Purtscher-like retinopathy in a patient with COVID-19-associated coagulopathy / Retinopatia tipo Purtscher em paciente com coagulopatia associada ao COVID-19

ABSTRACT The most frequently reported ophthalmic manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is conjunctivitis. We have described a case of Purtscher-like retinopathy in a patient with severe coronavirus disease 2019 (COVID-19)-associated coagulopathy. A young woman with multiple comorbidities was admitted for COVID-19-related acute respiratory distress syndrome. Her course was complicated by fungemia. Ophthalmic examination revealed bilateral posterior pole, intraretinal lesions and fluconazole was added for presumed fungal retinitis. At 1-week follow-up, widespread peripapillary cotton-wool spots and hemorrhages suggestive of Purtscher-like retinopathy were observed. The levels of D-dimers, fibrinogen, and C-reactive protein were markedly elevated prior to our consultation, indicating preceding prothrombotic and pro-inflammatory states. Subsequent venous duplex revealed deep venous thrombosis in the right subclavian and internal jugular veins. Von Willebrand factor indices were markedly elevated, suggesting severe COVID-19-associated coagulopathy. Purtscher-like retinopathy, a rare occlusive microangiopathy has been described in various pro-inflammatory and prothrombotic conditions. To the best of our knowledge, this is the first report of Purtscher-like retinopathy in COVID-19-associated coagulopathy.

RESUMO A manifestação oftálmica mais frequentemente re­latada da infecção por SARS-CoV-2 é a conjuntivite. Trata-se de estudo de caso de retinopatia tipo Purtscher em uma paciente com coagulopatia grave associada ao COVID-19. Uma jovem com múltiplas comorbidades foi admitida por síndrome do desconforto respiratório agudo relacionado ao COVID-19. Seu quadro foi complicado pela fungemia. O exame oftálmico revelou pólo posterior bilateral, lesões intraretinianas e o fluconazol foi adicionado para tratar a retinite fúngica presumida. No decorrer de uma semana, manchas largas peripapilares de algodão e hemorragias sugestivas de retinopatia tipo Purtscher foram observadas. Os dímeros D, o fibrinogênio e a proteína c-reativa estavam acentuadamente elevados antes da nossa consulta, indicando um estado pró-trombótico e pró-inflamatório precedente. O duplex venoso subsequente revelou trombose venosa profunda nas veias subclávia direita e jugular interna. Os índices de fatores von Willebrand estavam marcadamente elevados, sugerindo coagulopatia grave associada ao COVID-19. A retinopatia tipo Purtscher, uma microangiopatia oclusiva rara foi descrita em várias condições pró-inflamatórias e pró-trombóticas. Para nosso conhecimento, este é o primeiro relatório de retinopatia tipo Purtscher com coagulopatia associada ao COVID-19.

Purtscher-like retinopathy in a patient with COVID-19-associated coagulopathy.

The most frequently reported ophthalmic manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is conjunctivitis. We have described a case of Purtscher-like retinopathy in a patient with severe coronavirus disease 2019 (COVID-19)-associated coagulopathy. A young woman with multiple comorbidities was admitted for COVID-19-related acute respiratory distress syndrome. Her course was complicated by fungemia. Ophthalmic examination revealed bilateral posterior pole, intraretinal lesions and fluconazole was added for presumed fungal retinitis. At 1-week follow-up, widespread peripapillary cotton-wool spots and hemorrhages suggestive of Purtscher-like retinopathy were observed. The levels of D-dimers, fibrinogen, and C-reactive protein were markedly elevated prior to our consultation, indicating preceding prothrombotic and pro-inflammatory states. Subsequent venous duplex revealed deep venous thrombosis in the right subclavian and internal jugular veins. Von Willebrand factor indices were markedly elevated, suggesting severe COVID-19-associated coagulopathy. Purtscher-like retinopathy, a rare occlusive microangiopathy has been described in various pro-inflammatory and prothrombotic conditions. To the best of our knowledge, this is the first report of Purtscher-like retinopathy in COVID-19-associated coagulopathy.

Hydralazine-induced vasculitis presenting with ocular manifestations.

