Feasibility Analysis of Teleophthalmology Diagnosis and Referral in Remote Areas of Taiwan.

Background: Remote areas of Taiwan lack routine and specialized ophthalmology services. This study aimed to analyze feasibility of teleophthalmology service for diseases diagnosis and referral in remote areas of Taiwan. Methods: A retrospective study of medical records from 11 remote teleophthalmology clinics in the Taitung area of Taiwan was conducted from May 2020 to December 2021. Vision and intraocular pressure were checked. Ophthalmic imaging was performed by local trained nurses using a hand-held ophthalmoscope and slit lamp biomicroscope. The images were transmitted by telemedicine system to a medical center. Consultation was conducted via face-to-face real-time video calls. Ophthalmologists in the medical center provided diagnosis and treatment advice based on the real-time images and interactive history taking via the telemedicine system. All the images and data were collected and well-reviewed by ophthalmologists in the medical center, and disease prevalence and referral were analyzed for the program. A small-scale satisfaction questionnaire survey was conducted for efficacy evaluation of the program. Results: A total of 1,401 medical records from 1,094 patients were collected and screened. Patients' ages ranged from 9 months to 94 years, with a mean age of 57.27 (standard deviation ±20.47) years. The most frequent ophthalmologic diagnosis was dry eye disease (20.2%), followed by conjunctivitis (12.4%). Among 322 patients with underlying diseases of diabetes mellitus, 59 patients (18.3%) were diagnosed with diabetic retinopathy. Major diagnosis was made in 102 patients (7.3%) and referral to hospital for further management was suggested. This program had high overall satisfaction score of 89% (mean 4.43 ± 0.52 points) in satisfaction questionnaire survey. Conclusion: Teleophthalmology provides an alternative tool for ocular disease diagnosis and screening for patients in remote areas, especially during the COVID-19 pandemic. This service helps to detect major but undiagnosed diseases and promotes health care accessibility and availability in remote areas that lack specialists.

Diagnosing Fungal Keratitis and Simultaneously Identifying Fusarium and Aspergillus Keratitis with a Dot Hybridization Array.

Fungal keratitis (FK) is one of the most common microbial keratitis, which often leads to poor prognosis as a result of delayed diagnosis. Several studies implied that early differentiation of the two major FK, Fusarium and Aspergillus keratitis, could be helpful in selecting effective anti-fungal regimens. Therefore, a novel dot hybridization array (DHA) was developed to diagnose FK and differentiate Fusarium and Aspergillus keratitis in this study. One hundred forty-six corneal scrapes obtained from one hundred forty-six subjects impressed with clinically suspected FK were used to evaluate the performance of the DHA. Among these patients, 107 (73.3%) patients had actual FK confirmed by culture and DNA sequencing. We found that the DHA had 93.5% sensitivity and 97.4% specificity in diagnosing FK. In addition, this array had 93.2% sensitivity and 93.8% specificity in diagnosing Fusarium keratitis, as well as 83.3% sensitivity and 100% specificity in diagnosing Aspergillus keratitis. Furthermore, it had 83.9% sensitivity and 100% specificity in identifying Fusarium solani keratitis. Thus, this newly developed DHA will be beneficial to earlier diagnosis, more precise treatment, and improve prognosis of FK, by minimizing medical refractory events and surgical needs.

The association between cataract and sleep apnea: a nationwide population-based cohort study.

STUDY OBJECTIVES: The association between sleep apnea (SA) and cataract was confirmed in a comprehensive large-scale study. This study aimed to investigate whether SA was associated with increased risk of cataract. METHODS: The 18-year nationwide retrospective population-based cohort study used data retrieved from the Taiwan National Health Insurance Database. We selected adult patients with a diagnosis of SA, based on diagnostic codes (suspected SA cohort) or on presence of diagnosis after polysomnography (SA cohort), and matched each of them to 5 randomly selected, and age- and sex-matched control participants. The incidence rate of cataract was compared between patients with SA and the controls. The effect of SA on incident cataract was assessed using multivariable Poisson regression and Cox regression analyses. RESULTS: A total of 6,438 patients in the suspected SA cohort were matched with 32,190 controls (control A cohort), including 3,616 patients in the SA cohort matched with 18,080 controls (control B cohort). After adjusting for age, sex, residency, income level, and comorbidities, the incidence rates of cataract were significantly higher in the SA cohorts than in the corresponding control cohorts. SA was an independent risk factor for incident cataract (adjusted hazard ratio [95% confidence interval]: 1.4 [1.2-1.6]). In patients with SA, elder age, heart disease, chronic pulmonary disease, and diabetes mellitus were independent risk factors for incident cataract. CONCLUSIONS: Our study revealed a significantly higher risk for developing cataract in patients with SA. Physicians caring for patients with SA should be aware of this ophthalmic complication. CITATION: Liu P-K, Chang Y-C, Wang N-K, et al. The association between cataract and sleep apnea: a nationwide population-based cohort study. J Clin Sleep Med. 2022;18(3):769-777.

