Localized Recurrence of Multiple Myeloma in the Lacrimal Gland.

The authors report the case of a multiple myeloma recurrence isolated to the lacrimal gland. The patient is a 54-year-old man with a medical history of IgA kappa multiple myeloma status post multiple lines of chemotherapy and stem cell transplantation (×2) who was presumed to be without evidence of disease. Six years following the transplant, he presented with a lacrimal gland tumor with a biopsy consistent with multiple myeloma. Systemic disease evaluation at that time, including positron emission tomography scan, bone marrow biopsy, and serum analysis, were negative. To the best of the authors' knowledge, no prior reports exist describing an isolated lacrimal gland recurrence of multiple myeloma with ultrasound and MRI imaging.

Adverse events associated with femtosecond laser-assisted cataract surgery reported to the MAUDE database.

PURPOSE: To report real-world complications associated with femtosecond laser-assisted cataract surgery (FLACS). SETTING: Deidentified database. DESIGN: Retrospective review. METHODS: The U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database was culled for adverse events involving ophthalmic femtosecond laser during cataract surgery from January 2010 to January 2020. Reports in which the narrative description was inadequate to determine the nature of the complication were excluded. Each report was reviewed for complications, which were subsequently assigned to a complication category as determined by these authors. The number of events per year was determined and compared. RESULTS: Between January 2010 and January 2020, the MAUDE database search yielded 2927 reports involving femtosecond laser, of which 1927 met inclusion criteria and were included for analysis. These reports revealed 2704 complications: 1115 capsule tears (41.2%), 329 of which required vitrectomy, 372 instances of suction loss, 321 other capsulotomy-related complications, and 432 corneal or incisional complications. Rare complications included 54 reports of miosis, 16 reports of endophthalmitis, and 4 reports of toxic anterior segment syndrome. The number of events in the MAUDE database increased year over year between 2011 and 2017, peaking in 2017 at 303 events. CONCLUSIONS: By drawing on real-world data in the MAUDE database, this study identified the complications of greatest importance in clinical practice. Surgeons should be aware of the spectrum of possible complications to best prepare for all potential outcomes and to effectively counsel patients.

CBCT image artefacts generated by implants located inside the field of view or in the exomass.

OBJECTIVES: To compare artefacts in cone-beam computed tomography (CBCT) arising from implants of different materials located either inside the field of view (FOV) or in the exomass, and to test different image-acquisition parameters to reduce them. METHODS: CBCT scans of a human mandible prepared with either a titanium, titanium-zirconium, or zirconia implant were acquired with the Planmeca ProMax utilizing FOV sizes of 8 × 5 cm and 4 × 5 cm, which placed the implant inside the FOV (8 × 5 cm) or in the exomass (4 × 5 cm). The scanning parameters considered three conditions of metal artefact reduction (MAR), disabled, low, and high, and 2 kVp levels (80 and 90). The standard deviation (SD) of grey values of regions of interest was obtained. The effects of implant material, implant position, MAR condition, kVp level, and their interactions were evaluated by Analysis of Variance (α = 5%). RESULTS: The zirconia implant produced the highest SD values (more heterogeneous grey values, corresponding to greater artefact expression), followed by titanium-zirconium, and titanium. In general, implants in the exomass produced images with higher SD values than implants inside the FOV. MAR was effective in decreasing SD values, especially from the zirconia implant, only when the implant was inside the FOV. Images with 80 kVp had higher SD values than those with 90 kVp, regardless of the other factors (p < 0.05). CONCLUSIONS: Implants in the exomass lead to greater artefact expression than when they are inside the FOV. Special attention should be paid to scanning parameters that reduce metal-related artefacts, such as MAR activation and increasing kVp. This is especially important with a zirconia implant inside the FOV.

Histopathology of Age-Related Macular Degeneration and Implications for Pathogenesis and Therapy.

Aging is associated with a number of histological changes in the choroid, Bruch's membrane, RPE, and neuroretina. Outside of the normal physiologic aging spectrum of changes, abnormal deposits such as basal laminar deposits, basal linear deposits, and soft drusen are known to be associated with AMD. Progression of AMD to advanced stages involving geographic atrophy, choroidal neovascularization, and/or disciform scars can result in debilitating vision loss. Knowledge of the angiogenic pathway and its components that stimulate neovascularization has led to the development of a new paradigm of intravitreal anti-VEGF pharmacotherapy in the management of neovascular AMD. Currently however, there are no available treatments for the modification of disease progression in non-neovascular AMD, or for the treatment of geographic atrophy. Further understanding of the histopathology of AMD and the molecular mechanisms that contribute to pathogenesis of the disease may reveal additional therapeutic targets.