Purpose: The objective of the study is to report a case of ocular manifestations in a patient with hydralazine-induced vasculitis. Observations: An 88-year-old female was admitted for lower gastrointestinal bleeding. Nine days after admission, she developed bilateral conjunctival chemosis and injection, which rapidly progressed into grouped blistering eruptions of the periorbital skin, face, and neck. After extensive testing and evaluation, her constellation of findings was diagnosed as hydralazine-induced vasculitis. Treatment with intravenous steroids and discontinuation of hydralazine resulted in improvement of the cutaneous and ocular manifestations. Herein we describe the clinical course of an adult patient with symptoms and signs consistent with hydralazine-induced vasculitis to highlight that ophthalmological manifestations can be the first symptoms in patients with life-threatening dermatological conditions. Conclusions and Importance: To our knowledge, this report is the first case of hydralazine-induced vasculitis initially presenting with ocular manifestations.

A randomized trial of multimedia-facilitated informed consent for cataract surgery.

OBJECTIVE: The aim of this study was to evaluate the value and role of patient's education videos in the informed consent process for patients undergoing preoperative assessment of cataracts. DESIGN: The study is a single-center prospective randomized controlled trial. SUBJECTS PARTICIPANTS AND/OR CONTROLS: Participants enrolled in this study were specifically those undergoing first-time phacoemulsification cataract surgery with the placement of a monofocal lens implant. PARTICIPANTS AND METHODS: Subjects were randomized to either face-to-face surgeon-informed consent with a preceding education video or face-to-face surgeon-informed consent alone. MAIN OUTCOME MEASURES: The main outcome measures assessed were time to complete the informed consent process, patient's satisfaction, and patient's comprehension. RESULTS: The video and control groups were similar in satisfaction (4.67±0.104 video vs. 4.53±0.133 control; P=0.43) and comprehension (79.4%±2.82% video vs. 79.3%±3.39% control; P=0.99). Counseling time was statistically significantly different (117.5±10.9 seconds video versus 241.6±13.0 seconds control; P<0.0001). CONCLUSION: Use of a patient's education video for cataract surgery was associated with reduced physician counseling time yet similar comprehension and patient-reported satisfaction when compared with traditional counseling methods.

Effects of bevacizumab, ranibizumab, and aflibercept on phagocytic properties in human RPE cybrids with AMD versus normal mitochondria.

PURPOSE: A critical biological function of retina pigment epithelium (RPE) cells is phagocytosis of photoreceptor outer segment (POS) disc membranes. Mitochondrial damage and dysfunction are associated with RPE cells of age-related macular degeneration (AMD) retinas. In this study, we use a transmitochondrial cybrid model to compare the phagocytic properties of RPE cells that contain AMD mitochondria versus age-matched normal mitochondria and their response to treatment with anti-vascular endothelial growth factor (VEGF) drugs: bevacizumab, ranibizumab, and aflibercept. METHODS: Cybrids, which are cell lines with identical nuclei but mitochondria (mt) from different subjects, are created by fusing mtDNA depleted ARPE-19 cells with platelets from AMD or age-matched normal patients. AMD (n = 5) and normal (n = 5) cybrids were treated with 1 µm fluorescent latex beads (1.52 × 107 beads/mL) and either 2.09 µM of bevacizumab, 2.59 µM of ranibizumab, or 5.16 µM of aflibercept. These doses of anti-VEGF drugs are equivalent to intravitreal injections given to AMD patients with choroidal neovascularization. Flow cytometry was performed using the ImageStreamX Mark II to assess phagocytic bead-uptake. The average fold values for bead-uptake and SEM were calculated using GraphPad Prism software. RESULTS: Normal cybrids showed decreased bead-uptake with a fold value of 0.65 ±â€¯0.103 (p = 0.01) after treatment with bevacizumab, 0.80 ±â€¯0.034 (p = 0.0003) with ranibizumab, and 0.81 ±â€¯0.053 (p = 0.007) with aflibercept compared to the untreated normal cybrids (baseline fold of 1). The bevacizumab-treated, ranibizumab-treated, and aflibercept-treated AMD cybrids had decreased bead-uptake with a fold value of 0.71 ±â€¯0.061 (p = 0.001), 0.70 ±â€¯0.101 (p = 0.02), and 0.74 ±â€¯0.125 (p = 0.07), respectively, compared to the untreated AMD cybrids (baseline fold of 1). CONCLUSIONS: Our initial findings showed that when treated with bevacizumab and ranibizumab, both AMD cybrids and age-matched normal cybrids had a significant decrease in bead-uptake. A similar decrease in bead-uptake was found in normal cybrids treated with aflibercept and while the AMD values trended lower, they were not significant. This data suggests that anti-VEGF drugs can cause loss of phagocytic function.