Toxicity of amantadine hydrochloride on cultured bovine cornea endothelial cells.

Amantadine hydrochloride (HCl) is commonly prescribed for treating influenza A virus infection and Parkinson's disease. Recently, several studies have indicated that the use of amantadine HCl is associated with corneal edema; however, the cytotoxic effect of amantadine HCl has not been investigated. In the present study, the effects of amantadine HCl on cell growth, proliferation, and apoptosis in bovine cornea endothelial cells, and in vitro endothelial permeability were examined. Results showed that lower doses of amantadine HCl do not affect cell growth (≤ 20 µΜ), whereas higher doses of amantadine HCl inhibits cell growth (≥ 50 µΜ), induces apoptosis (2000 µΜ), increases sub-G1 phase growth arrest (2000 µΜ), causes DNA damage (≥ 1000 µΜ), and induces endothelial hyperpermeability (≥ 1000 µΜ) in bovine cornea endothelial cells; additionally, we also found that amantadine HCl attenuates the proliferation (≥ 200 µΜ) and arrests cell cycle at G1 phase (≥ 200 µΜ) in bovine cornea endothelial cells. In the present study, we measured the cytotoxic doses of amantadine HCl on cornea endothelial cells, which might be applied in evaluating the association of corneal edema.

Presumed cytomegalovirus retinitis in a non-immune compromised patient with breast carcinoma during treatment: A case report.

PURPOSE: Cytomegalovirus (CMV) retinitis is one of the most common opportunistic infections in immunocompromised patients, including patients with acquired immunodeficiency syndrome (AIDS). CMV retinitis in non-human immunodeficiency virus (HIV)-infected patients has been reported with variable presentations. Significant intraocular inflammation is common, and visual prognosis is poor if not properly managed. OBSERVATIONS: We present a case of presumed CMV retinitis in a non-immunocompromised breast cancer patient that occurred during cancer treatment. The ocular symptoms developed one day after partial mastectomy with intra-operative radiotherapy following five months of chemotherapy treatment. Ocular manifestations included panuveitis with mild peripheral retinitis. CONCLUSIONS AND IMPORTANCE: Early diagnosis and prompt treatment with oral valganciclovir based on the clinical manifestation and serologic test findings helped to preserve vision.

Chinese medicine, Gui Lu Er Xian Jiao - related serous retinal detachment 2nd to circumscribed choroidal hemangioma a case report.

PURPOSE: Circumscribed choroidal hemangioma is a rare condition where there is development of benign vascular tumors, and it generally appears in middle-aged adults. Here we report a case of Chinese medicine, Gui Lu Er Xian Jiao - related serous retinal detachment secondary to circumscribed choroidal hemangioma. OBSERVATIONS: A 55-year-old female, who had no remarkable ocular or medical history but has been taking a special Chinese compound medicine, Gui Lu Er Xian Jiao, for the past 2 years, presented with progressive blurred vision in the left eye for weeks. After serial ocular examinations, serous retinal detachment 2nd to circumscribed choroidal hemangioma was disclosed. Owing to the close timing association with medication history of Gui Lu Er Xian Jiao, we advised her to discontinue the Chinese medicine first. The serous retinal detachment resolved completely without any other management. CONCLUSIONS AND IMPORTANCE: The content of Gui Lu Er Xian Jiao has been reported to have angiogenesis effect, which possibly change the vascular permeability and induce the serous retinal detachment and therefore blurred vision in our patient. To the best of our knowledge, this is the first report on such relationship between Gui Lu Er Xian Jiao and serous retinal detachment 2nd to circumscribed choroidal hemangioma. The case report highlighted the importance of detailed history taking in the management of ocular diseases.

A Review of Local Therapy for the Management of Cystoid Macular Edema in Uveitis.

