Detection of vitrector shavings on OCT.

PURPOSE: To describe multiple retained intraocular foreign bodies felt to be from a vitrectomy instrument. METHODS: Observational case report. PATIENT: A 66-year-old male with history of rhegmatogenous retinal detachment repaired with PPV, scleral buckle, endolaser, and fluid-air exchange presented with dyschromatopsia OD. RESULTS: OCT demonstrated metallic vitrector shavings detected on OCT above the optic nerve head and macula. Repeat OCT 9 months later demonstrated movement of the vitrector shavings throughout the vitreous. CONCLUSION: We demonstrate retained intraocular foreign body shavings which are rarely seen following vitrectomy. These can be confirmed using OCT.

Utilizing perioperative patient positioning to correct intraocular lens implant subluxation.

Purpose: to describe how preoperative and intraoperative positioning techniques can be used to manage subluxed intraocular lenses (IOL) whilst saving patients from pars plana vitrectomy. Observations: An 88-year-old man with a complex past medical history including mild cognitive decline from early Alzheimer's dementia and pertinent ocular history of pseudoexfoliation syndrome and previous cataract surgery with IOL presented with decreased vision secondary to an inferiorly subluxed IOL/bag complex. The IOL was not visible in the operating room when he was supine but was visible in clinic the next day after he had slept in the prone position the night before. The patient was returned to the operating room the next day and a fixation suture was used to capture the IOL while he was upright. The IOL was then fixated to the sclera in standard position. Conclusions and Importance: Both pre and intraoperative positioning techniques can help anterior segment surgeons fixate subluxed IOLs that otherwise seem inaccessible from an anterior approach and thus avoiding the inherent risks associated with vitrectomy.

TEMPORARY KERATOPROSTHESIS WITH PENETRATING KERATOPLASTY IN CONJUNCTION WITH PARS PLANA VITRECTOMY FOR REPAIR OF RETINAL DETACHMENTS IN PATIENTS WITH ANTERIOR AND POSTERIOR SEGMENT PATHOLOGY.

PURPOSE: To review the visual and anatomical outcomes of combined anterior and posterior segment surgery for retinal detachment repair. METHODS AND PATIENTS: Eight patients with combined retinal and corneal disease underwent combined temporary keratoprosthesis with penetrating keratoplasty combined with pars plana vitrectomy for retinal detachment repair with silicone oil tamponade. Visual and anatomical outcomes were reviewed retrospectively. Follow-up ranged from 12 months to 37 months. RESULTS: Preoperative visual acuity ranged from light perception to hand motion. All but one case had proliferative vitreoretinopathy present at the time of surgery. Postoperative visual acuity ranged from hand motion to light perception. At the most recent follow-up visit, all of the patients had attached retinas, no patients had phthisis bulbi, and all but one patient had a clear cornea. However, 3 of these cases (38%) required repeat retinal detachment repair and one of them also required repeat penetrating keratoplasty, which was performed at the time of retinal repair. CONCLUSION: Combined full-thickness penetrating keratoplasty and retinal detachment repair has good anatomical outcomes and is an efficient way to treat complex anterior and posterior segment abnormality. Although postoperative visual function is limited; almost all patients were agreeable to repeat surgery if they were presented with the choice again.

Microbial profile of lacrimal system Dacryoliths in American Midwest patient population.

PURPOSE: Dacryoliths of the canalicular pathway are classically attributed to Actinomyces species as the most common organism. However, global shifts toward Streptococcus and Staphylococcus species have been reported. The objective of this article is to update the American Midwest epidemiology of lacrimal system dacryoliths for targeted clinical treatment. MATERIALS AND METHODS: A retrospective chart review from January 2015 to 2021 of patients with a history of surgical procedure for lacrimal removal of dacryolith for canaliculitis, canalicular obstruction, dacryocystitis, and nasolacrimal duct obstruction was included. Specimens were sent for histopathological evaluation and microbial culture. RESULTS: A total of 48 specimens were included. The most common organism isolated for canalicular pathology was Actinomyces spp (23%), followed by Staphylococcus spp (21%) and Streptococcus spp (19%). Histopathological staining accounted for 45% of Actinomyces isolation when culture data inconclusive. In a subgroup analysis of lacrimal sac dacryoliths, the most common organism was Staphylococcus spp (29%). Actinomyces species were not isolated from the lacrimal sac or nasolacrimal duct. CONCLUSION: Actinomyces maintains a microbial predominance in canalicular dacryoliths and requires careful culture and histopathological analysis for its fastidious nature. Lacrimal sac and nasolacrimal duct dacryolith found no isolates of Actinomyces, and the most common organism was Staphylococcus.

