Combined use of intravitreal bevacizumab and oral steroid treatment in three diabetic papillopathy patients: a diagnostic and treatment challenge.

Diabetic papillopathy (DP), a form of optic disc edema, is characterized by decreased visual acuity and mild to severe visual field defects. While there is no consensus about treatment, some publications report that intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection may be beneficial. To our knowledge, however, no research reports on the effects of combining anti-VEGF injection and oral steroids in DP treatment. In this case report we present three DP cases that showed rapid improvement following therapy with intravitreal bevacizumab and oral steroids. Optic disc edemas were significantly decreased, and visual acuities were markedly increased in the first week of treatment. This report suggests that combined use of these therapies may be safely used in patients diagnosed with DP.

Ocular ischemia syndrome after aesthetic treatment with hyaluronic acid.

A 49-year-old female with no pre-morbidities comes in with sudden, painless loss of vision in the left eye (OS) after a facial hyaluronic acid (HA) injection for aesthetic purposes one hour ago. Visual acuity was no light perception (NLP). OS examination revealed a mid-non-reactive mydriasis and complete ophthalmoplegia. Fundus examination of the OS suggested central retinal artery occlusion (CRAO). Systemic evaluation was normal. Given this diagnosis, ocular massage, anterior chamber paracentesis, anticoagulation, systemic antibiotherapy, and subcutaneous hyaluronidase around the injection sites and peribulbar region were performed. Despite these interventions, the patient did not regain vision, exhibiting signs of anterior and posterior ocular ischemia. Subsequently, she developed phthisis bulbi, necessitating evisceration. The management of this complication should be prompt, if possible, to mitigate its dire consequences.

Optic Perineuritis Presenting with Transient Monocular Vision Loss (TMVL): Case Report.

Optic perineuritis is an inflammatory condition that presents with reduced visual acuity and painful eye movement. The presentation of optic perineuritis is similar of optic neuritis which results in delayed diagnosis and management. Up to this date, we found a single case of optic neuritis that presented with transient monocular vision loss (TMVL). No cases of optic perineuritis were associated with TMVL. Here, we report a case of a 30-year-old woman who presented with recurrent attacks of painless vision loss in her left eye, reaching up to 30 attacks per day. Ophthalmological examination was otherwise unremarkable. Lab investigations were normal. Magnetic resonance imaging was done, which showed left optic nerve sheath enhancement suggestive of left-sided focal optic perineuritis. Patient was managed with 1 mg IV methylprednisolone for 3 days. We report this case to shed light on the importance of accurate and early diagnosis of optic perineuritis presenting with TMVL. Prompt management of optic perineuritis is crucial in reducing morbidity and risk of relapse.

Vision loss associated with silicone oil endotamponade in vitreoretinal surgery - a review.

PURPOSE: To clarify the definition, prevalence and classification of different types of unexplained vision loss associated with silicone oil (SO) endotamponades (SO in situ (SOIS) or after removal of SO (ROSO)) in vitreoretinal surgery and identifying the most specific clinical findings and suggesting possible causes. METHODS: Review of the literature regarding randomized clinical trials (RCTs), retrospective case-control, cohort studies and case series evaluating the risk of using SO, published in English between 1994 and 2023, conducting a computer-based search of the following databases: PubMed, Web of Science, Scopus and Embase. The search was supplemented using the Medline option 'Related Articles' and consulting review articles on the topic. RESULTS: Findings from reported clinical examinations in SOIS and ROSO are analyzed and finally different theories regarding the underlying pathophysiology are described. From the clinical point of view, findings have been found in OCT, OCTA, microperimetry and electrophysiological studies. Other clearly identifiable causes of vision loss related to the use of SO are listed and commented as differential diagnosis. Finally, the different physiopathological theories of the two types of causes of unexplained vision have been analyzed. CONCLUSION: Unexpected vision loss under or after SO tamponade (SOIS and ROSO) is a significant concern which is probably underestimated because it is not a clearly defined and known entity. The most frequently described changes were in the ganglion cell complex but this unexpected vision loss remains a serious and unexplained concern for vitreoretinal surgeons and should be identified by clinicians, addressed by manufacturers and reported to Health Authorities as a serious incident according to the new regulation.