ABSTRACT: Uveitic macular edema is a significant cause of visual impairment in most uveitis types. Treatment options of uveitis have advanced remarkably in recent years. Up to now, corticosteroids remain the mainstay of treatment. Nonsteroidal immunomodulators, and recently the biologic agents, which can reinforce efficacy and enable discontinuation or reduction of steroids to maintenance doses, are becoming increasingly popular in the management of uveitic macular edema. Several medications can be used in intraocular delivery and more and more sustained releasing implants are being developed. This review will briefly focus on the review of local therapy for the management of cystoid macular edema in uveitis, as many of these novel approaches are currently being evaluated in clinical trials.

Corneal burn injury in picosecond laser treatment: A potential hazard in cosmetic therapy.

Key PointsWithout appropriate protection, cosmetic laser treatments can cause severe ocular side effects and permanent visual impairment. We present this case to emphasize the importance of ocular protection during the entire treatment period, especially treatments of lesions over the eyelids. According to our knowledge and database search, this is the first reported ocular injury caused by picolaser.

Comparison of fungal and bacterial keratitis between tropical and subtropical Taiwan: a prospective cohort study.

BACKGROUND: Fungal keratitis (FK) has been shown to be a climate-sensitive disease. The differentiation between FK from bacterial keratitis (BK) was difficult. The purpose of this study was to compare the bacteriology and mycology between tropical and subtropical Taiwan and to investigate the independent risk factors for identification of fungi from bacteria. METHODS: Two hundred ninety-seven patients with clinical suspected microbial keratitis were prospectively enrolled. A fungal to bacteria rate (FBR), the number of fungi divided by bacteria identified, was determined to estimate the prevalence of fungi and bacteria. Clinical presentation, profiles of microorganisms, and predisposing risk factors were determined. Univariate and multivariate logistic regression analysis were used to investigate the independent risk factors. RESULTS: A total of 82 fungi and 143 bacteria were laboratory confirmed. The identification rate of fungus was higher in tropical Taiwan (p = 0.010). Among the fungi and bacteria confirmed, the FBR was 0.29 (22.4% vs. 77.6%) in subtropical Taiwan, and 0.70 (41.3% vs. 58.7%) in tropical Taiwan. Samples obtained in tropical area (p = 0.019), ocular trauma (p = 0.019), and plant exposure (p = 0.003) were independent risk factors for identification of fungus from bacteria. The predominant fungus isolated from corneal scraping were Fusarium solani (25%) and Trichosporon faecale (25%) in subtropical Taiwan; in tropical Taiwan was Fusarium spp. (50%). CONCLUSIONS: The identification rate of fungus was higher in tropical Taiwan than subtropical Taiwan. Awareness of the local epidemiology is crucial for early diagnosis of fungal keratitis in tropical area.

An Omics Approach to Diagnosing or Investigating Fungal Keratitis.

Fungal keratitis (FK) is one of the most severe corneal infectious diseases. FK often leads to poor visual prognosis and thus requires accurate diagnosis. Conventional approaches, including clinical diagnoses, smears, and cultures, often fail to provide reliable diagnostic value. Omics approaches, such as those using genomic, metagenomic, and tear proteomic data sources, provide promising features for improving the diagnosis and monitoring the progression of FK. Genomic approaches are based mainly on detecting amplicons of ribosomal RNA genes, and internal transcribed spacers are gradually gaining popularity in clinical practices. A metagenomic approach based on 16S rRNA genes may help monitor the dynamic change of conjunctival microbiota associated with an FK event, whereas that based on shot-gun and 18S rRNA target enrichment sequencing could have the potential to diagnose FK using clinical samples. A tear proteomic approach may provide comprehensive information about ocular surface defense and injury during FK. Representative up- and down-regulated proteins during FK could also be used as biomarkers to determine the clinical course and develop a treatment strategy in different stages of FK. Consequently, a personalized tear proteomic approach will soon play a key role in FK management.

A simple method for preventing graft detachment during phacoemulsification cataract surgery after Descemet stripping automated endothelial keratoplasty: A case report.

RATIONALE: Graft detachment and endothelial cell damages are 2 major concerns for cataract surgeries in cases after Descemet stripping automated endothelial keratoplasty (DSAEK). We invented a simple but innovative method to anchor the DSAEK graft with sutures during the surgery to avoid possible graft detachment. PATIENT CONCERNS: We present a 59-year-old male who had done DSAEK surgery. Due to progressed blurry vision due to cataract, he underwent sequential cataract surgery 1 year after DSAEK surgery. We applied the method to the patient successfully and the result was satisfying. DIAGNOSIS: Cataract post-DSAEK surgery. INTERVENTIONS: At the beginning of surgery, we made 4 radial fixation sutures with Nylon 10-0 though cornea-DSAEK graft at paracentral point and then through limbus. The sutures were located at 45°, 135°, 225°, and 315°. At the end of surgery, 4 fixation sutures were removed. OUTCOMES: The DSAEK graft was kept well attached during and after the surgery. Only low-grade corneal edema was found postoperation. LESSONS: We provide this special method and applied it to our patient successfully. By using our method, surgeons can reassure graft adhesion during and after surgery, especially for those need cataract surgery after DSAEK surgery.