Accuracy of Remote Diagnosis of Acute Posterior Segment Pathology by Residents and Attendings Captured with a Smartphone and Standard 20/28D Lens.

Background and Objective: To assess the use of a smartphone-based fundus camera in diagnosing acute posterior segment disease in the emergency room (ER) of an academic center, where standard fundus cameras are currently unavailable. Study Design/Patients and Methods: Images were obtained on 10 eyes with various types of posterior segment pathology. These were analyzed retrospectively by 35 reviewers (21 residents and 14 attending physicians). Accuracy of diagnosis was compared to in-office fundus photography. Results: The average probability of correct diagnosis was over 78%. There was no difference between resident and attending reviewers, except for one of the vitreous hemorrhage cases where residents performed better (p=0.039). Conclusion: Smartphone-based cameras are effective in screening for ocular diseases in the ER of academic centers, where residents and fellows are often the first providers to see various types of vision and life-threatening pathology.

Globe dislocation and optic nerve avulsion following all-terrain vehicle accidents.

Purpose: Open-air motor vehicles present unique trauma risks to the eyes and face. We describe two patients who suffered a crash while riding an all-terrain vehicle (ATV), leading to globe dislocation with optic nerve avulsion in order to raise awareness about the risks associated with ATV accidents. Observations: In both cases, the injury was caused by high-speed trauma to the orbit involving a tree branch. One patient sustained a life threatening arrythmia requiring a short stay in the intensive care unit, and both patients required emergent surgical management and eventual socket reconstruction. Conclusions and Importance: These cases highlight the need for greater advocacy on behalf of rider safety. The authors encourage ophthalmologists to counsel patients who use ATVs to wear helmets, seatbelts, and protective eyewear to prevent these types of injuries in the future.

Valsalva Retinopathy Masking as a Retinal Detachment on Point-of-care Ocular Ultrasound: A Case Report.

INTRODUCTION: Approximately two million people present to the emergency department (ED) with eye-related complaints each year in the United States. Differentiating pathologies that need urgent consultation from those that do not is imperative. For some physicians, ocular ultrasound has eclipsed the dilated fundoscopic exam as the standard posterior segment evaluation in the ED. CASE REPORT: A 60-year-old female presented with sudden onset visual disturbance in her right eye. Point-of-care ultrasound showed a hyperechoic band in the posterior segment concerning for a retinal detachment. Ophthalmology was consulted and diagnosed the patient with a condition known as Valsalva retinopathy. The patient was discharged from the ED with expectant management. CONCLUSION: This case highlights an important differential diagnosis that should be considered when ocular ultrasound demonstrates a hyperechoic band in the posterior segment. While previous literature has demonstrated that emergency physicians are able to accurately identify posterior segment pathology using ultrasound, there is limited information regarding their ability to differentiate between pathologies, some of which may not require urgent consultation. We highlight the important differentials that should be considered when identifying posterior segment pathology on point-of-care ultrasound and their appropriate dispositions.

Vision Loss Secondary to COVID-19 Associated Bilateral Cerebral Venous Sinus Thromboses.

A young, morbidly obese woman with recent SARS-CoV-2 infection requiring hospitalization presented with visual and neurologic complications secondary to bilateral cerebral venous sinus thromboses. With elevated intracranial pressure and severe papilledema, she rapidly progressed to complete bilateral vision loss despite anticoagulation, therapeutic lumbar punctures with lumbar drain, bilateral optic nerve sheath fenestrations, and endovascular thrombectomy. It is possible that obese patients with a SARS-CoV-2 infection may be at greater risk of hypercoagulable cerebrovascular complications. It is impossible to know if an even more rapid response would have led to a different outcome, but we report this case in the hope that publishing this and similar cases may result in improved treatment protocols to preserve vision.

