Ponesimod-Associated Macular Edema: Onset and Resolution.

Purpose: To present a patient with cystoid macular edema (CME) associated with ponesimod use and offer suggestions for the management of this condition. Methods: A case report is presented. Results: A 75-year-old woman with relapsing-remitting multiple sclerosis had an unremarkable baseline ophthalmic examination prior to starting ponesimod. At her 9-month follow-up, an examination showed the development of CME in the left eye. The patient's macular edema fully resolved after transitioning off ponesimod to an alternative systemic medication and starting treatment with a topical corticosteroid and nonsteroidal anti-inflammatory drug. Conclusions: To our knowledge, this is the first case report discussing the entity and management of ponesimod-associated macular edema. Ponesimod cessation and concomitant topical therapy can result in successful resolution of macular edema.

Effective Low-Cost Ophthalmological Screening With a Novel iPhone Fundus Camera at Community Centers.

Ophthalmologic care is inaccessible to many people due to a variety of factors, including the availability of providers, cost of equipment for ophthalmologic care, and transportation to clinics and appointments. Because many causes of blindness are both highly prevalent and preventable once identified, it is essential to address gaps in care for underserved populations. We developed a novel 3D-printed mobile retinal camera. In this study, we organized recurring student-run screening events around New York City that took place in community centers and churches, at which we utilized our device to take retinal images. Our screening events reached a diverse population of New Yorkers, disproportionately those with lower household income, many of whom had not had recent eye exams. To validate the device for use in telehealth ophthalmologic visits, we transmitted the images to a remote ophthalmologist for evaluation and compared the result with an on-site attending physician's dilated eye exam. The subjective assessment indicated that 97% of images captured with the mobile retinal camera were acceptable for telehealth analysis. Remote image assessment by achieved 92% sensitivity and 83% specificity in detecting optic disc cupping, compared to the gold-standard on-site dilated eye exam. In addition, the device was portable, affordable, and able to be used by those with relatively little ophthalmologic training. We have demonstrated the utility of this affordable mobile retinal camera for telehealth ophthalmologic evaluation during community screening events that reached an underserved population to detect disease and connect with long-term care.

Ocular syphilis resurgence in an urban underserved community in the United States.

AIM: To evaluate the clinical characteristics, demographics, and visual outcomes of patients with ocular syphilis at an urban hospital to increase awareness and assist in earlier diagnosis and treatment of the resurgent disease. METHODS: A retrospective chart review was performed on patients with ICD-9 and ICD-10 diagnosis codes correlating with syphilis or syphilis-related ocular diseases between 2010 and 2019. Variables evaluated included age, gender, race, vision, ocular findings, human immunodeficiency virus (HIV) status and men who have sex with men status, recreational drug and alcohol use. RESULTS: Ocular syphilis was diagnosed in 40 patients (53 eyes) of a total of 229 patients who tested positive for syphilis via serum and/or cerebrospinal fluid treponemal testing from 2010-2019. Among patients with ocular syphilis, most patients were males, aged 45 or above and Black, and had no diagnosed HIV infection. Approximately 50% patients had 20/40 vision or better. Nearly 50% had non-granulomatous anterior uveitis as their initial presentation, and 49% of patients had involvement of the posterior segment. Neovascular glaucoma (5.7%), papillitis (7.5%), vasculitis (5.7%), and retinal detachment (5.7%) were rarer presentations of the disease and were associated with a poorer visual prognosis. CONCLUSION: Given the increased prevalence and protean manifestations of syphilis, early diagnosis and treatment are paramount. More studies on ocular syphilis are warranted to understand this resurging disease.

Choroidal Metastasis With Secondary Retinal Detachment in a Man With BCRA2-Associated Breast Adenocarcinoma.

Breast cancer with ocular metastasis is rare in men. Such cases with BRCA2 gene mutation are even less common. This case report describes a 59-year-old man with recently diagnosed breast adenocarcinoma who presented for surgical repair of a retinal detachment in his left eye. Clinical exanimation revealed a left inferior retinal detachment without a clear retinal break. Spectral-domain optical coherence tomography (SD-OCT) of the left macula showed sub-retinal fluid extending into the fovea and a thickened choroid. B-scan ultrasonography was obtained and showed a diffuse inferior choroid mass measuring 5 millimeters (mm) at the apex with an overlying retinal detachment, consistent with breast cancer metastasis to the choroid. He was initiated on chemotherapy and whole-brain radiation with symptomatic improvement. This case illustrates the importance of obtaining a thorough medical history and additional testing when indicated.

Socioeconomic and Demographic Factors Contributing to COVID-19-Related Delays and Reductions in Primary Retinal Detachment Repair in a US Hot Spot.

