Herpes simplex virus dissemination with necrotizing hepatitis following Descemet membrane endothelial keratoplasty.

BACKGROUND: Corneal transplants are the most common type of transplant and increasing in frequency. Donor cornea tissues are a rare source of herpes simplex virus (HSV) transmission and not routinely tested for presence of HSV. Donor graft-to-recipient transmission typically causes graft failure and anterior uveitis, and extra-ocular HSV disease has not been previously reported. We present a case of HSV transmission from donor cornea tissue that nearly cost the corneal transplant recipient his life. CASE REPORT: An elderly immunocompetent man developed an acute illness 10 days after having donor corneal tissue implanted in a Descemet membrane endothelial keratoplasty (DMEK). He was found to have HSV necrotizing hepatitis per liver biopsy, trilineage cytopenia, rhabdomyolysis, acute kidney failure, altered mental status, early-stage hemophagocytic lymphohistiocytosis (HLH), and donor corneal tissue implant infection resulting in graft failure and anterior uveitis. HSV DNA was detected in cerebral spinal fluid, peripheral blood, explanted donor corneal tissue, and anterior chamber fluid (220 million HSV DNA copies per mL). HSV-1 seroconversion denoted a primary HSV infection, and the patient had no other risk factor for HSV acquisition. Early recognition of HSV dissemination prompting treatment with intravenous acyclovir, as well as a short course of HLH-directed therapy, resolved the systemic illness. Vision was restored to near normal by replacement of the infected corneal graft with new donor DMEK tissue in conjunction with intravitreal foscarnet treatment. CONCLUSION: Awareness of the potential risk of donor cornea tissue transmitting HSV and leading to life-threatening HSV disease is paramount to early diagnosis and treatment. The role of donor cornea tissue in HSV transmission and disease merits additional attention and investigation.

Diffuse Lamellar Keratitis in a Patient Undergoing Collagen Corneal Cross-Linking 18 Years After Laser In Situ Keratomileusis Surgery.

PURPOSE: To report a case of diffuse lamellar keratitis (DLK) after corneal collagen cross-linking in an eye with a remote history of laser in situ keratomileusis (LASIK) surgery. METHODS: This is a case report and literature review. RESULTS: This report describes the development of unilateral stage IV DLK in a patient who underwent bilateral corneal cross-linking for corneal ectasia 18 years after LASIK surgery. The patient was treated with high-dose topical steroids that were tapered over 1 month and multiple flap lifts. The ultimate best-corrected visual outcome was 20/60. CONCLUSIONS: DLK is a potential sight-threatening complication of refractive surgery that can occur at any time in the postoperative period, even years after the procedure. Undergoing a subsequent corneal procedure that may disrupt or promote inflammation within the surgical flap-stromal interface, such as corneal collagen cross-linking, is a recognized risk factor for the development of DLK. This case suggests that patients with any history of LASIK surgery undergoing corneal cross-linking or other lamellar corneal surgeries may benefit from closer follow-up (eg, daily) than patients with no history of LASIK.

Overnight Safety Evaluation of a Multi-Pressure Dial in Eyes with Glaucoma: Prospective, Open-Label, Randomized Study.

PURPOSE: To investigate the safety and tolerability of the multi-pressure dial (MPD) worn overnight for seven consecutive days. DESIGN: Prospective, open-label, randomized, single-site study. SUBJECTS: Twenty eyes of 10 subjects with open-angle glaucoma were fitted with an MPD and randomized to negative pressure application of -10 mmHg in one eye (study eye) worn overnight for 7 consecutive days. METHODS: Safety measures included best-corrected visual acuity (BCVA), intraocular pressure (IOP) changes from baseline during and after negative pressure application, slit lamp and dilated fundus exam findings, and rate of adverse events. Subjective assessments were completed daily by the subjects during the 7-day study period and immediately following the study period. RESULTS: Prior to the 7-day testing period, application of 10 mmHg negative pressure reduced mean IOP from 18.2 ± 3.8 mmHg to 14.0 ± 2.1 mmHg (p<0.01), a 22% reduction. After 7 days of consecutive nightly wear, repeat IOP measurements with the application of negative pressure showed a decrease in mean IOP from 16.9 ± 4.3 mmHg to 13.5 ± 3.7 mmHg. The observed IOP reduction was in addition to the subjects' current treatment regimen. There were no statistically significant changes in IOP, BCVA from baseline following the 7-day period of nightly wear with the application of negative pressure. The patient-reported outcomes were favorable. CONCLUSION: The MPD can safely and comfortably be worn overnight. The decrease in IOP of >20% in addition to current therapy is both clinically and statistically significant. The MPD shows promise as a potential new treatment option for nocturnal IOP control.