Active Learning of Contrast Sensitivity to Assess Visual Function in Macula-off Retinal Detachment.

PURPOSE: To characterize the contrast sensitivity function (CSF) in patients with successful repair of macula-off rhegmatogenous retinal detachment (RD) using an adaptive computerized contrast testing device. METHODS: CSF was prospectively measured in macula-off RD patients following successful repair and age-matched controls at W. K. Kellogg Eye Center and Massachusetts Eye and Ear, employing the active learning device Manifold Contrast Vision Meter (Adaptive Sensory Technology, San Diego, CA). Outcome measures included average area under the CSF curve (AULCSF), CS thresholds at 1-18 cycles per degree (cpd) and best correctd visual acuity (BCVA) in RD eyes fellow eyes and controls. A sub-analysis was performed in eyes with BCVA of 20/30 or better. RESULTS: Twenty-three macula-off RD eyes status post repair, fellow healthy eyes and 45 age-matched control eyes underwent CSF testing. The mean BCVA of the 23 RD eyes was 0.250 logMAR, significantly reduced compared to fellow eyes 0.032 (p<0.001) and controls 0.026 (p< 0.00001). There was a statistically significant reduction in AULCSF in RD eyes compared to the fellow eyes (p<0.0001) and to age-matched controls (Z-score -0.90, p<0.0001) and CSF reduction across all spatial frequencies. In the 15 RD eyes with BCVA of 20/30 or better, the mean CSF was significantly reduced compared to fellow eyes (p=0.0158) and controls (p=0.0453). CONCLUSIONS: CSF in macula-off RD eyes following repair was significantly reduced compared to fellow eyes and age-matched controls. CSF seems to be a promising visual function endpoint with potential applications in the clinical practice and future clinical trials.

Treated PDR Reveals Age-Appropriate Vision Deterioration But Distorted Retinal Organization.

Purpose: We determined the progression of visual function, macular structure, and quality of life in patients with regressed proliferative diabetic retinopathy (PDR) after panretinal photocoagulation (PRP). Methods: In this prospective study, 22 patients who underwent PRP for PDR and 11 age-matched control participants underwent examinations at baseline and after 5 years. Visual acuity, contrast sensitivity, reading acuity, frequency doubling perimetry, Humphrey field analyzer, and dark adaptation were measured. The Low Luminance Questionnaire and National Eye Institute Vision Function Questionnaire-25 were administered. Macular spectral-domain optical coherence tomography was taken. Results: After 5 years, patients who had previously undergone PRP for PDR (18.4 ± 7.9 years previously) showed significant deterioration in contrast sensitivity, reading acuity, frequency doubling perimetry 24-2 pattern standard deviation, and Humphrey field analyzer 10-2 foveal sensitivity, which were equivalent to age-related decreases in control participants. They revealed no further impairment in vision-related activities on questionnaires. In contrast with controls, their maculas showed pathologic disorganization of the retinal layers, especially the nerve fiber layer, which were thicker and constituted a greater proportion of the overall retinal thickness than the norm and associated with impaired vision. Conclusions: Patients with treated PDR had age-related decreases in vision, but stable quality of life. Prior injuries from the diabetes and, possibly, laser treatment led to substantial disruption in the retinal structure, which may explain the loss of vision. Translational Relevance: Despite PRP treatment, patients with regressed PDR had pathologic progression of the nerve fiber layer; further investigation may identify a new therapeutic target to reverse the visual deficits.

Reading deficits in diabetic patients treated with panretinal photocoagulation and good visual acuity.