A novel method for demonstrating cold agglutinin disease: a case report.

BACKGROUND: Cold agglutinin disease is a rare disorder characterized by an autoimmune hemolytic anemia occurring at low temperatures. Physical examination findings, often limited to acrocyanosis, are combined with a thermal amplitude test to help establish the diagnosis. Thermal amplitude testing determines the highest temperature at which the cold agglutination will occur and is an important parameter in diagnosing cold agglutinin disease. CASE PRESENTATION: Here we describe a 57-year-old white man of German and Nicaraguan descent with known chronic cold agglutinin disease who presented to our ophthalmology clinic for evaluation of a cataract. During routine cataract surgery, the lowered temperature of the conjunctiva from intermittent flow of balanced salt solution at room temperature induced a cold agglutination reaction in conjunctival vessels easily visible under a surgical microscope. CONCLUSIONS: To the best of our knowledge, this method of demonstrating cold agglutinin disease has not been described in the literature and could easily be performed utilizing an ordinary slit lamp. This method could be used as an alternative and rapid screening method for cold agglutinin disease.

Characterization of Corneal Endothelial Injury During Penetrating Keratoplasty.

PURPOSE: To characterize corneal endothelial injury during penetrating keratoplasty in a controlled wet laboratory environment using human tissue. To identify potential areas or steps within surgery in which insult to the corneal endothelium may be most affected by trauma during routine penetrating keratoplasty. METHODS: Human donor corneas (n = 12) with intact endothelium underwent experimental penetrating keratoplasty. Endothelial injury was evaluated after each suture quartile using trypan staining, a validated modality for assessing endothelial injury. Insult was quantified using high-resolution photography and computer software. RESULTS: Statistical significance was found in the change in staining between quartiles as determined by repeated-measures analysis of variance (F3,11 = 5.83, P < 0.0044). A post hoc Tukey test indicated that the change in staining during the first quartile (3.38% ± 0.5%) was significantly lower than the remaining quartiles at P < 0.021. The change in staining did not differ significantly between the second (8.36% ± 1.2%), third (7.88% ± 1.2%), and fourth (7.73% ± 0.9%) quartiles at P > 0.97. CONCLUSIONS: Evidence from this investigation suggests that injury to the endothelium occurs most during the second quartile. This may be a promising area in which clinicians could target their efforts to avoid injury to this vital tissue layer for best surgical outcomes and graft longevity.

Overview of Advanced LIGO adaptive optics.

This is an overview of the adaptive optics used in Advanced LIGO (aLIGO), known as the thermal compensation system (TCS). The TCS was designed to minimize thermally induced spatial distortions in the interferometer optical modes and to provide some correction for static curvature errors in the core optics of aLIGO. The TCS is comprised of ring heater actuators, spatially tunable CO2 laser projectors, and Hartmann wavefront sensors. The system meets the requirements of correcting for nominal distortion in aLIGO to a maximum residual error of 5.4 nm rms, weighted across the laser beam, for up to 125 W of laser input power into the interferometer.

ANXIOUS AND AGGRESSIVE: THE CO-OCCURRENCE OF IED WITH ANXIETY DISORDERS.

