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PURPOSE: To investigate the effects of faricimab, a bispecific antibody targeting VEGF and Ang-2 (thus increasing Tie-2 activity), in patients with CSC based on a recent genetic study that implicated Tie-2 signaling in CSC pathophysiology. DESIGN: A retrospective interventional multicenter case series. METHODS: We included patients with chronic CSC (persistent or recurrent SRF for ≥6 months) who received at least one faricimab 6mg injection between January 1 2022 and April 1 2024. Study sites included Massachusetts Eye and Ear and University of California San Francisco. Patients with evidence of a choroidal neovascular membrane on color photos, optical coherence tomography (OCT) and/or fluorescein angiography were excluded. 16 eyes (15 patients) met the inclusion criteria. The median central macular thickness at each visit from 52 weeks before to 52 weeks after the first faricimab injection was calculated using automated Heidelberg Spectralis ETDRS subfield measurements. RESULTS: Prior to treatment with faricimab, CSC had been diagnosed a median of 4.1 years (range 0.9-8) earlier and SRF (and intraretinal fluid [IRF] in a subset) had been continuously present for a median of 30 weeks (range 9-257). Decreases in macular thickness were observed in 14/16 eyes after the first faricimab injection and in 14/16 eyes in the full follow-up period compared with prior, 10 of which experienced complete resolution of SRF following the start of the first series of injections at a median of 4 weeks (range 2-25). One eye worsened after the second injection. The median improvement in macular thickness was 40µm [range -3 to 89.5] (P=0.0007). Upon review of OCT images, reductions in macular thickness were consistent with reductions in SRF and/or IRF. Visual acuity improved by 2 lines or more in 6/16 eyes. CONCLUSIONS: In a retrospective case series of patients with chronic CSC and longstanding SRF, we observed improvement in macular thickness after intravitreal faricimab. While the small number of patients and variable natural history of CSC preclude definitive conclusions, a randomized controlled trial seems warranted.
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Improving access to comfortable and well-fitting glasses for children with craniofacial differences may improve their visual outcomes. The purpose of this study was to describe challenges in spectacle fitting facing patients with frontonasal dysplasia and to report successful methods for creating custom 3D designed glasses. Additionally, the process of systematically collecting and analyzing spectacle-fitting challenges can inform future processes of automated design of 3D printed glasses and can be applied to other specific craniofacial syndromes.
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Anormalidades Craniofaciais , Óculos , Criança , Humanos , Face , Anormalidades Craniofaciais/terapiaRESUMO
BACKGROUND/PURPOSE: Visualization of peripheral retinal structures with optical coherence tomography (OCT) can be challenging but can offer valuable clinical information. We describe a method for intraoperative OCT of the peripheral retina. METHODS: An investigational microscope-integrated OCT system with real-time 4D volumetric imaging was used in conjunction with a Goldmann style mirrored contact lens intraoperatively to capture peripheral images in three patients. RESULTS: We identified retinoschisis, a retinal break, and areas of focal retinal detachment using our peripheral OCT method. CONCLUSION: Use of a Goldmann lens in conjunction with intraoperative OCT offers surgeons the ability to resolve peripheral pathology that cannot be easily evaluated with OCT otherwise.
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Descolamento Retiniano , Perfurações Retinianas , Retinosquise , Humanos , Tomografia de Coerência Óptica/métodos , Retina/diagnóstico por imagem , Retina/patologia , Descolamento Retiniano/patologia , Retinosquise/patologia , Perfurações Retinianas/patologiaRESUMO
A 28-year-old woman presented to the emergency department with a 5-day history of bilateral blurry vision, eye redness, discharge, photophobia, and pain. There were more than 20 cells per high-power field of 1 mm × 1 mm beam, with fibrin bilaterally and 2.5-mm hypopyon in the right eye and 2.7-mm hypopyon in the left eye. What would you do next?