Purpose: This work evaluates demographic and socioeconomic predictors of delayed care for rhegmatogenous retinal detachments (RRDs) during the spring 2020 COVID-19 shutdown in a US hot spot. Methods: This multicenter, retrospective, case-control study took place in 3 academic vitreoretinal practices in metropolitan Boston. Consecutive patients treated for RRD during the COVID-19 state of emergency were compared with patients treated during the same period in 2018 and 2019. The primary outcome was macula status for RRD. Secondary outcomes included visual acuity, symptom duration, proportion with proliferative vitreoretinopathy, time to procedure, method of repair, and patient demographics. Results: The total number of acute RRD decreased by 13.7% from 2018 to 2020 and 17.2% from 2019 to 2020. Symptom duration was significantly longer in 2020 than 2018 and 2019 (median, 7 vs 4 days) with a higher proportion of macula-off detachments (80 of 125 [64%] in 2020 vs 75 of 145 [51.7%] in 2018 and 78 of 151 [51.6%] in 2019). The 2020 cohort included significantly fewer patients in the racial and/or ethnic minority group than in 2019 (P = .02), and use of low-income, government-sponsored health insurance was a predictor of macula-off status during the pandemic (P = .04). Conclusions: RRDs during the spring 2020 COVID-19 lockdown were more likely to be macula-off at presentation. Because sociodemographic factors including race, ethnicity, and income level were associated with deferral of care, ophthalmologists should consider measures targeting vulnerable populations to avoid preventable vision loss as the pandemic continues or in future health care emergencies.

Risk factors for fellow eye treatment in protocol T.

PURPOSE: To identify risk factors for fellow eye treatment of diabetic retinopathy with Vascular Endothelial Growth Factor (VEGF) injections during the Diabetic Retinopathy Clinical Research Network (DRCR.Net) Protocol T trial METHODS: In this post-hoc analysis of randomized clinical trial data, Cox regression analysis was performed at 52 and 104 weeks to determine risk factors for treatment in 360 fellow eyes. Survival analysis was performed to determine mean time to treatment based upon medication used. RESULTS: Of 360 fellow eyes, 142 (39.4%) required treatment between weeks 4 and 104. Risk factors predicting a lower likelihood of year 1 treatment included older subject age (Hazard Ratio [HR]=0.98, 95% CI 0.96-0.99; p = 0.02) and higher baseline study eye ETDRS score (HR=0.98, 95% CI 0.97-0.99, p = 0.04). Center-involving DME at baseline in the fellow eye was predictive of a higher treatment need at both 52 (HR=1.89, 95% CI 1.42-2.51, p < 0.0001) and 104 weeks (HR=2.68, 95% CI 1.75-4.11, p < 0.0001). Subjects treated in the study eye with aflibercept (HR=0.574, 95% CI 0.371-0.887, p = 0.013) and ranibizumab (HR=0.58, 95%CI 0.36-0.94, p = 0.03) were less likely to require first year fellow eye injection than subjects treated with bevacizumab although this difference was no longer significant at week 104 (aflibercept HR=0.77, 95% CI 0.52-1.16, p = 0.21; ranibizumab HR=0.66, 95% CI 0.43-1.00, p = 0.05). Mean time to treatment was significantly shorter in the bevacizumab group (bevacizumab 25.83 weeks, aflibercept 38.75 weeks, ranibizumab 34.70 weeks (p=0.012)). CONCLUSION: Bilateral treatment with intravitreal anti-VEGF injections was common during the DRCR.net Protocol T. Medication choice may impact the risk of fellow eye treatment.

Combined phaco-vitrectomy provides lower costs and greater area under the curve vision gains than sequential vitrectomy and phacoemulsification.

PURPOSE: A majority of phakic patients undergoing pars plana vitrectomy for epiretinal membrane or macular hole require subsequent cataract surgery within 1-2 years. Combined phaco-vitrectomy eliminates the need for a second surgery and may enable patients to attain their best vision sooner. This study aims to compare the visual outcomes, complication rates, and costs of combined phaco-vitrectomy versus sequential vitrectomy followed by cataract surgery. METHODS: Records were searched by CPT® codes to identify patients with both cataract and vitrectomy surgery at our institution over a 5-year period (2013-2018). Chart review included medical history, demographics, exam findings, operating room records, visual acuity (VA), and clinical outcomes. Statistical analyses were performed with SPSS v19 (IBM). Area under the curve for visual acuity was calculated as the trapezoidal mean of the change in Early Treatment of Diabetic Retinopathy Study letters. RESULTS: After exclusion, 81 eyes of 78 patients underwent both cataract and vitrectomy surgeries at our institution. Thirty-four eyes underwent separate, sequential vitrectomy then phacoemulsification surgery, and 47 eyes had combined phaco-vitrectomy surgery. Total operating room times (120.81 ± 3.41 vs 161.03 ± 5.45 min; p < 0.0001) and associated costs were significantly lower in the combined surgery compared with those in the sequential surgery group. Baseline and final visual acuity were similar between the two groups. Baseline VA was 35.53 letters (~ 20/200) and 32.81 letters (~ 20/220) and increased to final VA of 63.74 (~ 20/53) and 60.91 letters (~ 20/61), in the sequential and combined groups respectively. Area under the curve for vision was greater in the combined surgery group, with subjects gaining an average of + 9.11 ± 3.32 letters from sequential surgery, and + 19.53 ± 3.53 letters in the combined surgery group (p = 0.04). Additionally, patients in the combined group attained their best visual acuity 449 days (15 months) sooner than those receiving sequential surgery. CONCLUSIONS: Combined phaco-vitrectomy surgery resulted in greater area under the curve visual acuity benefit and attainment of best visual acuity 15 months sooner compared with conventional sequential surgeries. There were no significant differences in complication rates or clinical outcomes between the groups, but operative times and costs were lower for combined surgery, supporting a favorable cost-benefit ratio. Graphical abstract.