Molecular Bioburden of the Lens Storage Case for Contact Lens-Related Keratitis.

PURPOSE: To elucidate the bioburden of a lens care system in patients with contact lens (CL)-related keratitis. METHODS: In this prospective case-control study, the CL storage case was used as the target of bioburden assessment. Participants were CL wearers with (n = 26) or without (n = 24) keratitis in southern Taiwan. The case fluid sample was consecutively collected and assessed using a dot hybridization assay (DHA) for bioburden assessment. The DHA was composed of 3 universal bacterial probes for detecting all bacteria, genus-specific probes for Pseudomonas and Acinetobacter, and 1 probe for Acanthamoeba. The receiver operating characteristic curve was used to analyze the differentiating performance of a probe. RESULTS: The storage case bioburden was significantly higher in those with CL-related keratitis than in control subjects; patients with CL-related keratitis had stronger standardized signals in all universal bacterial probes. Moreover, in the cases of these patients, the bioburden was significantly heavier in confirmed infectious keratitis than in presumed noninfectious keratitis. Receiver operating characteristic analysis showed that stronger signals in all 3 universal bacterial probes and the Pseudomonas probe might suggest that the wearers have infectious keratitis. Only the storage case of the Acanthamoeba keratitis case showed positive detection by the Acanthamoeba probe. CONCLUSIONS: A heavier bioburden in the lens storage case was associated with a higher risk of CL-related keratitis and infectious keratitis. Inappropriate maintenance of the CL will lead to microbial contamination and transfer the pathogen onto the ocular surface causing keratitis accordingly. The DHA assessment for the lens storage case might provide an alternative way to differentiate infectious from noninfectious CL-related keratitis.

Amantadine Use as a Risk Factor for Corneal Edema: A Nationwide Cohort Study in Taiwan.

PURPOSE: To evaluate the association between amantadine use and corneal toxicity in a nationwide population. DESIGN: Retrospective cohort study of nationwide population-based administrative database. METHODS: This study analyzed data in the Taiwan Longitudinal Insurance Database for a group of 8195 patients diagnosed with Parkinson disease during a 15-year period (January 1, 1996 to December 31, 2010). A control group of 8195 patients without Parkinson disease was randomly matched with the Parkinson group by age, sex, and comorbidity index. The Kaplan-Meier method was used to calculate the cumulative incidence of corneal edema. Incident rate ratios and Cox proportional hazard regressions were estimated to compare the risk of corneal edema. The same methods were then used to compare the risk between patients with and without amantadine treatment. RESULTS: The incidence of corneal edema in the Parkinson group (123 patients; 1.50%) was significantly higher than that in the control group (82 patients; 1.0%) (P = .004). The incidence ratio for corneal edema in the Parkinson group vs the controls was 5.77. When the Parkinson group was further subgrouped by use and non-use of amantadine, the hazard ratio for corneal edema was 1.79 times higher in the amantadine subgroup. Analyses of the amantadine subgroup by cumulative dose revealed that the 30-day hazard ratio for corneal edema was 2.05 higher in patients given moderate doses (2000-4000 mg) of amantadine and 2.84 times higher in the subgroup of patients given high doses (>4000 mg). CONCLUSIONS: Amantadine increases the risk of corneal edema in a dose-dependent manner.

Malignant melanoma of the choroid in the eye with oculodermal melanocytosis of a Chinese woman.

In this study, we report a rare case of choroidal melanoma in an eye with oculodermal melanocytosis (Nevus of Ota). A 56-year-old Taiwanese woman with oculodermal melanocytosis in the right eye was found to have an ipsilateral uveal melanoma. Histopathology of the enucleated eye confirmed the diagnosis of malignant choroidal melanoma of mixed cell type. A search of the literature revealed strong evidence that oculodermal melanocytosis can predispose to the development of uveal melanoma in Caucasians. Only seven such cases have been reported in the East Asian population. This is believed to be the first such reported case in a patient of Chinese descent.

Primary ocular caruncular basal cell carcinoma in a Chinese patient.