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Supuração , Feminino , HumanosRESUMO
Purpose: To evaluate the holistic cost of longer acting anti-VEGF therapy for macular degeneration when considering the associated costs of travel to the retina clinic. Design: Theoretical evaluation of cost using publicly available pricing data and reimbursements at the Veterans Affairs (VA) Medical Center. Patients and Methods: Setting: VA Medical Center. Study population: Patients with age related macular degeneration. Main outcome measures: Three-year cost of therapy when considering medication as well as travel costs and time spent in transit. Results: Based on cost data derived purely from wholesale acquisition cost and projected injection frequency over the first three years of treatment, faricimab is less expensive than ranibizumab and aflibercept by $37,709 and $6359, respectively. Aflibercept is less expensive ranibizumab by $31,350 over the first 3 years of treatment. When considering even small distances traveled by patients, these cost differences grow, amplified at even larger distances: at 25 miles, ranibizumab becomes $38,814 and $32,133 more expensive than faricimab and aflibercept, respectively. Aflibercept becomes $6681 more expensive than faricimab. At 100 miles, ranibizumab becomes $41,502 and $34,038 more expensive than faricimab and aflibercept, respectively. Aflibercept becomes $7464 more expensive than faricimab. Conclusion: Longer acting anti-VEGF therapies may differ not only in their wholesale acquisition cost, but also in the frequency of per label injections and associated clinic visits. Taking into account distance and time cost of travel may contribute to a more holistic view of cost differences among these therapies.
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Importance: Finding a suitable fit in glasses for pediatric patients with congenital and acquired craniofacial abnormalities is difficult; consequently, these children are at high risk of vision loss secondary to refractive amblyopia as they often have poor adherence to daily glasses wearing. Custom 3-dimensional (3D)-printed glasses may have an improved design and fit, but access is limited by the availability of computed tomography and magnetic resonance imaging (MRI). Objective: To describe a method for using a commercially available smartphone 3D surface imaging (3DSI) technique to capture facial anatomy as a basis for custom glasses design. Design, Setting, and Participants: This quality improvement study analyzes data from a case series in a primary academic center with multiple referral centers throughout the United States. The evaluation included reported fit descriptions from patients with poor glasses adherence due to craniofacial abnormalities. Main Outcomes and Measures: Key anatomic parameters for glasses fit (face width, distance from ear bridge to nasal bridge, distance from center of pupil to center of nasal bridge, distance from lateral to medial canthus, ear vertical offset, and nasal bridge width) were compared between scans. A 3DSI scan was considered successful if these key parameters could be determined and the difference in measurements was less than 5% between MRI and 3DSI. A second outcome measure included the fit of glasses designed by the 3DSI method as reported by the patient, parent, or guardian. Results: Measurements of key parameters for glasses fit were similar across MRI and 3DSI scans with a mean (SD) difference of 1.47 (0.79) mm between parameters (range, 0.3-4.60 mm). Among 20 patients aged 1 to 17 years with craniofacial abnormalities, all achieved a successful fit (reporting daily glasses adherence without irritation) as judged by the patient, parent, or guardian. A mean of 1.7 revisions were made from initial prototype to final frame production using 3DSI technology. Conclusions and Relevance: This study demonstrated that smartphone-enabled 3DSI coupled with widely available 3D printing technology can produce custom frames with a successful fit for patients with craniofacial anomalies. This accessible and well-tolerated imaging process may have implications for adherence with glasses wearing among patients at risk of vision loss due to amblyopia.
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Ambliopia , Anormalidades Craniofaciais , Humanos , Criança , Óculos , Smartphone , Imageamento Tridimensional , Transtornos da VisãoRESUMO
PURPOSE: To investigate the clinical outcomes of methicillin-resistant Staphylococcus aureus (MRSA) endophthalmitis. METHODS: Clinical courses were reviewed for 17 eyes (15 patients) with endogenous MRSA endophthalmitis based on positive blood and vitreous culture or clinical suspicion between 2013 to 2019 at Duke University Hospitals. RESULTS: Of 17 eyes, initial VA ranged from 20/40 to light perception. Of 15 patients, 9 had predisposing risk factors for bacteremia. All eyes received intravitreal vancomycin, 13 also received ceftazidime, and 2 also received amikacin instead of ceftazidime. Nine eyes developed retinal detachment; 6 underwent vitrectomy. Final VA ranged from 20/20 to no light perception and was ≥20/200 in 8 eyes. Eleven eyes had improved VA, 2 eyes were unchanged, and 4 were worse. CONCLUSIONS: This study is the largest series on endogenous MRSA endophthalmitis to date. Patients had a higher proportion of final VA ≥20/200, similarly high rate of RD, and fewer enucleations compared to prior reports.