The Graded Incomplete Letters Test (GILT): a rapid test to detect cortical visual loss, with UK Biobank implementation.

Impairments of object recognition are core features of neurodegenerative syndromes, in particular posterior cortical atrophy (PCA; the 'visual-variant Alzheimer's disease'). These impairments arise from damage to higher-level cortical visual regions and are often missed or misattributed to common ophthalmological conditions. Consequently, diagnosis can be delayed for years with considerable implications for patients. We report a new test for the rapid measurement of cortical visual loss - the Graded Incomplete Letters Test (GILT). The GILT is an optimised psychophysical variation of a test used to diagnose cortical visual impairment, which measures thresholds for recognising letters under levels of increasing visual degradation (decreasing "completeness") in a similar fashion to ophthalmic tests. The GILT was administered to UK Biobank participants (total n=2,359) and participants with neurodegenerative conditions characterised by initial cortical visual (PCA, n=18) or memory loss (typical Alzheimer's disease, n=9). UK Biobank participants, including both typical adults and those with ophthalmological conditions, were able to recognise letters under low levels of completeness. In contrast, participants with PCA consistently made errors with only modest decreases in completeness. GILT sensitivity to PCA was 83.3% for participants reaching the 80% accuracy cut-off, increasing to 88.9% using alternative cut-offs (60% or 100% accuracy). Specificity values were consistently over 94% when compared to UK Biobank participants without or with documented visual conditions, regardless of accuracy cut-off. These first-release UK Biobank and clinical verification data suggest the GILT has utility in both rapidly detecting visual perceptual losses following posterior cortical damage and differentiating perceptual losses from common eye-related conditions.

Characterisation and Visual Outcomes of Fulminant Idiopathic Intracranial Hypertension: A Narrative Review.

Fulminant idiopathic intracranial hypertension (IIH) is a rapid vision-degrading presentation of IIH with limited published studies. This study composed a narrative review of fulminant IIH with the aim of better characterising fulminant IIH presentation and visual outcomes. SCOPUS and PubMed were searched for papers referencing IIH, benign intracranial hypertension, or pseudotumour cerebri. Abstracts were screened for rapid degradation in vision. All studies were required to meet both the modified Dandy and fulminant IIH criteria. Thirty-six studies met the inclusion criteria. Demographics, treatments, and visual outcome data were collected. Case studies made up 69% of the studies and 31% were case series. In total, 72 patients with fulminant IIH were reported, of which 23.6% were paediatric and 96% were female. Surgical intervention occurred in 85% of patients. Anaemia was present in 11% of patients and 85.7% of paediatric patients had a sixth cranial nerve palsy. In conclusion, we propose the following practice guidelines to assist in diagnosing and treating fulminant IIH patients: 1) patients who present with optic disc oedema require urgent visual field testing to evaluate for vision loss; 2) a paediatric patient presenting with a sixth cranial nerve palsy should have a comprehensive eye examination; 3) fulminant IIH can occur in patients with a normal body mass index; and 4) anaemia should be tested for in the setting of fulminant IIH. As little is known about the optimal treatment mechanisms for this presentation, multi-institutional and international collaborations will be a critical step for future research.

Ocular Syphilis as a Primary Manifestation of Neurosyphilis: A Case Report.

Sexually transmitted infectious diseases could affect a variety of organs, generating significant symptomatology. In the elderly population, infectious causes for vision problems are not generally considered. We present the case of an elderly patient with blurred vision and darkening of visual fields. He underwent an unsuccessful biopsy of the temporal artery as his vision disturbances presented also with episodic headaches. He was found to have an elevated rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) test in his cerebrospinal fluid (CSF) analysis. He was treated for ocular syphilis with a total resolution of his vision loss.