PURPOSE: Patients with proliferative diabetic retinopathy (PDR) treated with panretinal photocoagulation (PRP) can have abnormal visual functioning that may be missed by Snellen visual acuity alone. We investigated reading deficits in patients treated with PRP for PDR using the Minnesota reading (MNREAD) test. METHODS: Thirty patients treated with PRP and 15 controls underwent best-corrected visual acuity (BCVA), the MNREAD, frequency doubling perimetry (FDP), and fundus photography. Panretinal photocoagulation (PRP)-treated subjects were compared to controls on MNREAD results by two-sample t-tests and Wilcoxon tests and Pearson correlations were used to assess the association between performance on MNREAD and other central visual function tests within PRP subjects. RESULTS: Panretinal photocoagulation (PRP)-treated patients had reduced MNREAD acuity (p < 0.0001) and increased critical print size (p = 0.01) compared to controls but not a significantly reduced maximum reading speed (p = 0.06). Logmar MNREAD acuity was strongly positive correlated with logMAR BCVA (r = 0.58, p = 0.0098) and strongly negatively correlated with FDP foveal threshold (r = -0.63, p = 0.0030). Maximum reading speed was positively correlated with FDP foveal threshold (r = 0.57, p = 0.0143) and FDP mean deviation (r = 0.51, p = 0.0432). Visual acuity did not correlate with the sensitivities on the FDP. CONCLUSION: The MNREAD test reveals that PRP reduces reading ability and other aspects of macular function, and thus provides new understanding of how vision-related quality of life is impaired. These findings may lead to improved means to evaluate and enhance vision following treatment for PDR.

Macular hyperpigmentary changes in ABCA4-Stargardt disease.

BACKGROUND: Stargardt disease (STGD) and age-related macular degeneration (AMD) share clinical and pathophysiological features. In AMD, macular hyperpigmentary changes are associated to a worse prognosis. The purpose of this study was to characterize macular hyperpigmentary changes in patients with STGD and associate them with the severity of phenotype. MATERIALS AND METHODS: This retrospective cross-sectional study included 141 patients with STGD. Hyperpigmentary changes were evaluated on color fundus photography and spectral-domain optical coherence tomography. Severity of phenotype was assessed by full-field electroretinogram (ffERG) and fundus autofluorescence (FAF) patterns, and visual acuity (VA). RESULTS: Thirty patients (21.7%) showed macular hyperpigmentary changes in four distinct patterns. Out of seventeen patients who had follow-up images, eleven patients demonstrated increases of the hyperpigmented lesions, and progression of the underlying RPE atrophy overtime. VA remained stable. Of 28 patients who had ffERG, 17 patients presented with reduction of photopic and scotopic responses, while 8 presented with reduction of photopic responses only, and 3 presented with preserved photopic and scotopic responses. Of 25 patients who had FAF available, 12 presented with widespread disease extending anteriorly to the vascular arcades, while eight presented with widespread disease, extending beyond the vascular arcades, and 5 presented with disease confined to the foveal area. CONCLUSION: In this study, we demonstrated that patients with STGD with macular hyperpigmented lesions had a severe phenotype. Overtime, hyperpigmented lesions increased in size, spread across the retina, and migrated to different retinal layers. Macular hyperpigmentation may be a marker of advanced stage of the disease.

Contrast sensitivity deficits in patients with mutation-proven inherited retinal degenerations.

BACKGROUND: Patients with retinal diseases frequently complain of poor visual function even when visual acuity is relatively unaffected. This clinical finding has been attributed to deficits in contrast sensitivity (CS). The purpose of our study was to evaluate the CS in patients with clinical and genetic diagnosis of inherited retinal degeneration (IRD) and relatively preserved visual acuity. METHODS: Seventeen patients (30 eyes) with IRD and visual acuity of 20/40 or better, and 18 controls (18 eyes) without any ocular condition underwent slit lamp examination, visual acuity testing via standard Snellen chart testing, CS testing via the Quick Contrast Sensitivity Function (QCSF), and Spectral Domain Optical Coherence Tomography (SD-OCT). CS were measured at 1.0, 1.5, 3.0, 6.0, 12.0, and 18.0 cycles per degree (cpd). T tests with general estimated equations were used to compare CS between groups. Wald chi square followed by pairwise comparisons was used to compare CS between multiple groups. RESULTS: We included 12 patients with rod-cone dystrophy (RCD), 3 patients with Stargardt disease (STGD) and 2 patients with Best disease. Patients with IRD had significantly worse CS than controls (p < 0.001) in all spatial frequencies. Patients with STGD had more marked deficits in CS than patients with Best disease (p < 0.001) and RCD (p < 0.001) despite having similar visual acuities. CONCLUSION: Patients with IRD, especially patients with STGD with relatively preserved visual acuity have marked deficits in CS when measured across a range of spatial frequencies. We recommend that clinical trials for STGD incorporate CS measured over a range of spatial frequencies as a secondary clinical endpoint for monitoring visual function. CS may provide an explanation for complaints of visual dysfunction when visual acuity is not significantly altered.