Ocular Outcomes after Treatment of Cytomegalovirus Retinitis Using Adoptive Immunotherapy with Cytomegalovirus-Specific Cytotoxic T Lymphocytes.

PURPOSE: To describe ocular outcomes in eyes with cytomegalovirus (CMV) retinitis treated with adoptive immunotherapy using systemic administration of CMV-specific cytotoxic Tlymphocytes (CMV-specific CTLs). DESIGN: Retrospective cohort study. PARTICIPANTS: Patients with active CMV retinitis evaluated at a tertiary care academic center. METHODS: Treatment of CMV retinitis with standard-of-care therapy (systemic or intravitreal antivirals) or CMV-specific CTLs (with or without concurrent standard-of-care therapies). MAIN OUTCOME MEASURES: The electronic medical record was reviewed to determine baseline characteristics, treatment course, and ocular outcomes, including best-corrected visual acuity (BCVA), treatments administered (CMV-specific CTLs, systemic antivirals, intravitreal antivirals), resolution of CMV retinitis, any occurrence of immune recovery uveitis, cystoid macular edema, retinal detachment, or a combination thereof. RESULTS: Seven patients (3 of whom had bilateral disease [n = 10 eyes]) were treated with CMV-specific CTLs, whereas 20 patients (6 of whom had bilateral disease [n = 26 eyes]) received standard-of-care treatment. Indications for CMV-specific CTL therapy included persistent or progressive CMV retinitis (71.4% of patients); CMV UL54 or UL97 antiviral resistance mutations (42.9%); side effects or toxicity from antiviral agents (57.1%); patient intolerance to longstanding, frequent antiviral therapy for persistent retinitis (28.6%); or a combination thereof. Two patients (28.6%; 4 eyes [40%]) received CMV-specific CTL therapy without concurrent systemic or intravitreal antiviral therapy for active CMV retinitis, whereas 5 patients (71.4%; 6 eyes [60%]) continued to receive concurrent antiviral therapies. Resolution of CMV retinitis was achieved in 9 eyes (90%) treated with CMV-specific CTLs, with BCVA stabilizing (4 eyes [40%]) or improving (4 eyes [40%]) in 80% of eyes over an average follow-up of 33.4 months. Rates of immune recovery uveitis, new-onset cystoid macular edema, and retinal detachment were 0%, 10% (1 eye), and 20% (2 eyes), respectively. These outcomes compared favorably with a nonrandomized cohort of eyes treated with standard-of-care therapy alone, despite potentially worse baseline characteristics. CONCLUSIONS: CMV-specific CTL therapy may represent a novel monotherapy or adjunctive therapy, or both, for CMV retinitis, especially in eyes that are resistant, refractory, or intolerant of standard-of-care antiviral therapies. More generally, adoptive cell transfer and adoptive immunotherapy may have a role in refractory CMV retinitis. Larger prospective, randomized trials are necessary.

Clinical Outcomes and Lens Constant Optimization of the Zeiss CT Lucia 602 Lens Using a Modified Yamane Technique.

PURPOSE: To report the clinical and refractive outcomes of a modified Yamane technique for scleral fixation of the CT Lucia 602 lens. DESIGN: Retrospective case series. PATIENTS: One hundred twenty-one eyes with dislocated posterior chamber lens implants, surgical aphakia, subluxed crystalline lenses, capsular tear, anterior chamber, or iris sutured posterior chamber lens intolerance were included. METHODS: Secondary implantation of the Zeiss CT Lucia 602 lens was performed by a single surgeon using a modified Yamane technique employing a single needle, rather than the double-needle approach. One hundred twelve eyes underwent simultaneous 3 port pars plana vitrectomy and 9 eyes had previously undergone posterior vitrectomy surgery. Exclusion criteria were age <18, simultaneous glaucoma or corneal procedures, staged corneal transplantation, and follow-up <30 days. MAIN OUTCOME MEASURES: A paired t-test was used to compare pre- and post-operative corrected distance visual acuity (CDVA), the mean predictive error, and the mean absolute predictive error between the manufacturer's and optimized constants for Hoffer Q, Holladay I, and SRK/T. Complication rates were reported. RESULTS: One hundred twenty-one consecutive eyes with a mean follow-up of 237 days were included. The pre-operative CDVA was 0.871 ± 0.785 logMAR (mean ± standard deviation, Snellen equivalent 20/149), which improved to 0.401 ± 0.608 (Snellen equivalent 20/50) post-operatively. In 109 eyes with reliable postoperative refractions, the mean predictive refractive error (D) ± std was +0.74 ± 1.37 for Hoffer Q, +0.66 ± 1.41 for Holladay 1, and +0.47 ± 1.49 for SRK/T (p<0.05). Refractive outcome analysis yielded a mean optimized personalized anterior chamber depth (pACD) of 5.69, Surgeon Factor of 1.79, and A constant of 118.56. Vision-limiting complications occurred in 11 eyes (9.1%). CONCLUSION: Scleral fixation of the CT Lucia 602 lens using a single-needle modification of the Yamane technique resulted in very good visual acuity, predictable postoperative refractive errors, but some vision-limiting complications in this heterogeneous group of eyes with significant comorbidities.