Concomitant Occurrence of Peripheral Neuropathy and Vision Loss Due to Multivitamin Deficiency After Bariatric Surgery.

Vitamin deficiencies, especially after Bariatric surgery, are common and, when not properly addressed, can lead to debilitating complications. Bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal; this alteration makes these patients more susceptible to developing nutritional deficiencies. Peripheral neuropathy is one of the complications that can arise from nutritional deficiencies, and it can cause severe functional impairment. Vision loss is a relatively uncommon complication after weight loss procedure. Changes in the retinal nerve fiber layer, choroidal thickness, and visual fields due to hypovitaminosis result in nutritional optic neuropathy and retinopathy. The main retinal complication is nyctalopia (night blindness), which is caused by vitamin A deficiency. We present a case of concomitant peripheral neuropathy and vision loss secondary to reduced levels of multiple vitamins following gastric bypass surgery. This case highlights the need for regular vitamin level monitoring and appropriate replenishment in patients after bariatric surgery to prevent significant morbidities.

ACR Appropriateness Criteria® Orbital Imaging and Vision Loss-Child.

Orbital disorders in children consist of varied pathologies affecting the orbits, orbital contents, visual pathway, and innervation of the extraocular or intraocular muscles. The underlying etiology of these disorders may be traumatic or nontraumatic. Presumed location of the lesion along with the additional findings, such as eye pain, swelling, exophthalmos/enophthalmos, erythema, conjunctival vascular dilatation, intraocular pressure, etc, help in determining if imaging is needed, modality of choice, and extent of coverage (orbits and/or head). Occasionally, clinical signs and symptoms may be nonspecific, and, in these cases, diagnostic imaging studies play a key role in depicting the nature and extent of the injury or disease. In this document, various clinical scenarios are discussed by which a child may present with an orbital or vision abnormality. Imaging studies that might be most appropriate (based on the best available evidence or expert consensus) in these clinical scenarios are also discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Full-Thickness Macular Hole: An Exceptional Case Presentation in Behçet's Disease.

Behçet's disease (BD) is a vascular disorder affecting a variety of organ systems. It is an auto-immune disease with inflammatory vasculitis that is systemic in nature, the exact etiology of which is unknown. Obliterative vasculitis, recurrent aphthous ulcers, mucocutaneous manifestations, recurrent genital ulcerations, and intraocular inflammation, especially chronic relapsing uveitis, are the characteristic features of BD. The case report presents a unique manifestation of BD in a 20-year-old Pakistani male who presents with a one-year-old history of viral encephalitis, after which he developed a blurring of vision. On examination, he had recurrent aphthous ulcers, recurrent ulcerations of genitalia, and a history of lesions of the skin. After making the patient undergo a cascade of investigations for evaluating and assessing the various signs and symptoms, a diagnosis of BD with bilateral panuveitis and a full-thickness macular hole (FTMH) in the right eye was established. Immuno-suppressants, steroids, and azathioprine were used as treatment options, following which the state of remission was attained.

Barriers to Eye Care for Adults in the United States and Solutions for It: A Literature Review.

Vision loss and blindness is a significant public health concern that has had a profound impact on various communities in the United States. Both anticipated and unforeseen barriers have been linked to the rising rates of vision loss and blindness in the country. Extensive research has identified numerous barriers that put many Americans at a disadvantage when trying to seek high-quality eye care services. Not only do the barriers to eye care services create problems for eye health, but also create a poor quality of life. Therefore, understanding and identifying barriers to eye healthcare services is incredibly important. In addition to understanding and identifying barriers, it is also important to identify solutions to the problems created by these barriers. A systematic review of articles characterizing the barriers to eye care was completed which resulted in the identification of the major barriers that affect Americans. The review of previous research was also used to identify available solutions for problems associated with the barriers to eye care services. The major barriers identified were cost, insurance, transport and accessibility, eye health care literacy, and communication. Because of the identification of the major barriers, solutions were also identified. Health education and increased vision screenings were found to be the most used forms of solutions by healthcare professionals promoting good eye health. Telemedicine has also been cited as a possible solution to the growing problem of visual impairment and blindness within the American population.