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Staphylococcus aureus Resistente à Meticilina , Humanos , Centros de Atenção TerciáriaRESUMO
The force required for trocar insertion in hypotonous eyes can cause significant deformation of the globe and result in an iatrogenic injury to the lens, posterior capsule, or retina from the sharp trocar tip. We developed a device designed to stabilize the globe and provide counterpressure without significant globe deformation during trocar insertion. Our novel device was modeled using computer-aided design software, three-dimensional (3D) printed, and validated in an ex vivo porcine model. The risk of trocar-retinal touch was evaluated by comparing the distance between the trocar tip and opposing retina with either a cotton swab or our 3D printed device. We found an increased distance between the retina and trocar tip at the time of trocar insertion using our novel device: 3.3 ± 1.3 mm (P = 0.035), suggesting an improved safety margin. This device has the potential to improve the safety of trocar insertion in eyes at risk of trocar-associated injury, including hypotonous, previously vitrectomized, and nanophthalmic eyes.
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Instrumentos Cirúrgicos , Animais , SuínosRESUMO
Handheld optical coherence tomography (OCT) makes it possible to acquire intraoperative and clinical imaging in infants and children for whom standard OCT is not possible. In patients with a retinal pathology who are left aphakic after surgery, however, image clarity is affected by insufficient refractive correction with handheld OCT. We describe a technique for supplementing the refractive power of the handheld OCT device with an aphakic contact lens to improve image clarity.
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Lentes de Contato , Tomografia de Coerência Óptica , Criança , Humanos , Lactente , RetinaRESUMO
PURPOSE: Invasive fungal sinusitis is a rare but potentially lethal disease that primarily affects immunocompromised patients. The purpose of this study was to review an academic medical center's experience in the presentation, diagnosis, and treatment of invasive fungal sinusitis. METHODS: A retrospective chart review was performed at a single institution over a 17-year period. Medical records, radiographic imaging, and operative reports were analyzed. Bivariate and multivariable analyses were performed to determine factors that affected visual acuity outcomes and mortality. RESULTS: Fifty-five patients with histopathologically confirmed invasive fungal sinusitis were included. The average duration of follow up was 1.8 ± 2.6 years (range: 1 week to 10 years). The most common causes of immunosuppression were hematologic malignancy (45%), diabetes (31%), and organ transplantation (9%). At presentation, 35% of individuals were neutropenic (absolute neutrophil count < 500/µl). All patients received systemic antifungal treatment. A surgical intervention was performed on 50 patients (91%), and all but one had functional endoscopic sinus surgery. Nine (16%) patients underwent orbital exenteration. Multivariable analysis of visual acuity outcomes demonstrated that individuals infected with Zygomycota had 6-7 lines worse vision than those infected with Ascomycota (mean difference in logMAR 0.66, 95% confidence interval 0.27 to 1.06, p = 0.001). Patients who had functional endoscopic sinus surgery had 7-8 lines better visual acuity than those without functional endoscopic sinus surgery (mean difference in logMAR -0.76, 95% confidence interval -1.13 to -0.38, p < 0.001). The overall death rate due to infection was 24%. Bivariate models demonstrated no difference in mortality in patients receiving exenteration versus those who did not (p = 0.14). Multivariable analysis of mortality demonstrated that neutropenia increased mortality (adjusted odds ratio 10.05, 95% confidence interval 1.49 to 67.67, p = 0.02). Having a greater number of surgeries was associated with an increased rate of survival (adjusted odds ratio 0.39, 95% confidence interval 0.15 to 0.96, p = 0.04). CONCLUSIONS: Invasive fungal sinusitis is an aggressive disease with significant mortality. Patients with neutropenia had a lower rate of survival, and infection with Zygomycota was associated with worse visual acuity outcomes. Those having functional endoscopic sinus surgery had better final visual acuity, and an increased number of surgeries was associated with a decreased chance of death. Exenteration yielded no observed survival benefit.Endoscopic sinus debridement portends better visual acuity outcomes in patients with invasive fungal sinusitis, whereas exenteration yields no difference in survival benefit.