Hypopyon following selective laser trabeculoplasty.

PURPOSE: To report a hypopyon following selective laser trabeculoplasty (SLT). OBSERVATIONS: An 85-year-old woman with primary open-angle glaucoma underwent routine SLT. In the early post-procedural period, she presented with pain and decreased vision, and she was found to have hypopyon, trabeculitis, and corneal edema. The patient was treated with prednisolone acetate and empirically with valacyclovir due to the possibility of herpetic keratouveitis. Work-up for potential etiologies was unrevealing. Her symptoms resolved with treatment, and at eight months follow-up her visual acuity and intraocular pressure had stabilized to her baseline. CONCLUSIONS: Though safe, SLT may be associated with rare adverse events requiring intervention. Hypopyon following SLT is extremely rare, and investigation for causes unrelated to the history of SLT should be undertaken as appropriate. IMPORTANCE: To the best of our knowledge, this is the first report of a hypopyon following SLT in a patient with no history of inflammatory intra-ocular disease.

Normative ranges of nasal airflow variables in healthy adults.

PURPOSE: Virtual surgery planning based on computational fluid dynamics (CFD) simulations of nasal airflow has the potential to improve surgical outcomes for patients with nasal airway obstruction (NAO). Virtual surgery planning requires normative ranges of airflow variables, but few studies to date have quantified inter-individual variability of nasal airflow among healthy subjects. This study reports CFD simulations of nasal airflow in 47 healthy adults. METHODS: Anatomically accurate three-dimensional nasal models were reconstructed from cone beam computed tomography scans and used for steady-state inspiratory airflow simulations with a bilateral flowrate of 250 ml/s. Normal subjective sensation of nasal patency was confirmed using the nasal obstruction symptom evaluation and visual analog scale. Healthy ranges for several CFD variables known to correlate with subjective nasal patency were computed, including unilateral airflow, nasal resistance, airspace minimal cross-sectional area (mCSA), heat flux (HF), and surface area stimulated by mucosal cooling (defined as the area where HF > 50 W/m2). The normative ranges were targeted to contain 95% of the healthy population and computed using a nonparametric method based on order statistics. RESULTS: A wide range of inter-individual variability in nasal airflow was observed among healthy subjects. Unilateral airflow varied from 60 to 191 ml/s, airflow partitioning ranged from 23.8 to 76.2%, and unilateral mCSA varied from 0.24 to 1.21 cm2. These ranges are in good agreement with rhinomanometry and acoustic rhinometry data from the literature. A key innovation of this study are the normative ranges of flow variables associated with mucosal cooling, which recent research suggests is the primary physiological mechanism of nasal airflow sensation. Unilateral HF ranged from 94 to 281 W/m2, while the surface area stimulated by cooling ranged from 27.4 to 64.3 cm2. CONCLUSIONS: These normative ranges may serve as targets in future virtual surgery planning for patients with NAO.

Comorbid hepatitis C does not modulate prevalence or severity of diabetic retinopathy.

PURPOSE: There are limited and conflicting data regarding the impact of comorbid hepatitis C virus (HCV) infection on diabetic retinopathy (DR). This study sought to compare the prevalence and severity of DR among patients with diabetes mellitus (DM) with and without HCV. PATIENTS AND METHODS: This was a retrospective, case-control study of patients with DM comparing 120 patients with comorbid HCV and 120 age-matched controls. DR prevalence and several measures of severity were compared between groups. Subgroup analyses were performed among HCV patients with cirrhosis, comorbid HIV, or history of treatment with interferon. Statistical analysis for between-group comparisons utilized both univariate and multivariate analyses. RESULTS: Cases and controls exhibited similar baseline characteristics: average hemoglobin A1c, DM duration, and age (p>0.05). Among cases and controls, there was no difference in DR prevalence (35.8% versus 42.5%, respectively, p=0.29) or severity (p>0.05). Within the HCV subgroup, DR severity was reduced in patients with HIV or cirrhosis. However, multivariate analysis identified reduced DM duration in these subgroups as the primary contributor to lesser DR severity, rather than HIV or cirrhosis. CONCLUSION: In this study, comorbid HCV did not modulate the prevalence or severity of DR among patients with DM. These findings may inform clinical monitoring among HCV-positive diabetics undergoing ophthalmic evaluation.