The influence of assistive technologies on experiences of risk among older adults with age-related vision loss (ARVL).

PURPOSE: Living with risk is a salient part of everyday living and although risk affects everyone, older adults are often regarded as a high-risk group, particularly older adults who are aging with a disability, such as vision loss. A prominent focus within low vision rehabilitation is the provision, and training, of older adults in the use of low vision assistive devices as a strategy to manage risks in both the home and community environment. This study aimed to unpack the influence of assistive technologies on experiences of risk among eleven older adults (aged 65+) with age-related vision loss. MATERIALS AND METHODS: This critical ethnographic study used home tours, the go-along method, and a semi-structured in-depth interview. RESULTS: The study identified five prevailing themes including: 1) Moving away from the individualization of risk; 2) The cost of assistive technologies as a risk contributor; 3) Practicing 'responsible living'; Technology as an adaptive strategy to risk taking; 4) Resisting the label of 'at risk'; The influence of technology on self-identity; and 5) Technology as a substitution versus supplement for social connectedness. CONCLUSIONS: The study findings highlight the importance of moving beyond a technico-scientific perspective of risk, in which risk is framed as an objective phenomenon located in older adults' bodies, and instead framing risk within a broader sociocultural perspective which moves our attention to those contextual or environmental factors that shape experiences of risk for older adults with vision loss.

Risk taking is an inevitable aspect of everyday living.An individualized approach to risk management is problematic.The cost of assistive technology is a contributing risk factor.Technology use may cause risks to social identity, embarrassment, and stigma.Technology use can help mitigate risk among older adults.

Systematic review and meta-analysis of the prevalence of myopia among school-age children in the Eastern Mediterranean Region.

Background: The recent increase in myopia is a major public health concern worldwide, including in the Eastern Mediterranean Region (EMR). Aim: To provide data on the prevalence of myopia among school-age children in the EMR. Methods: This study was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol. We searched the Web of Sciences, Scopus, Index Medicus for the Eastern Mediterranean Region, ProQuest, PubMed, and Medline for studies on the prevalence of myopia in the EMR published from January 2000 to May 2022. The data were analysed using MedCalc version 19.6.1 and myopia was defined as refractive error ≥ 0.50 D. The overall pooled prevalence of myopia was estimated using a random-effects model and its associated 95% confidence intervals. Results: The meta-analysis included 27 quality-assessed studies from 13 countries among 51 111 school-age children. The overall pooled prevalence of childhood myopia from 2000 to 2022 was 5.23%, which was significantly higher among females than males (4.90% vs 3.94%). The prevalence of myopia was significantly higher among children aged 11-17 years than among those aged 5-10 years (7.50% vs 3.90%). There was a higher prevalence of myopia with cycloplegic refraction than noncycloplegic refraction (5.95% vs 3.73%). There was highly significant heterogeneity between the studies. Conclusion: Prevalence of myopia among school-age children in the EMR was high, particularly among older children, and it was more common among females. Early intervention to slow myopia progression is essential in the EMR to protect children from irreversible vision loss.

Vision Problems As a Contributor to Lower Engagement in Care Among Aging Men Living with HIV.