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Infecções Fúngicas Invasivas/mortalidade , Sinusite/microbiologia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Análise Multivariada , Estudos Retrospectivos , Fatores de Risco , Sinusite/mortalidade , Acuidade VisualRESUMO
Children with craniofacial malformations frequently require spectacles but have difficulty finding an acceptable fit with current offerings of pediatric spectacle frames. We describe a novel method for creating custom 3D-printed spectacle frames based on a 3D reconstruction of a prior computed tomography scan. This method offers the ability to create better-fitting spectacles to children who are not served by "off the rack" frames.
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Anormalidades Craniofaciais/complicações , Anormalidades Craniofaciais/terapia , Óculos , Imageamento Tridimensional/métodos , Impressão Tridimensional , Erros de Refração/terapia , Tomografia Computadorizada por Raios X/métodos , Pré-Escolar , Desenho de Equipamento , Feminino , Humanos , Refração Ocular/fisiologia , Erros de Refração/etiologia , Erros de Refração/fisiopatologiaAssuntos
Retinopatia Diabética/diagnóstico , Hipertensão Maligna/diagnóstico , Papiledema/diagnóstico , Gravidez em Diabéticas/diagnóstico , Transtornos da Visão/diagnóstico , Doença Aguda , Pressão Sanguínea/fisiologia , Diabetes Mellitus Tipo 1/diagnóstico , Retinopatia Diabética/fisiopatologia , Feminino , Frequência Cardíaca/fisiologia , Humanos , Hipertensão Maligna/fisiopatologia , Papiledema/fisiopatologia , Gravidez , Gravidez em Diabéticas/fisiopatologia , Taxa Respiratória/fisiologia , Transtornos da Visão/fisiopatologia , Acuidade Visual/fisiologia , Adulto JovemRESUMO
Normal development of the visual system in infants relies on clear images being projected onto the retina, which can be disrupted by lens opacity caused by congenital cataract. This disruption, if uncorrected in early life, results in amblyopia (permanently decreased vision even after removal of the cataract). Doctors are able to prevent amblyopia by removing the cataract during the first several weeks of life, but this surgery risks a host of complications, which can be equally visually disabling. Here, we investigated the feasibility of focusing light noninvasively through highly scattering cataractous lenses to stimulate the retina, thereby preventing amblyopia. This approach would allow the cataractous lens removal surgery to be delayed and hence greatly reduce the risk of complications from early surgery. Employing a wavefront shaping technique named time-reversed ultrasonically encoded optical focusing in reflection mode, we focused 532-nm light through a highly scattering ex vivo adult human cataractous lens. This work demonstrates a potential clinical application of wavefront shaping techniques.
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Catarata/diagnóstico por imagem , Cristalino/diagnóstico por imagem , Adulto , Idoso , Ambliopia/diagnóstico por imagem , Animais , Galinhas , Humanos , Masculino , Óptica e Fotônica , Retina/diagnóstico por imagem , Espalhamento de RadiaçãoRESUMO
PURPOSE: Reducing surgery-related patient anxiety without under-emphasizing surgical risk is challenging for even the most experienced surgeon. The purpose of this study is to identify specific anxieties faced by patients in hopes of better informing the preoperative surgeon-patient dialogue. SETTING: Comprehensive and specialty ophthalmology clinics at the University of California, San Francisco. DESIGN: A prospective, survey-based study in which a pre- and postoperative questionnaire was administered to patients undergoing routine phacoemulsification. The surgeon was masked to patient enrollment and questionnaire responses. MATERIALS AND METHODS: A 36-item questionnaire on patient anxiety was developed from existing literature, building on the validated Surgical Fear Questionnaire. Patients were eligible if they were aged >18 years and willing to participate. Patients were excluded if having more than phacoemulsification alone or if unable to respond in English, and were retroactively excluded if there were complications during surgery. The primary outcome was self-reported anxiety on an 11-point Likert scale. RESULTS: Sixty-one patients were included for analysis. Preoperatively, patients reported greatest anxiety around the operation itself and becoming blind. Reflecting postoperatively, patients reported the greatest anxiety for the operation itself. Statistically significant decreases were greatest for anxiety about the operation failing (p<0.001) and becoming blind (p<0.001). No decrease was observed for the operation itself (p=0.1). CONCLUSION: More effort must be made to specifically discuss the steps of the operation itself and the expected visual outcomes to alleviate patient anxiety. The authors hope these data can provide insight for surgeons into patient anxiety surrounding cataract surgery and help strengthen the patient-physician relationship.