BACKGROUND: Evidence suggests that impulsive aggression and explosive anger are common among individuals with anxiety disorders; yet, the influence of intermittent explosive disorder (IED) on the onset, course, consequences, and patterns of comorbidity among those with anxiety disorders is unknown. METHODS: Data were drawn from the National Comorbidity Survey Replication (N = 9,282) and Adolescent Supplement (N = 9,632), nationally representative surveys conducted between 2001 and 2004. Diagnoses were based on structured lay-administered interviews. Lifetime diagnoses were assessed with structured instruments. Outcomes included comorbidity, functional and role impairment, and treatment utilization. RESULTS: Adolescents with a lifetime anxiety disorder had a higher prevalence of a lifetime anger attacks (68.5%) and IED (22.9%) than adolescents without a lifetime anxiety disorder (48.6 and 7.8%, respectively), especially social phobia and panic disorders. Similar elevation was found for adults. Age of onset and course of anxiety disorders did not differ by IED. Severe functional impairment associated with anxiety was higher among adolescents (39.3%) and adults (45.7%) with IED than those without IED (29.2 and 28.2%, respectively). Comorbidity for all other disorders was elevated. However, individuals with anxiety disorders and IED were no more likely to use treatment services than those with anxiety disorders without IED. CONCLUSIONS: Individuals with IED concomitant to anxiety disorder, especially social phobia and panic, are at marked risk for worse functional impairment and a higher burden of comorbidity, but onset and course of anxiety disorder do not differ, and those with anxiety and IED are no more likely to utilize treatment services. Assessment, identification, and specialized treatment of anger in the context of anxiety disorders are critical to reducing burden.

Racial/ethnic differences in use of alcohol, tobacco, and marijuana: is there a cross-over from adolescence to adulthood?

Black adolescents in the US are less likely to use alcohol, marijuana, and tobacco compared with non-Hispanic Whites, but little is known about the consistency of these racial/ethnic differences in substance use across the lifecourse. Understanding lifecourse patterning of substance use is critical to inform prevention and intervention efforts. Data were drawn from four waves of the National Longitudinal Study of Adolescent Health (Add Health; Wave 1 (mean age = 16): N = 14,101; Wave 4 (mean age = 29): N = 11,365). Outcomes included alcohol (including at-risk drinking, defined as 5+/4+ drinks per drinking occasion or 14+/7+ drinks per week on average for men and women, respectively), cigarette, and marijuana use in 30-day/past-year. Random effects models stratified by gender tested differences-in-differences for wave by race interactions, controlling for age, parents' highest education/income, public assistance, and urbanicity. Results indicate that for alcohol, Whites were more likely to use alcohol and engage in at-risk alcohol use at all waves. By mean age 29.9, for example, White men were 2.1 times as likely to engage in at-risk alcohol use (95% C.I. 1.48-2.94). For cigarettes, Whites were more likely to use cigarettes and smoked more at Waves 1 through 3; there were no differences by Wave 4 for men and a diminished difference for women, and difference-in-difference models indicated evidence of convergence. For marijuana, there were no racial/ethnic differences in use for men at any wave. For women, by Wave 4 there was convergence in marijuana use and a cross-over in frequency of use among users, with Black women using more than White women. In summary, no convergence or cross-over for racial/ethnic differences through early adulthood in alcohol use; convergence for cigarette as well as marijuana use. Lifecourse patterns of health disparities secondary to heavy substance use by race and ethnicity may be, at least in part, due to age-related variation in cigarette and marijuana use.

Transoral incisionless fundoplication: initial experience in patients referred to an integrated academic institution.

Transoral incisionless fundoplication is a new treatment for patients with gastroesophageal reflux disease. We present our initial experience with 10 patients undergoing this procedure with varying past surgical histories. All procedures were performed under general nasotracheal anesthesia. RAND-36 and Visual Analog Scale symptom scores were collected at pre and postoperative appointments for a mean of 9.2 months. The mean procedure time was 68 minutes. There were no intraoperative or postoperative complications. Patients with prior pancreaticoduodenectomy had observed reduced working space due to prior distal gastrectomy and required additional insufflation due to no pyloric resistance to insufflation of the small bowel. The patient with prior fundoplication required additional time and force for fastener penetration of the resultant scar from the partially disrupted fundoplication. All patients were discharged within 23 hours of the procedure. Throughout the follow-up period, patients reported gradual changes in medication requirements and symptom scores. There were no late complications. Transoral incisionless fundoplication is technically safe in well-selected patients including those with prior esophageal and gastric surgery.