Research to Prevent Blindness

This brief communication was supported in part by an unrestricted grant from Research to Prevent Blindness, Inc. New York, NY. The author has no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Allen M. Putterman, M.D., Department of Ophthalmology, University of Illinois Medical College, 111 N. Wabash, Suite 1722, Chicago, IL 60602. E-mail: [email protected]

Rohowetz, Landon J. MD; Staropoli, Patrick MD; Hudson, Julia MD; Sridhar, Jayanth MDEditor(s): Grewal, Dilraj; Valikodath, Nita; Justin, Grant A. Author Information

To report the clinical presentation and outcomes in patients with Valsalva retinopathy. Retrospective case series of patients diagnosed with Valsalva retinopathy between June 1, 2010 and May 31, 2020. Clinical notes, operative reports, fundus photography, and optical coherence tomography images were reviewed. The study comprised 58 eyes of 58 patients. The most common causes were lifting (34.4%), vomiting (20.6%), straining (20.6%), and coughing (17.2%). Mean best-corrected visual acuity (BCVA) at diagnosis was 20/163. The most frequently involved vitreoretinal compartment was the subhyaloid space (42.3%) followed by the intraretinal (32.7%), intravitreal (23.1%), and subretinal (13.4%) spaces. Mean BCVA of all patients was 20/59 at 3 months, 20/48 at 6 months, and 20/22 at 1 year. Mean time to clearance of hemorrhage on clinical exam was 99.0 ± 18.7 days in patients who underwent observation and 4.5 ± 3.5 days after surgery in patients who received pars plana vitrectomy. Valsalva retinopathy is generally associated with a favorable visual prognosis. Most eyes perform well with observation although pars plana vitrectomy may be indicated in patients requiring rapid resolution of hemorrhage.

To describe a case of bilateral choroidal vascular malformations in a patient with hereditary hemorrhagic telangiectasia (HHT). Case report. A 78-year-old man with HHT was incidentally noted to have focal, large deep choroidal vessels on optical coherence tomography with corresponding elevation of the overlying retina. Indocyanine green angiography revealed dilated, intensely fluorescent vessels in arterial phase emptying into massively dilated choroidal veins consistent with choroidal arteriovenous malformation. This case presents multimodal imaging findings of choroidal arteriovenous malformations in HHT. Choroidal vascular malformations may represent an underrecognized clinical feature of this syndrome.

To describe an outbreak of late-onset toxic anterior segment syndrome (TASS) after the implantation of a specific hydrophilic acrylic intraocular lens (IOL). University Hospitals of Leuven, Belgium. Retrospective, single-center, observational study. All eyes undergoing cataract surgery with a monofocal, toric, or enhanced depth-of-focus (EDoF) Synthesis (Cutting Edge) IOL between August 2019 and March 2020 were reviewed. Data were collected on the surgical procedure, postoperative course, time until onset of symptoms, clinical features, and additional treatments. A laboratory surface analysis of all 3 IOL subtypes was performed in the Intermountain Ocular Research Center at the University of Utah, USA. Furthermore, other possible causes of prolonged postoperative inflammation rather than the IOL itself were investigated. Among the 203 eyes included, 28 TASS cases were identified (13.8%), among which 25 received a monofocal IOL, and 3 received an EDoF IOL. The mean time until onset was 28.9 (±19.9) days. Patients presented with anterior chamber cells (92.9%), deposits on the IOL (57.1%), or fibrinous inflammation (35.7%). 4 eyes (14.3%) underwent a surgical intervention, whereas 24 eyes showed a resolution of inflammation with topical therapy alone. Laboratory analysis showed the presence of both aluminum and silicon particles on the monofocal IOL, silicon particles only on the EDoF IOL, and no particles on the toric IOL surface. This report describes an outbreak of atypical, late-onset TASS after cataract surgery, possibly correlated with aluminum and silicon contamination of the IOL surfaces.

We thank Sandali et al. for their thoughtful comments. We are delighted to learn that their experience in regard to safety and visual recovery associated with 3D digital visualization and use of lower coaxial illumination levels during cataract surgery is also a positive one. Although we did not formally examine the relationship between lower coaxial illumination levels and patient impressions of reduced photophobia and improved operative tolerance during cataract surgery, we agree with Sandali et al. and have anecdotally found this to be the case as well. For example, one young man with keratoconus was only able to tolerate the procedure at a 5% (of maximum) light intensity level; the 3D digital visualization system allowed sufficient visualization at that illumination level for the procedure to be performed safely. In regard to the possible association between a faster visual recovery and use of 3D digital visualization and lower coaxial illumination levels, we find the observations of Sandali et al. most interesting and a direct correlation with our own results. Nevertheless, as they elaborate so well, the speed of visual recovery likely depends not only on intraoperative light intensity levels but also on preoperative macular integrity, as well as probably a host of other factors. In our study, all patients had no known history of retinal pathology, and all patients exhibited grossly normal preoperative macular ocular coherence tomography (Spectralis, Heidelberg Engineering) studies—with the exception of 1 patient in the 3D digital visualization group with evidence of moderate age-related macular degeneration. That said, an even more in-depth and extensive preoperative and postoperative analysis of macular anatomy and function, perhaps expanded to other relevant tests such as fundus autofluorescence, optical coherence tomography angiography, and focal electroretinograms, would be of great value, and we hope future studies incorporate this type of analysis. Sandali et al. also astutely point out that the presence of corneal edema on postoperative day 1 would affect the analysis of visual recovery times. We attempted in this study to control for this by selecting patients with only mild to moderate cataracts and no ocular comorbidities that would predispose to a postoperative complication such as corneal edema. And, in fact, no patient in either the 3D digital or the analog microscope visualization group was found to exhibit clinically apparent corneal edema postoperatively. That said, formal corneal thickness measurements offer an added level of precision, and we hope to see future studies incorporating this type of measurement. Again, we appreciate the superb and detailed insights offered by Sandali et al. In aggregate, the pilot studies from our group, as well as theirs, suggest that cataract surgery can be performed safely with greatly reduced illumination, and the putative benefits of reducing intraoperative light levels deserve our most careful characterization.

