesis. Six of these genes were further validated and found to have reduced expression in HRECs under high glucose conditions, suggestive of an important role in the development of PDR.

Mycobacterium chelonae Scleral Abscess After Intravitreal Ranibizumab Injection.

PURPOSE: To report a case of Mycobacterium chelonae scleral abscess after an intravitreal injection of ranibizumab. METHODS: A 54-year-old female received an intravitreal ranibizumab injection for diabetic macular edema. Two weeks postinjection, a scleral abscess developed at the injection site. The patient was treated with incision and drainage of the abscess, subconjunctival injection of amikacin, topical clarithromycin and amikacin, and oral clarithromycin. RESULTS: After 4 weeks of treatment, the inflammation and infection resolved, and the patient returned to best-corrected preinjection visual acuity. CONCLUSIONS: Injection-site scleral abscesses are very rare and serious complications of intravitreal injections. Once the abscess is drained, it is possible to identify the organism and treat the infection with appropriate combination antibiotic therapy.

Hydroxychloroquine retinopathy: A review of imaging.

Hydroxychloroquine (HCQ) retinopathy can result in permanent vision loss. In early stages of HCQ retinopathy, patients are usually asymptomatic with preservation of visual acuity. We aspire that our review, in conjunction with the American Academy of Ophthalmology screening guidelines, shall shed light on effective screening measures utilizing multimodal imaging techniques to detect early signs of HCQ retinopathy before advanced changes manifest clinically.

Characterization of cells from patient-derived fibrovascular membranes in proliferative diabetic retinopathy.

PURPOSE: Epiretinal fibrovascular membranes (FVMs) are a hallmark of proliferative diabetic retinopathy (PDR). Surgical removal of FVMs is often indicated to treat tractional retinal detachment. This potentially informative pathological tissue is usually disposed of after surgery without further examination. We developed a method for isolating and characterizing cells derived from FVMs and correlated their expression of specific markers in culture with that in tissue. METHODS: FVMs were obtained from 11 patients with PDR during diabetic vitrectomy surgery and were analyzed with electron microscopy (EM), comparative genomic hybridization (CGH), immunohistochemistry, and/or digested with collagenase II for cell isolation and culture. Antibody arrays and enzyme-linked immunosorbent assay (ELISA) were used to profile secreted angiogenesis-related proteins in cell culture supernatants. RESULTS: EM analysis of the FVMs showed abnormal vessels composed of endothelial cells with large nuclei and plasma membrane infoldings, loosely attached perivascular cells, and stromal cells. The cellular constituents of the FVMs lacked major chromosomal aberrations as shown with CGH. Cells derived from FVMs (C-FVMs) could be isolated and maintained in culture. The C-FVMs retained the expression of markers of cell identity in primary culture, which define specific cell populations including CD31-positive, alpha-smooth muscle actin-positive (SMA), and glial fibrillary acidic protein-positive (GFAP) cells. In primary culture, secretion of angiopoietin-1 and thrombospondin-1 was significantly decreased in culture conditions that resemble a diabetic environment in SMA-positive C-FVMs compared to human retinal pericytes derived from a non-diabetic donor. CONCLUSIONS: C-FVMs obtained from individuals with PDR can be isolated, cultured, and profiled in vitro and may constitute a unique resource for the discovery of cell signaling mechanisms underlying PDR that extends beyond current animal and cell culture models.

Blurry vision after orbital decompression surgery.

Pathologic myopia may be associated with abnormal vitreomacular adhesions that can portend a higher risk of retinal detachment. The authors report a case of rhegmatogenous retinal detachment with a complex macular tear after orbital decompression surgery in a patient with pathologic myopia. This case highlights the importance of retinal detachment in the setting of orbital decompression.

Correlation of outer retinal microstucture and foveal thickness with visual acuity after pars plana vitrectomy for complications of proliferative diabetic retinopathy.

PURPOSE: To compare spectral domain optical coherence tomography (SDOCT)-measured macular thickness, outer retinal layers architecture, and best-corrected visual acuity (BCVA) in eyes with proliferative diabetic retinopathy after pars plana vitrectomy. METHODS: In this retrospective case study, consecutive eyes operated by single surgeon were included. Retinal thickness was measured with SDOCT (Cirrus OCT; Carl Zeiss Meditec, Inc) as follows: automated central 1-mm subfield thickness (CFT), manually measured central foveal point thickness (CPT), integrity of external limiting membrane (ELM), and photoreceptor inner and outer segments (IS/OS). Three vitreoretinal-trained masked experts independently graded ELM and IS/OS layers. RESULTS: Of the 36 eyes included, 50% were those of women whose mean age was 49 years (range, 24-66 years). Mean preoperative BCVA was 20/600 (range, light perception to 20/80) and mean postoperative follow-up was 19 months (range, 4-43 months). Mean postoperative BCVA improved to 20/80 (range, counting fingers to 20/25; P < 0.0001) with mean SDOCT 1 mm CFT of 260 µm and manual CPT of 236 µm. Mean ELM integrity grade was 1.9 (range, 0-5), while the mean grade of IS/OS integrity was 2.2 (range, 0-5). The correlation coefficients (r) were 0.17 (P = 0.32) for logarithm of the minimum angle of resolution BCVA versus SDOCT automated CFT, 0.192 (P = 0.26) for BCVA versus SDOCT CPT, 0.52 (P = 0.012) for BCVA versus ELM, and 0.55 (P = 0.006) for BCVA versus IS/OS. CONCLUSION: SDOCT-measured CFT and CPT correlate weakly with BCVA, while ELM and IS/OS integrity correlates well with BCVA. Outer retinal microstructure may represent anatomically better level of postoperative visual function than retinal thickness after pars plana vitrectomy for complications of proliferative diabetic retinopathy.

Smartphones in ophthalmology.

The potential usefulness of smartphones in the medical field is evolving everyday. This article describes various tools available on smartphones, largely focusing on the iPhone, for the examination of an ophthalmic patient, for patient and physician education, as well as reference tools for both ophthalmologists and vision researchers. Furthermore, the present article discusses how smartphones can be used for ophthalmic photography and image management, and foremost, the usefulness of the applications such as the Eye Handbook for the ophthalmologist and interested students, patients, physicians, and researchers, currently available in the iPhone.

Spectral domain optical coherence tomography findings of acute branch retinal artery occlusion from calcific embolus.

An 82-year-old female presented with sudden painless decrease in vision in the right eye after awakening. She could see the "superior half" of her vision from the right eye only. On examination, best-corrected vision was 20/300 in the right eye and 20/30 in the left eye. The fundus in the right eye revealed recent superotemporal branch retinal artery occlusion (BRAO) with calcified plaque at the disc. Spectral domain optical coherence tomography (OCT) (OTI Ophthalmic Technologies, Inc.), revealed hyperreflectivity and increased thickness of the inner retinal layers of the superior compared to the inferior retina. Imaging at the optic disc revealed the blocked artery containing a highly reflective material. The high reflectivity of the material and underlying optical shadowing could be characterized as calcific emboli.