PURPOSE: To investigate vision impairment as a barrier to engagement in medical care among aging persons living with HIV (PLWH) who experience multimorbidity and complex care needs. SETTING: Multicenter AIDS Cohort Study (MACS), a prospective observational cohort of aging PLWH men. METHODS: We examined relationships of self-reported vision difficulty with indicators of care engagement: 1) adherence to HIV antiretroviral therapy (ART; defined as taking ≥95% of medications); 2) self-reported avoidance of medical care; 3) self-reported tendency to ask a doctor questions about care (>2 questions at a medical visit), as well as with quality of life. A modified version of the National Eye Institute Vision Function Questionnaire was administered at three semi-annual visits (from October 2017 to March 2019) to assess difficulty performing vision-dependent tasks. RESULTS: We included 1063 PLWH (median age 57 years, 31% Black). Data on care engagement outcomes were analyzed using repeated measures logistic regression with generalized estimating equations adjusted for race, and at visit values for age, education level, depressive symptoms, alcohol use, and smoking status. Compared to no vision difficulty, those reporting moderate to extreme vision difficulty on at least one task had 2.2 times higher odds (95% CI: 1.4, 3.4) of having less than optimal ART adherence, 1.9 times higher odds (95% CI: 1.1, 3.4) of avoiding necessary medical care and median quality of life scores 8 points lower. CONCLUSION: These findings suggest vision impairment decreases medical care engagement including HIV care and quality of life among aging PLWH.

Bilateral optic neuropathy associated with lorlatinib monotherapy for ALK-positive metastatic lung adenocarcinoma.

Purpose: This report details the characteristics of a case of bilateral optic neuropathy during treatment with oral lorlatinib for ALK-positive metastatic adenocarcinoma of the lung. Observations: A 57-year-old woman with metastatic adenocarcinoma of the lung receiving treatment with lorlatinib presented to the ophthalmology urgent care with bilateral loss of vision that had progressed to no light perception over the previous 2 weeks. She was hospitalized for an extensive autoimmune, infectious, neoplastic, and paraneoplastic workup, which revealed enhancement of both optic nerves extending up to the optic chiasm and an area of restricted diffusion in the splenium of the corpus callosum on MRI. Lorlatinib was discontinued by her oncologist and she received treatment with five days of pulse-dose intravenous solumedrol as well as five days of plasmapheresis with gradual improvement in her vision. In follow-up, her vision had improved to 20/40 and 20/30. Conclusion and importance: There have been few reports describing vision loss associated with lorlatinib, an ALK/ROS1 targeted tyrosine kinase inhibitor used to treat metastatic lung adenocarcinoma. This report details the characteristics of a case of bilateral retrobulbar optic neuropathy as well as the treatment and recovery of such a case. Further exploration is needed in order to improve our understanding of the pathogenesis of this rare but potentially devastating adverse effect.

Kissing choroidal sign: A case report.

Choroidal detachment (CD) is a rare and potentially vision-threatening complication of glaucoma surgery. Inflammation and prolonged ocular hypotony can promote fluid accumulation between the choroid and sclera. Risk factors include trauma, advanced age, use of anticoagulant medications, systemic hypertension, atherosclerosis, and diabetes. CD ultrasound findings will show 2 layers, detaching as far anteriorly as the ciliary bodies, that protrude convexly into the vitreous without extending to the optic disc, often described as the appositional or kissing choroidal sign. In contrast, retinal detachments will show a distinct "V" shape due to the retina's fixation to the optic nerve head posteriorly. In the case of hemorrhagic CD, therapy should be targeted at reducing intraocular pressure. In this case, the patient was started on atropine and prednisolone drops and discontinued on all glaucoma medications in the left eye. While serous choroidal detachments are usually benign, persistent choroidal effusions may cause significant morbidity with hemorrhagic CD having a worse prognosis. Point of care ultrasound can help emergency physicians quickly distinguish between choroidal and retinal detachments and thus guide management in a safe and timely manner.

Association Between Multisensory Impairment and Depression Among Older Adults: A Population-Based Analysis.