Serratia marcescens is a frequent ocular bacterial pathogen implicated in keratitis, endophthalmitis, and conjunctivitis. We evaluated the risk factors and treatment outcomes of ocular infections due to S. marcescens. In this retrospective observational study, all S. marcescens-positive cases between February 2002 and February 2020 were reviewed for ocular risk factors that included log of minimal angle of resolution visual acuity (VA), medical management, and time to epithelial defect closure. Fifty-one patients were identified (72.5% females, 46.8±23.3 years). Forty-six patients had complete medical records, and 5 had microbiology data available. The most prevalent ocular risk factors were, contact lens (CL) use (68.6%), corneal disease (52.9%), and history of ocular surgery (41.2%). Mean presenting VA was 1.3±1.0. About half of the patients presented with a central ulcer (49%, 25), large infiltrate (20.4±31.8 mm2 mean), and hypopyon (43.1%, 22). All cases were reported to be susceptible to ciprofloxacin. Defect closure occurred in 52.3±117.1 days and final VA was 0.86±0.88. Adjunctive treatments were required in 14 cases (27.5%). One patient underwent surgical intervention. Features associated with poor VA outcomes included, history of glaucoma (P=0.038), older age at presentation (P<0.001), presence of hypopyon (0.045), poor VA at presentation (0.0086), time to epithelial defect closure (0.0196), and large infiltrate size (P=0.0345). S. marcescens keratitis and conjunctivitis is associated with CL use and history of ocular surface disease. Worse outcomes were associated with older age, infiltrate size, presence of hypopyon, worse initial VA, longer time to epithelial defect closure, and history of glaucoma.

Ocular injuries occur frequently in sports, affecting the globe, surrounding soft tissues, and the orbital bony structure. This review provides the craniofacial surgeon a broad general overview of epidemiology, mechanism of disease, and prevention.

To report outcomes of secondary intraocular lens (IOL) implantation in the Infant Aphakia Treatment Study (IATS). Multicenter clinical practice. Secondary analysis of patients enrolled in a randomized clinical trial. Details regarding all secondary IOL surgeries conducted in children enrolled in the IATS were compiled. Visual outcomes, refractive outcomes, and adverse events at the age of 10½ years were evaluated. Comparisons were made with eyes that remained aphakic and with eyes randomized to primary IOL placement. The study included 114 infants, 57 in the aphakic group and 57 in the primary IOL group; 55 of 57 patients randomized to aphakia with contact lens correction were seen for the 10½-year study visit; 24 (44%) of 55 eyes had secondary IOL surgery. Median age at IOL surgery was 5.4 years (range 1.7 to 10.3 years). Mean absolute prediction error was 1.00 ± 0.70 diopters (D). At age 10½ years, the median logarithm of the minimum angle of resolution visual acuity (VA) was 0.9 (range 0.2 to 1.7), similar to VA in the 31 eyes still aphakic (0.8, range 0.1 to 2.9); the number of eyes with stable or improved VA scores between the 4½-year and 10½-year study visits was also similar (78% secondary IOL eyes; 84% aphakic eyes). For eyes undergoing IOL implantation after the 4½-year study visit (n = 22), the mean refraction at age 10½ years was -3.20 ± 2.70 D (range -9.90 to 1.10 D), compared with -5.50 ± 6.60 D (n = 53, range -26.50 to 3.00 D) in eyes with primary IOL (P = .03). Delayed IOL implantation allows a more predictable refractive outcome at age 10½ years, although the range of refractive error is still large.

To examine the effect of teaching experience of supervising surgeons on resident cataract surgery intraoperative complication rates. Zuckerberg San Francisco General Hospital, University of California San Francisco, USA. Retrospective chart review. Cataract surgeries performed by University of California San Francisco (UCSF) ophthalmology residents from 2010 to 2017 were reviewed. Only cases supervised by anterior segment attendings with more than 10 years of postresidency surgical experience were included. Cases were categorized as being supervised by either full-time UCSF teaching attendings or volunteer private practice attendings. Cases were graded as low risk (0 risk factors), intermediate risk (1 risk factor), or high risk (≥2 risk factors) based on 8 preoperative and intraoperative risk factors. Complication rates were compared between the 2 attending groups among varying risk grades. Of 1377 cases, 101 developed complications. Among low-risk cases, full-time teaching attendings (25/619 [4.04%]) had a similar complication rate to volunteer attendings (17/387 [4.39%]) (odds ratio [OR] 0.92; P = .79). In intermediate-risk cases, full-time teaching attendings (28/195 [14.36%]) had slightly worse complication rates than volunteer attendings (10/88 [11.36%]) (OR 1.63; P = .45). High-risk cases had the highest complication rates, with the complication rates of full-time teaching attendings (16/72 [22.22%]) somewhat lower than those of volunteer attendings (5/16 [31.25%]) (OR 0.64; P = .48). For low-risk resident-performed cataract surgeries, supervision by full-time faculty and volunteer attendings yielded similar complication rates; thus, residency programs might safely recruit volunteer attendings to supervise low-risk cataract surgeries to support resident training. The analysis of higher-risk cases was limited by a low surgical volume.