Successful management of epithelial ingrowth after sequential intracameral 5-fluorouracil and Descemet-stripping automated endothelial keratoplasty.

To describe the successful treatment of epithelial ingrowth using combined surgical excision with intracameral adjuvant 5-fluorouracil (5-FU) followed by Descemet-stripping automated endothelial keratoplasty (DSAEK). A 71-year-old man presented with epithelial ingrowth after clear corneal phacoemulsification. He underwent surgical excision of the membrane together with pars plana vitrectomy, air fluid exchange, and intracameral 5-FU. This treatment resulted in corneal decompensation for which DSAEK was performed 6 months later. Despite interface haze, the postoperative corrected distance visual acuity returned to 20/40 three months after DSAEK. There was no clinical evidence of recurrence of the epithelial ingrowth 9 months after the surgical removal. Intracameral 5-FU can be used in conjunction with surgical excision and subsequent DSAEK to successfully treat epithelial ingrowth.

Corneal Clouding in a Young Woman With Low HDL Cholesterol.

This report describes the early diagnosis of lecithin cholesterol acyl transferase deficiency in a young asymptomatic woman who initially presented to ophthalmology with bilateral corneal clouding. The diagnosis was suggested by characteristic slit-lamp findings, undetectable high-density lipoprotein, and proteinuria, and it was confirmed by cardiology consultation and genetic testing. (Level of Difficulty: Beginner.).

Removal of calcific band keratopathy without ethylenediaminetetraacetic acid (EDTA) in eyes with limited visual potential.

PURPOSE: Treatment of calcific band keratopathy (CBK) is commonly performed with ethylenediaminetetraacetic acid (EDTA), but EDTA has become more difficult to obtain. This paper describes a technique for treating CBK using a diamond-dusted burr without EDTA in eyes with limited visual potential. PATIENTS AND METHODS: In this paper, we provide detailed instructions on how to perform the surgical technique for treating CBK, along with a surgical video. We performed a retrospective review of consecutive patients with clinically significant CBK who underwent this procedure from December 2012 to July 2015. RESULTS: Seven eyes of six patients were included for analysis. Preoperatively, all patients suffered from ocular discomfort. All eyes had poor preoperative visual acuity due to non-corneal ocular disease. The most common causes of CBK in this series were retinopathy of prematurity (three eyes) and chronic uveitis (two eyes). Postoperatively, all patients reported partial or complete relief of discomfort. The length of follow-up ranged from 15 days to 31 months. Two eyes experienced recurrence of CBK. This occurred at 4 and 28 months after treatment. CONCLUSION: The diamond-dusted burr can easily and effectively remove the corneal epithelium and underlying calcium deposits. Therefore, it may be used to effectively treat discomfort from CBK.

Cytomegalovirus retinitis in the post-cART era.

PURPOSE OF REVIEW: To review the epidemiology, diagnosis, and management of cytomegalovirus retinitis (CMVR) in the post-combined antiretroviral era (cART) era. RECENT FINDINGS: Although cART has dramatically reduced CMVR incidence and morbidity in the HIV population, CMVR continues to cause significant vision loss in both HIV and non-HIV patients, especially amongst patients without immune reconstitution. Advances in imaging including ultra-widefield fundus and autofluorescence imaging, optical coherence tomography, and adaptive optics may reflect CMVR activity; however, the diagnosis remains a clinical one. There have been minimal advances in therapy, with several agents no longer available due to market concerns. SUMMARY: Despite reduced incidence and morbidity in the post-cART HIV population, CMVR continues to cause vision loss amongst HIV and non-HIV patients. Diagnosis remains primarily clinical, and therapy centers upon immune reconstitution along with systemic and/or intravitreal antivirals. Further studies are necessary to determine whether advanced imaging can influence management, and whether novel antiviral agents or adoptive immune transfer have a role in treatment of drug-resistance CMVR.

Correlation between Subjective Nasal Patency and Intranasal Airflow Distribution.