OBJECTIVE: In this study, we examine how impairments in vision, hearing, touch, and olfaction relate to depression in older adults, considering both individual and multisensory impairments (MSIs). STUDY DESIGN: Analysis of cross-sectional data from a longitudinal investigation involving black and white older adults aged 70 to 79 at enrollment. SETTING: We studied 1640 black and white participants in the Health ABC study using complete sensory evaluation data from years 3 to 5. METHODS: Our MSI assessment utilized data obtained for visual acuity, hearing perception, olfactory performance, and tactile function. We performed multivariable logistic regression analyses to examine the associations between the presence of individual and MSIs and depression which was defined as the presence of antidepressants prescribed for depression, or a Center for Epidemiological Studies Depression Scale score of greater than 10. RESULTS: We observed a possible dose-response relationship between the number of sensory impairments and depression. In adjusted models, when compared to no impairments, vision (odds ratio [OR] = 1.45, 95% confidence interval [CI]: 1.09-1.93) and hearing impairments (OR = 1.49, 95% CI: 1.11-1.99) were significantly associated with depression, whereas olfaction (OR = 1.11, 95% CI: 0.83-1.47) and tactile impairments (OR = 1.28, 95% CI: 0.96-1.70) were not. Participants with 3 sensory impairments had a higher rate of depression (OR = 2.05, 95% CI: 1.22-3.54) compared to those without impairments, and this risk increased further for those with 4 sensory impairments (OR = 2.95, 95% CI: 1.48-5.88). CONCLUSION: The findings suggest that individuals with MSI represent a high-risk population for depression, warranting close monitoring to screen for depression. The study emphasizes the importance of considering multiple sensory impairments in the context of mental health and supports the early identification and monitoring of depression in this population.

Prevalence of Keratoconus in the Young Eastern Population of Saudi Arabia.

BACKGROUND: Keratoconus (KCN) is a progressive corneal ectasia that manifests at a young age and significantly impacts vision and quality of life. Early diagnosis allows for effective treatment with corneal collagen crosslinking, yet there is a lack of screening methods. This research aims to screen adolescents and young adults for this sight-threatening disease using quick corneal tomography mapping. METHODS: This prospective cross-sectional study is being conducted at Johns Hopkins Aramco Healthcare in Saudi Arabia, focusing on subjects aged 13-23. We are presenting the data from our study as internal pilot study data. Bilateral corneal imaging with Pentacam HR (Oculus, Wetzlar, Germany), utilizing Scheimpflug corneal tomography, was performed. Historical data on allergies, eye rubbing, KCN, family history, previous eye surgery, and contact lens use were collected. The Belin Ambrosio Enhanced Ectasia Display total D value served as an objective criterion for suspect KCN (SKCN) diagnosis. RESULTS: In this study with 110 participants, KCN was identified in 2.75% of participants and SKCN in 11.93%. Systemic allergies or eczema were reported by 2.80%, with no cases in the KCN or SKCN groups. Eye rubbing behavior was observed in 5.50%, with the highest prevalence (33.30%) in the KCN group. A family history of KCN was found in 21.10%, with SKCN having the highest prevalence (30.80%). CONCLUSION: This restricted population study reveals a significant KCN rate of 2.75%. The condition, easily detected and treatable with corneal collagen crosslinking, highlights the need for larger population studies to determine the disease's true prevalence. Efficient screening programs tailored to regional data are essential for early detection and intervention.

Amiodarone-Associated Optic Neuropathy in a Patient With Associated Arrhythmia.

Amiodarone is a commonly used antiarrhythmic used to treat atrial fibrillation and ventricular tachycardias. While this agent can present with pulmonary, thyroid, and hepatic side effects, it can also, less commonly cause neurologic toxicity, particularly optic neuropathy. Optic neuropathy can manifest as acute vision loss. The management of amiodarone-associated optic neuropathy (AAON) includes early recognition of symptom manifestation so that the medication can be discontinued promptly. Here, we describe a case of a 64-year-old male who developed acute onset complete left-sided vision loss after initiation of amiodarone.