A case of the blues: Inadvertent ocular injury from accidental instillation of blue ink.

PURPOSE: Many consumer products and non-ophthalmic medications are packaged in plastic "eye dropper" bottles, posing a risk of accidental ocular chemical injury when these substances are mistaken for eye drops. OBSERVATIONS: We present the case of an elderly glaucoma patient who mistook blue stamper ink for the glaucoma medication Combigan®, and suffered ocular injury as a result. CONCLUSIONS AND IMPORTANCE: The packaging of non-ophthalmic products in plastic "eye dropper" bottles poses a significant risk of accidental ocular chemical injury. Elderly individuals with low vision and/or cognitive deficits may be at particular risk of accidental injury. Ophthalmologists have been calling for a greater distinction between the packaging of ophthalmic and non-ophthalmic products for over 35 years, but to date little progress has been made in this regard.

Retinopathy of prematurity: a review of risk factors and their clinical significance.

Retinopathy of prematurity (ROP) is a retinal vasoproliferative disease that affects premature infants. Despite improvements in neonatal care and management guidelines, ROP remains a leading cause of childhood blindness worldwide. Current screening guidelines are primarily based on two risk factors: birth weight and gestational age; however, many investigators have suggested other risk factors, including maternal factors, prenatal and perinatal factors, demographics, medical interventions, comorbidities of prematurity, nutrition, and genetic factors. We review the existing literature addressing various possible ROP risk factors. Although there have been contradictory reports, and the risk may vary between different populations, understanding ROP risk factors is essential to develop predictive models, to gain insights into pathophysiology of retinal vascular diseases and diseases of prematurity, and to determine future directions in management of and research in ROP.

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.

Cytomegalovirus Retinitis: A Review.

Cytomegalovirus (CMV) is a ubiquitous DNA herpes virus that causes significant morbidity and mortality in immunocompromised individuals. CMV retinitis is a potentially blinding manifestation of CMV infection that was commonly seen in advanced acquired immunodeficiency syndrome (AIDS) in the era before modern combination antiretroviral therapy era, but is also recognized in patients with immune deficiency from multiple causes. The advent of and advances in antiretroviral therapies for human immunodeficiency virus have decreased the incidence of CMV retinitis by over 90% among AIDS patients, and improved visual outcomes in those affected. The diagnosis is generally a clinical one, and treatment modalities include systemic and intravitreal antiviral medications. Retinal detachment and immune recovery uveitis are sight-threatening complications of CMV retinitis that require specific treatments.

The Global Education Network for Retinopathy of Prematurity (Gen-Rop): Development, Implementation, and Evaluation of A Novel Tele-Education System (An American Ophthalmological Society Thesis).

PURPOSE: To describe the design, implementation, and evaluation of a tele-education system developed to improve diagnostic competency in retinopathy of prematurity (ROP) by ophthalmology residents. METHODS: A secure Web-based tele-education system was developed utilizing a repository of over 2,500 unique image sets of ROP. For each image set used in the system, a reference standard ROP diagnosis was established. Performance by ophthalmology residents (postgraduate years 2 to 4) from the United States and Canada in taking the ROP tele-education program was prospectively evaluated. Residents were presented with image-based clinical cases of ROP during a pretest, posttest, and training chapters. Accuracy and reliability of ROP diagnosis (eg, plus disease, zone, stage, category) were determined using sensitivity, specificity, and the kappa statistic calculations of the results from the pretest and posttest. RESULTS: Fifty-five ophthalmology residents were provided access to the ROP tele-education program. Thirty-one ophthalmology residents completed the program. When all training levels were analyzed together, a statistically significant increase was observed in sensitivity for the diagnosis of plus disease, zone, stage, category, and aggressive posterior ROP (P<.05). Statistically significant changes in specificity for identification of stage 2 or worse (P=.027) and pre-plus (P=.028) were observed. CONCLUSIONS: A tele-education system for ROP education is effective in improving diagnostic accuracy of ROP by ophthalmology residents. This system may have utility in the setting of both healthcare and medical education reform by creating a validated method to certify telemedicine providers and educate the next generation of ophthalmologists.