Recurrent Corneal Erosions in Corneal Dystrophies: a Review of the Pathogenesis, Differential Diagnosis, and Therapy.

INTRODUCTION: Recurrent corneal erosions in corneal dystrophies are visually significant and bothersome to patients. The goal of this article is to review the pathogenesis, differential diagnosis, and management of recurrent corneal erosions in corneal dystrophies. PATIENTS AND METHODS: Forty-eight articles and 1 textbook recently published on corneal erosions in corneal dystrophies were reviewed. The findings on the pathogenesis and clinical characteristics of erosions in each dystrophy were summarized. Any contradicting opinions for which the literature was unclear were either omitted or recorded as lacking strong evidence. RESULTS AND CONCLUSIONS: The epithelial-stromal complex plays an important role in the pathogenesis of erosions in corneal dystrophies. The clinical features of each corneal dystrophy guide their diagnosis and management. A better understanding of the pathogenesis and clinical features of erosions in corneal dystrophies can lead to better clinical outcomes.

Adenoviral keratitis: a review of the epidemiology, pathophysiology, clinical features, diagnosis, and management.

PURPOSE OF REVIEW: Adenoviral keratitis is a common and bothersome ocular infection that produces a lot of burden on healthcare systems and patients. The goal of this article is to provide a review of the topic, with an emphasis on current attempts at advancing strategies in diagnosis and management. RECENT FINDINGS: Sixty-eight articles and one textbook published on adenoviral keratitis were reviewed. The findings on the epidemiology, pathophysiology, clinical features, diagnosis, and management were summarized. Any contradicting opinions for which the literature was unclear were either omitted or recorded as lacking strong evidence. SUMMARY: Although significant effort has been made to develop new methods for diagnosis and management, adenoviral keratitis is predominantly diagnosed clinically with prevention being the mainstay of management. The use of newer DNA analysis techniques and topical anti-inflammatory agents for treatment of corneal infiltrates show promising results, but a better understanding of the pathogenesis and clinical features can lead to more targeted methods of diagnosis and therapy.

Affective context interferes with brain responses during cognitive processing in borderline personality disorder: fMRI evidence.

Emotion dysregulation in borderline personality disorder (BPD) is associated with loss of cognitive control in the face of intense negative emotion. Negative emotional context may interfere with cognitive processing through the dysmodulation of brain regions involved in regulation of emotion, impulse control, executive function and memory. Structural and metabolic brain abnormalities have been reported in these regions in BPD. Using novel fMRI protocols, we investigated the neural basis of negative affective interference with cognitive processing targeting these regions. Attention-driven Go No-Go and X-CPT (continuous performance test) protocols, using positive, negative and neutral Ekman faces, targeted the orbital frontal cortex (OFC) and the anterior cingulate cortex (ACC), respectively. A stimulus-driven Episodic Memory task, using images from the International Affective Pictures System, targeted the hippocampus (HIP). Participants comprised 23 women with BPD, who were compared with 15 healthy controls. When Negative>Positive faces were compared in the Go No-Go task, BPD subjects had hyper-activation relative to controls in areas reflecting task-relevant processing: the superior parietal/precuneus and the basal ganglia. Decreased activation was also noted in the OFC, and increased activation in the amygdala (AMY). In the X-CPT, BPD subjects again showed hyper-activation in task-relevant areas: the superior parietal/precuneus and the ACC. In the stimulus-driven Episodic Memory task, BPD subjects had decreased activation relative to controls in the HIP, ACC, superior parietal/precuneus, and dorsal prefrontal cortex (dPFC) (for encoding), and the ACC, dPFC, and HIP for retrieval of Negative>Positive pictures, reflecting impairment of task-relevant functions. Negative affective interference with cognitive processing in BPD differs from that in healthy controls and is associated with functional abnormalities in brain networks reported to have structural or metabolic abnormalities. Task demands exert a differential effect on the cognitive response to negative emotion in BPD compared with control subjects.