Short-Term Steady-State Pattern Electroretinography Changes Using a Multi-Pressure Dial in Ocular Hypertensive, Glaucoma Suspect, and Mild Open-Angle Glaucoma Patients: A Randomized, Controlled, Prospective, Pilot Study.

INTRODUCTION: This study evaluates the effects of the multi-pressure dial (MPD) on steady-state pattern electroretinography (ss-pERG) parameters. The study is a randomized, controlled, prospective, pilot trial in a private practice setting with ocular hypertensive (OHT), glaucoma suspect, and open-angle glaucoma (OAG) subjects. METHODS: This study included nine patients (64 ± 9.0 years, nine female) with OHT, glaucoma suspect, or mild OAG. One eye of each subject was randomized to receive negative periocular pressure, while the contralateral eye served as the intrasubject control through the goggle without negative pressure. The Diopsys High Contrast Sensitivity ss-pERG protocol was conducted on both eyes of each subject while wearing the MPD device. Application of negative periocular pressure was set at 50% of baseline intraocular pressure for each study eye. RESULTS: Following 2 h of negative periocular pressure application, the difference in MagnitudeD (MagD) from baseline for eyes randomized to receive negative periocular pressure (+ 0.17 versus - 0.26) was statistically significant (p = 0.023). Over the same period, the change in MagD/Magnitude (MagD/Mag ratio) from baseline for eyes randomized to receive negative periocular pressure was also higher (+ 0.14 versus - 0.16), compared to the control eyes, approached significance (p = 0.059). CONCLUSIONS: Following 2 h of MPD wear, the measured MagD and MagD/Mag ratio improved compared to control, suggesting that negative periocular pressure application to the anterior globe can lead to short-term improvement in one measure of retinal ganglion cell function.

Prospective Interventional Cohort Study of Ocular Surface Disease Changes in Eyes After Trabecular Micro-Bypass Stent(s) Implantation (iStent or iStent inject) with Phacoemulsification.

INTRODUCTION: This study sought to assess ocular surface disease changes following cataract surgery combined with trabecular micro-bypass stent(s) implantation (iStent or iStent inject). METHODS: This prospective interventional single-arm clinical trial enrolled 47 eyes with mild-to-moderate open-angle glaucoma (OAG) on 1-4 glaucoma medications who underwent phacoemulsification and trabecular micro-bypass stent(s) implantation. Key glaucoma and ocular surface data through 3 months postoperatively included the Ocular Surface Disease Index score (OSDI), corneal/conjunctival staining (Oxford Schema), fluorescein tear break-up time (FTBUT), conjunctival hyperemia (Efron Scale), glaucoma medications, and intraocular pressure (IOP). RESULTS: Mean OSDI scores improved from 40.1 ± 21.6 (severe) preoperatively to 17.5 ± 15.3 (mild) at 3 months (p < 0.0001). While 73% of eyes had moderate or severe OSDI scores preoperatively, 29% had such scores at 3 months, and the OSDI score was normal in 57% of eyes versus 9% preoperatively. Mean FTBUT increased from 4.3 ± 2.4 s preoperatively to 6.4 ± 2.5 s at 3 months (p < 0.0001); mean Oxford corneal/conjunctival staining reduced from 1.4 ± 1.0 preoperatively to 0.4 ± 0.6 at 3 months (p < 0.0001); mean Efron conjunctival hyperemia score reduced from 1.4 ± 0.7 preoperatively to 1.2 ± 0.6 at 3 months (p = 0.118). The number of glaucoma medications decreased from 1.5 ± 0.9 to 0.6 ± 0.8 mean medications (60% reduction, p < 0.0001), with all eyes maintaining or reducing medications versus preoperatively and 55% of eyes becoming medication-free (versus 0% preoperatively). Mean IOP reduced from 17.4 ± 4.2 mmHg to 14.5 ± 3.2 mmHg (p < 0.0001). The safety profile was excellent. CONCLUSION: Implantation of trabecular micro-bypass stent(s) (iStent or iStent inject) with cataract surgery produced significant improvements in ocular surface health, alongside significant reductions in IOP and medications. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT04452279.

Extended depth of focus lens implantation after radial keratotomy.