Risk factors for retinopathy of prematurity: insights from outlier infants.

PURPOSE: To investigate the characteristics of outlier infants for insights into ROP risk. METHODS: Chart data were collected from 1,354 infants screened for ROP at Weill Cornell Medical Center and Columbia University Medical Center. ROP exam results and clinical risk factors were recorded. The cohort was stratified by weight, highest ROP stage, and need for ROP treatment. Descriptive and correlational statistics were performed. RESULTS: For the overall cohort, regression analysis found that birth weight (OR: 0.741 per 100 g; 95 % CI: 0.606, 0.905), gestational age at birth (OR: 0.563 per week; 95 % CI: 0.454, 0.697), multiple gestation (OR 2.02, 95 % CI: 1.15, 3.56), bronchopulmonary dysplasia (OR: 4.68, 95 % CI: 1.93, 11.35), and necrotizing enterocolitis (OR 2.80, 95 % CI: 1.40, 5.16) were independent risk factors for treatment-requiring ROP. Black race was found to be a protective factor for treatment-requiring ROP (OR 0.244, 95 % CI: 0.095, 0.626). Among 15 infants with BW <500 g, there were no significant differences in any clinical risk factors between the 12 (80 %) with ROP vs the three (20 %) without ROP. Similarly, among infants with BW >1500 g, the 17 (9 %) with ROP only differed from the 166 (91 %) without ROP with respect to a higher incidence of necrotizing enterocolitis among those with ROP (11.8 % vs 0 %). CONCLUSIONS: Although known clinical risk factors were predictive of ROP stage and need for laser treatment in this cohort, they were not significantly associated with ROP at extremes of birth weight. This suggests that other clinical, maternal, or genetic factors may protect from or predispose to ROP.

Histopathologic changes in punctal stenosis.

PURPOSE: To describe the pathologic changes in punctal stenosis by reporting the histopathologic findings in a series of punctoplasty specimens. METHODS: Observational retrospective chart review. Electronic health records of all patients having punctoplasty over a 2-year period at an academic oculoplastic practice were examined. All patients whose records included pathology reports were entered into a database. RESULTS: Twenty-four patients, representing 30 eyes, had pathology records in the electronic health records. Patients were 75% women and had an average age of 65 (19-88) years. Associated conditions included blepharitis (71%), dry eye syndrome, or Meibomian gland dysfunction (63%). Histopathologic examination demonstrated chronic inflammation in 11 eyes (36.7%), fibrosis in 7 eyes (23.3%), chronic inflammation and fibrosis in 4 eyes (13.3%), squamous metaplasia in 3 eyes (10%), normal conjunctival mucosa in 3 eyes (10%), and Actinomyces israelii canaliculitis in 2 eyes (6.7%). CONCLUSIONS: Nearly all histopathologic specimens revealed findings consistent with inflammation, fibrosis, or both. These findings provide evidence to support the hypothesis that the many etiologic causes of punctal stenosis are linked by a common pathophysiologic mechanism involving inflammation.

Temporal horizons in pain management: understanding the perspectives of physicians, physical therapists, and their middle-aged and older adult patients.

PURPOSE: The management of chronic noncancer pain (CNCP) involves trade-offs between immediate and delayed consequences of various treatments. Temporal trade-offs may be particularly salient for older adults because of age-related differences in prognosis and perceptions of future time. This study examined how perceptions of time influence the management of CNCP among patients and providers with particular emphasis on age differences. DESIGN AND METHODS: Focus groups were conducted with 28 CNCP patients (5 groups), 21 physicians (4 groups), and 23 physical therapists (3 groups). Audiotapes were transcribed and analyzed using standard qualitative methods. RESULTS: Analyses identified multiple aspects of time perceptions that are relevant to the management of CNCP: the long-term prognosis, the time horizon used for concrete treatment planning, and concerns about future side effects. Although there was some overlap, these aspects showed divergent patterns across age groups and between patients and providers. Patients and providers agreed that pain is more stable and chronic in older adults. Time horizons in treatment planning differed between patients who were present-focused and providers who were focused on longer term effects, but treatment horizons did not differ by patient age. Finally, although providers were more concerned about future side effects in older people, patients' concerns did not differ by age. IMPLICATIONS: Time horizons have practical implications for the quality of the patient-provider relationship and self-management of CNCP. A better understanding of the underlying mechanisms could inform interventions to reduce age disparities in pain care.