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INTRODUCTION: Repair of retinal detachment frequently requires use of intraocular gas. Patients are instructed to position themselves postoperatively to appose the intraocular bubble to the retinal break(s). We developed a novel wearable wireless positioning sensor, which provides real-time audiovisual feedback on the accuracy of positioning. METHODS: Eight healthy volunteers wore the wireless sensor for 3 hours while instructed to maintain their head tilted toward the 2 o'clock meridian with no audiovisual feedback. Positioning accuracy was recorded. The subjects repeated the experiment for 3 hours with the audiovisual feedback enabled. RESULTS: With no audiovisual feedback, the percentage of time greater than 10° out of position varied from 8.9% to 93.9%. With audiovisual feedback enabled, these percentages ranged from 9.4% to 65%. Three subjects showed significant improvement in their time out of position (P<0.01, Fisher's exact test). Four subjects demonstrated a nonsignificant improvement, and one subject had a significant increase in time out of position with feedback (P<0.01). When pooled, all subjects demonstrated a statistically significant decrease in degrees out of position (P<0.001, Wilcoxon test) and a statistically significant improvement in total time out of position (P<0.001). CONCLUSION: The novel positioning sensor showed improved positioning compliance in half of the healthy volunteers during our short pilot study. Other subjects derived little benefit from the feedback. The causes for this observation are unclear. However, given the significant improvement as a group, this new technology could be beneficial to patients who struggle with postoperative positioning.
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A 68-year-old immunocompromised man with rhino-orbital-cerebral mucormycosis was treated with retrobulbar injections of amphotericin B deoxycholate in conjunction with intravenous antifungals and endoscopic sinus debridement. Transient episodes of orbital inflammation were noted after retrobulbar injections, but progression of orbital infection was halted and visual acuity restored with eventual hospital discharge. To the authors' knowledge, clearance of orbital mucormycosis with retrobulbar amphotericin B injections has not been previously reported. This intervention may be a viable therapeutic option in cases of orbital mucormycosis where aggressive orbital debridement is not favored and/or the burden of orbital disease is not substantial. However, physicians should be aware of the risk of transient orbital inflammation secondary to retrobulbar amphotericin B deoxycholate.
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Anfotericina B/administração & dosagem , Infecções Oculares Fúngicas/tratamento farmacológico , Hospedeiro Imunocomprometido , Mucormicose/tratamento farmacológico , Doenças Orbitárias/tratamento farmacológico , Idoso , Antifúngicos/administração & dosagem , Endoscopia , Infecções Oculares Fúngicas/diagnóstico , Seguimentos , Humanos , Injeções Intraoculares , Imageamento por Ressonância Magnética , Masculino , Mucormicose/diagnóstico , Doenças Orbitárias/diagnóstico , Acuidade VisualRESUMO
BACKGROUND: Chlorhexidine skin preparation has been shown to provide highly effective antimicrobial presurgical skin cleansing. However, there is a significant risk of ocular toxicity when it is used in periocular areas. CASE DESCRIPTION: We describe 2 cases of significant corneal damage resulting from 4% chlorhexidine gluconate preoperative skin cleanser, despite the use of protective occlusive dressing over the eyes. Because of the potential for severe corneal toxicity resulting from use of chlorhexidine, alternative agents such as 10% povidone-iodine should be considered for skin preparation near periocular areas whenever possible. CONCLUSIONS: If chlorhexidine gluconate must be employed near periocular areas, great care must be exercised to avoid contact with the eyes, and additional protective measures (e.g., absorbent eye pads along with tightly occlusive dressings) must be used whenever possible.