PURPOSE: To identify the visual performance of radial keratotomy (RK) patients that have undergone cataract surgery with implantation of an extended depth of focus (EDOF) intraocular lens (IOL). DESIGN: Retrospective chart review with questionnaire. METHODS: Medical charts of patients with a history of RK that had undergone phacoemulsification with implantation of the Tecnis Symfony IOL (J&J Vision) were reviewed. Data collected included preoperative demographics, number of RK incisions, pupil size, and preoperative visual acuity and manifest refraction. Primary outcome measures of the study included postoperative uncorrected distance visual acuity (UCVA) and manifest refraction spherical equivalent (SE) at each follow-up visit. Secondary outcomes included results from a telephone questionnaire assessing visual performance and satisfaction. RESULTS: Twenty-four eyes of 12 patients were included. UCVA improved from an average Snellen equivalent 20/73 preoperatively to 20/33 at an average final follow-up of 6 months (P=0.0011), while average manifest SE improved from +1.68 D to -0.18 D (P<0.0001). At final follow-up, 15 of 24 eyes (62.5%) were at or within 0.5 D of target refraction, while 20 of 24 eyes (83.3%) were at or within 1.0 D. In total, 79% of eyes (19 of 24) had UCVA of 20/40 or better at distance. In the survey, 78% of patients reported satisfaction with their vision after surgery and 44% of patients reported being spectacle free for all tasks. CONCLUSIONS: An EDOF lens implant can produce good visual outcomes and satisfaction in patients with a history of RK.

MELANOCYTOMA OR JUXTAPAPILLARY MELANOMA?

PURPOSE: To report the case of a melanocytoma of the optic disc leading to severe vision loss, raising concern for possible malignant transformation and optic nerve infiltration. METHODS: Case report. RESULTS: A 36-year-old Arabic woman presented to an outside facility with severe vision loss and a clinical picture concerning for optic neuritis with central retinal vein occlusion. On referral to the authors' institution 1 month after initial presentation, the vision of the patient was no light perception in the affected eye, and examination revealed the presence of a pigmented lesion adjacent to the nerve. Although standard 3-T magnetic resonance imaging orbits suggested 15 mm of optic nerve involvement, ultrahigh resolution 7-T magnetic resonance imaging was able to detect only 2 mm of optic nerve involvement. CONCLUSION: Melanocytoma of the optic disc is most often benign and causes few visual symptoms. However, in rare cases it can lead to severe vision loss and raise concern for malignant transformation. A 7-T magnetic resonance imaging provides higher resolution optic nerve images.

Prednisolone versus dexamethasone for prevention of pseudophakic cystoid macular edema.

OBJECTIVE: Prevention of cystoid macular edema (CME) is important to achieve good surgical outcomes after cataract surgery. Although many options for management exist, control of postoperative inflammation with topical steroids is one of the most commonly employed. We evaluated the difference in incidence of pseudophakic CME in patients treated with prednisolone or dexamethasone topical steroids. METHODS: The study was a retrospective chart review of patients who had undergone phacoemulsification at the Cole Eye Institute of the Cleveland Clinic. Reviewable patient charts had to indicate the topical steroid used and whether or not an additional medication (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs]) was used after surgery. Excluded were patients who underwent combination procedures (e.g., trabeculectomy), perioperative anti-vascular endothelial growth factor or intraocular steroid, eyes with epiretinal membrane or prior retinal vein occlusion, those who developed postoperative endophthalmitis, patients with less than 3 months of follow-up, and patients who received topical NSAIDs. Pseudophakic CME was defined as new or worsening macular edema on optical coherence tomography within the first 3 months after cataract extraction. RESULTS: In total, 1135 patient charts were included in the analysis; 721 patients were treated with prednisolone acetate, and 414 were treated with dexamethasone. Patient characteristics were similar between the 2 treatment groups. No significant difference was found in the rate of postoperative CME for patients receiving prednisolone or dexamethasone (4.0% vs 4.1%, p = 0.94). CONCLUSIONS: There was no significant difference in the rate of pseudophakic CME when either prednisolone acetate or dexamethasone sodium phosphate was used after cataract surgery.

Isolated Abducens Palsy Heralding Occult Human Immunodeficiency Virus-Related Lymphoma.

A 40-year-old African American man with recently diagnosed Human Immunodeficiency Virus (HIV) presented with isolated left abducens palsy. Initial neuro-imaging and laboratory evaluation, including cerebrospinal fluid (CSF) analysis, were unremarkable. Continued search for causative aetiology revealed systemic lymphoma diagnosed ultimately by bone marrow biopsy. Systemic lymphoma is commonly encountered in the HIV patient population, but presentation can be unusual and has been seen, albeit rarely, in the setting of isolated cranial neuropathy. This case demonstrates the often diligent investigation required in the setting of isolated cranial neuropathies in patients with HIV.