Objectives (1) Analyze the relationship between intranasal airflow distribution and subjective nasal patency in healthy and nasal airway obstruction (NAO) cohorts using computational fluid dynamics (CFD). (2) Determine whether intranasal airflow distribution is an important objective measure of airflow sensation that should be considered in future NAO virtual surgery planning. Study Design Cross-sectional. Setting Academic tertiary medical center and academic dental clinic. Subjects and Methods Three-dimensional models of nasal anatomy were created based on computed tomography scans of 15 patients with NAO and 15 healthy subjects and used to run CFD simulations of nasal airflow and mucosal cooling. Subjective nasal patency was quantified with a visual analog scale (VAS) and the Nasal Obstruction Symptom Evaluation (NOSE). Regional distribution of nasal airflow (inferior, middle, and superior) was quantified in coronal cross sections in the narrowest nasal cavity. The Pearson correlation coefficient was used to quantify the correlation between subjective scores and regional airflows. Results Healthy subjects had significantly higher middle airflow than patients with NAO. Subjective nasal patency had no correlation with inferior and superior airflows but a high correlation with middle airflow (| r| = 0.64 and | r| = 0.76 for VAS and NOSE, respectively). Anterior septal deviations tended to shift airflow inferiorly, reducing middle airflow and reducing mucosal cooling in some patients with NAO. Conclusion Reduced middle airflow correlates with the sensation of nasal obstruction, possibly due to a reduction in mucosal cooling in this region. Further research is needed to elucidate the role of intranasal airflow distribution in the sensation of nasal airflow.

Comparison of the Diagnostic Image Quality of the Canine Maxillary Dentoalveolar Structures Obtained by Cone Beam Computed Tomography and 64-Multidetector Row Computed Tomography.

The objective of this blinded study was to validate the use of cone beam computed tomography (C) for imaging of the canine maxillary dentoalveolar structures by comparing its diagnostic image quality with that of 64-multidetector row CT Sagittal slices of a tooth-bearing segment of the maxilla of a commercially purchased dog skull embedded in methylmethacrylate were obtained along a line parallel with the dental arch using a commercial histology diamond saw. The slice of tooth-bearing bone that best depicted the dentoalveolar structures was chosen and photographed. The maxillary segment was imaged with cone beam CT and 64-multidetector row CT. Four blinded evaluators compared the cone beam CT and 64-multidetector row CT images and image quality was scored as it related to the anatomy of dentoalveolar structures. Trabecular bone, enamel, dentin, pulp cavity, periodontal ligament space, and lamina dura were scored In addition, a score depicting the evaluators overall impression of the image was recorded. Images acquired with cone beam CT were found to be significantly superior in image quality to images acquired with 64-multidetector row CT overall, and in all scored categories. In our study setting cone beam CT was found to be a valid and clinically superior imaging modality for the canine maxillary dentoalveolar structures when compared to 64-multidetector row CT.

Dimensional changes of upper airway after rapid maxillary expansion: a prospective cone-beam computed tomography study.

INTRODUCTION: The aim of this prospective study was to use cone-beam computed tomography to assess the dimensional changes of the upper airway in orthodontic patients with maxillary constriction treated by rapid maxillary expansion. METHODS: Fourteen orthodontic patients (mean age, 12.9 years; range, 9.7-16 years) were recruited. The patients with posterior crossbite and constricted maxilla were treated with rapid maxillary expansion as the initial part of their comprehensive orthodontic treatments. Before and after rapid maxillary expansion cone-beam computed tomography scans were taken to measure the retropalatal and retroglossal airway changes in terms of volume, and sagittal and cross-sectional areas. The transverse expansions by rapid maxillary expansion were assessed between the midlingual alveolar bone plates at the maxillary first molar and first premolar levels. The measurements of the before and after rapid maxillary expansion scans were compared by using paired t tests with the Bonferroni adjustment for multiple comparisons. RESULTS: After rapid maxillary expansion, significant and equal amounts of 4.8 mm of expansion were observed at the first molar (P = 0.0000) and the first premolar (P = 0.0000) levels. The width increase at the first premolar level (20.0%) was significantly greater than that at the first molar level (15.0%) (P = 0.035). As the primary outcome variable, the cross-sectional airway measured from the posterior nasal spine to basion level was the only parameter showing a significant increase of 99.4 mm(2) (59.6%) after rapid maxillary expansion (P = 0.0004). CONCLUSIONS: These results confirm the findings of previous studies of the effect of rapid maxillary expansion on the maxilla. Additionally, we found that only the cross-sectional area of the upper airway at the posterior nasal spine to basion level significantly gains a moderate increase after rapid maxillary expansion.