Although basal cell carcinoma (BCC) is the most common eyelid neoplasm, BCC that originates from the lacrimal caruncle is extremely rare. To the best of our knowledge, only seven cases have been reported and here we report the first documented primary caruncular BCC in an Oriental patient. A 73-year-old Chinese man presented with a telangiectatic, multilobulated, pigmented tumor that measured 5×5 mm, which had arisen from the lacrimal caruncle of the left eye 3 months previously. The patient underwent tumor excision, and histopathological examination revealed BCC. He received adjuvant chemotherapy with intra-arterial methotrexate (30 mg/m(2)). A nodular pigmented BCC recurred in the bulbar conjunctiva close to the original tumor 3 months later, and he underwent a second excision. Bleomycin (8.5 mg/m(2) monthly) was added to the chemotherapy regimen, which was changed to fluorouracil (300 mg/m(2) monthly) 2 months later. The tumor did not recur during follow-up of 22 months. Malignant tumors of the caruncle are infrequent. BCC should be considered in the differential diagnosis of a pigmented caruncular lesion.

Refractive status of mountain aborigine schoolchildren in southern Taiwan.

Myopia is an epidemic health problem in Taiwan's schoolchildren. The prevalence of myopia has been increasing yearly, and the average age at which myopia develops has also become younger. Due to insufficient eye care in remote areas, the refractive status of aboriginal schoolchildren has not been well established. In 2005 and 2006, under the sponsorship of the Bureau of Health Promotion, we surveyed the ocular refraction of aboriginal schoolchildren in southern Taiwan mountain townships. From five primary schools in two townships, 371 children aged from 7 to 13 years of age were enrolled in our study. Refractive status under cycloplegia and subjective visual acuity were obtained. The crude prevalence of myopia (< -0.25 diopter [D]) was 25.6%. Although the prevalence increased with age, the annual change in mean refractive status was slower in the schoolchildren of mountain aborigines. The spherical equivalents of 93% of children were within +/- 1 D. The highest myopia was only -2.50 D. Seven children (1.82%) were refractive amblyopic, for which high hyperopia, astigmatism or anisometropia were the main causes. As aboriginal children were noted to be more myopic in this study than in the past, better eye care should be implemented in these remote areas.

Ptosis as an initial manifestation of orbital lymphoma: a case report.

Ptosis on its own is an infrequent initial manifestation of orbital lymphoma. Orbital lymphoma usually presents as a palpable mass with proptosis, diplopia, and conjunctival ("salmon-pink") swelling. We report here a 62-year-old female patient who presented with right eye ptosis. The initial imaging study showed an indistinct enlargement of the superior rectus-levator muscle complex. After 3-4 months, ptosis and upward gazing movement were further restricted. The imaging study revealed a definite soft-tissue mass in the superior orbit surrounding the superior rectus-levator muscle complex. A tumor biopsy through anterior orbitotomy revealed a large diffuse B-cell lymphoma. With the experience of this case, we suggest that orbital lymphoma should be included in the differential diagnosis of ptosis accompanied by impairment of levator muscle function.

Effect of indocyanine green on the growth and viability of cultured human retinal pigment epithelial cells.

The aim of this study was to evaluate the effects of indocyanine green (ICG), which is a fluorescent dye recently used for staining during manipulation of the internal limiting membrane (ILM) in surgery, on cultured human retinal pigment epithelial (HRPE) cells. Different concentrations, up to 0.25% (weight/volume), of ICG were added to the culture medium, which contained the cultured human RPE cells. Then the cell-growth curve and cell viability were assayed with a direct cell count and MTS cell proliferation kit, respectively. Two (2) models of experimentations, a dose-response group and a short-term application group, were designed. We obtained data for IC(50) values for 24-, 48-, and 72-hour ICG treatments, which were 0.062%, 0.041%, and 0.035%, respectively. This implies that the longer the culture duration, the lower the concentration of ICG, which can inhibit the HRPE cells. In the group of 3-day sequential incubations with ICG treatment, a 0.01% concentration significantly inhibited HRPE growth. In addition, HRPE cells were damaged immediately after ICG treatment, and the damage was ICG dose-related. In the sequential 3-day incubation, compared to the control group, the surviving HRPE cells of each treated group had the same growth rate. In conclusion, ICG has a relatively toxic effect on cultured HRPE cells, even in much lower concentrations than clinical nondilution status (0.25%). Since an ICG toxic effect on HRPE cells was found in our study (in vitro), we highly recommend staining the ILM with as low a concentration of ICG as possible, and washing out the residual intravitreal ICG as thoroughly as possible after finishing the peeling of the ILM.