Dural Arteriovenous Fistula Presenting with Purely Contralateral Ophthalmic Manifestations.

PURPOSE: To report a case of dural arteriovenous fistula presenting with purely contralateral ophthalmic manifestations. DESIGN: Interventional case report. RESULTS: A 70-year-old male presenting with right-sided proptosis, injection, and choroidal effusions with a completely quiet fellow eye was found to have a left-sided dural arteriovenous fistula. After recognition on cerebral angiography, successful endovascular embolization was achieved, along with complete resolution of the contralateral ocular signs. CONCLUSIONS: Entirely unilateral ocular signs suggestive of an intracranial arteriovenous fistula may herald the presence of a contralateral vascular lesion.

A Case Report of Drug-Induced Myopathy Involving Extraocular Muscles after Combination Therapy with Tremelimumab and Durvalumab for Non-Small Cell Lung Cancer.

Recently developed anti-tumour therapies targeting immune checkpoints include tremelimumab and durvalumab. These agents have incompletely characterised side effect profiles. The authors report a 68-year-old man treated for non-small cell lung cancer (NSCLC) with a combination of tremelimumab and durvalumab. After treatment he developed diplopia, ptosis, fatigue, weakness, and an inflammatory myopathy affecting the extraocular muscles requiring hospitalisation. Electromyography (EMG) testing and muscle biopsy suggested inflammatory myopathy without sign of myasthenia. Within 1 month of withdrawal of cancer therapies and initiation of oral steroid therapy, ocular and systemic symptoms had resolved. This notable adverse effect has not been previously described for these drugs administered singly or in combination, and ophthalmologists should be aware of this presentation in patients treated with these agents.

VISCOELASTIC ASSISTED DRAINAGE OF SUPRACHOROIDAL HEMORRHAGE ASSOCIATED WITH SETON DEVICE IN GLAUCOMA FILTERING SURGERY.

PURPOSE: The purpose of this article is to describe a novel surgical technique for the management of large suprachoroidal hemorrhages associated with the insertion of glaucoma seton devices. METHODS: In this interventional case series, the authors describe six eyes of six patients who had management of suprachoroidal hemorrhage with pars plana choroidal drainage along with simultaneous insertion of viscoelastic into the posterior segment. All patients had a median of 8-month postoperative follow-up. RESULTS: Five of the 6 patients had useful final vision ranging from 20/40 to 20/200. In all cases, the postoperative intraocular pressures did not increase beyond 28 mmHg and responded to aqueous humor suppressants. CONCLUSION: As suprachoroidal hemorrhage can be a devastating complication of glaucoma surgery, the authors report a relatively straightforward surgical technique that can restore ambulatory vision in a high proportion of patients.

Sight-threatening ocular manifestations of acute febrile neutrophilic dermatosis (Sweet's syndrome).

Sweet's syndrome is a primarily dermatologic disorder with many features of systemic inflammation. It is generally characterized by a neutrophilic dermatosis in the setting of fever and an elevated white blood cell count. Inflammation has been described to occur in many organ systems including the lung, bone, liver, spleen, brain and eye. Ocular inflammation is a well-known comorbidity that may occur in the setting of Sweet's syndrome, including conjunctivitis, episcleritis, scleritis, iritis and choroiditis, among other forms. In the current article, we have compiled a series of cases that describe three separate patients who demonstrated a rare form of ocular involvement in Sweet's syndrome, retinal vasculitis. The evidence from these three cases and other reports in recent ophthalmologic literature suggest overlapping of ocular manifestations of Sweet's syndrome and the closely related Behçet's disease. It is important to be aware of the sometimes challenging differential between these two disorders and their sight-threatening complications.

Semantic and subword priming during binocular suppression.

In general, stimuli that are familiar and recognizable have an advantage of predominance during binocular rivalry. Recent research has demonstrated that familiar and recognizable stimuli such as upright faces and words in a native language could break interocular suppression faster than their matched controls. In this study, a visible word prime was presented binocularly then replaced by a high-contrast dynamic noise pattern presented to one eye and either a semantically related or unrelated word was introduced to the other eye. We measured how long it took for target words to break from suppression. To investigate word-parts priming, a second experiment also included word pairs that had overlapping subword fragments. Results from both experiments consistently show that semantically related words and words that shared subword fragments were faster to gain dominance compared to unrelated words, suggesting that words, even when interocularly suppressed and invisible, can benefit from semantic and subword priming.