Tennessee Retina

In 2024, the American Society of Retina Specialists (ASRS) Research and Safety in Therapeutics (ReST) Committee became aware of reports of coring of vial stoppers in relation to preparation of intravitreal injections. A literature review was performed to further understand and characterize this occurrence within the context of retina practice and the broader medical community. Relevant articles were identified through a systematic search of PubMed using predefined criteria. Coring can be observed when a needle punctures the rubber stopper of a medication vial, pushing a small piece or pieces of the stopper material into the container and introducing extrinsic particles into the drug product. Factors associated with coring include larger gauge needles, perpendicular needle entry, multiple-use vials, and thicker rubber stoppers. Rubber stopper thickness and composition also influence the likelihood of coring. To prevent patient safety issues from coring, filter needles are commonly used to draw up medications from vials because they are effective in mitigating particulate matter from entering syringes. No documented cases of clinical complications related to coring in ophthalmology have been identified. Coring represents an unreported phenomenon in the preparation of intraocular medications. Although there have been no safety implications in retina practice related to coring and intravitreal drug vials, these reports underscore the importance of careful medication preparation, inspection of vials, the use of appropriate needles, and adherence to best clinical practices.

Uveal melanoma (UM) is an aggressive cancer of the eye that frequently results in metastatic death. UMs are most likely to metastasize when they are small, at a time when they are difficult to distinguish from benign nevi and often observed without treatment. Unfortunately, little is known about the early genetic evolution of UM or potential biomarkers to indicate small tumors undergoing malignant transformation. Here, we performed targeted next generation sequencing for the 7 canonical UM driver mutations in 1140 primary UMs, including 131 small early-stage tumors. We found that the evolutionary burst of genetic aberrations that determines the archetypal UM subtypes and metastatic propensity has already occurred by the time most small tumors are biopsied, although a significantly larger proportion of small tumors are still evolving compared to larger tumors. We found that the 15-gene expression profile (15-GEP) support vector machine discriminant score was the best indicator of tumors in transition from low-risk Class 1 to high-risk Class 2 signature. While BAP1, SF3B1 and EIF1AX mutations were associated with poor, intermediate and good prognosis, respectively, mutation analysis was inferior to the prospectively validated 15-GEP + PRAME expression classifier for predicting metastasis-free and overall survival. These results provide a more complete picture of genetic evolution in UM, and they move us closer to a molecular definition of malignant transformation in this cancer type.

To describe the patterns of ocular inflammation after coronavirus disease 2019 vaccination, assess underlying commonalities, and understand outcomes. Retrospective, multicenter cohort study, conducted between 2020 and 2021. Patients with no previous uveitis history ( de novo ) or a known uveitis history (recurrent) who developed ocular inflammation within 42 days of coronavirus disease 2019 vaccination were identified. Characteristics of the uveitis, treatment approaches, and clinical outcomes were assessed. Fifty-five eyes of 39 patients with ocular inflammation temporally related to vaccination were identified. Twenty-two patients (36 eyes) were de novo , while 17 (19 eyes) were recurrent. Anterior uveitis was most common. HLA-B27 positivity was found in 6 (27.2%) de novo patients, and 5 (29.4%) recurrent patients. Most patients required only observation, topical, or systemic corticosteroids. Among vaccinated patients, 12.3% of new uveitis referrals during the study period were related to coronavirus disease 2019 vaccination. Among patients with a history of quiescent uveitis, only 0.85% experienced a flare after vaccination. Most inflammation thought to be secondary to coronavirus disease 2019 vaccination achieved quiescence with observation or steroids, and the overall incidence is low. Anterior uveitis was the most common. HLA-B27 positivity occurred at a higher rate than reported in the baseline population.

We present a case of the development of invasive fungal sinusitis in a patient with acute Vogt-Koyanagi-Harada Disease (VKHD). Observational case report. A 39-year-old African American female presented with acute vision loss in both eyes and reported pain around her left eye. Examination revealed a bilateral posterior uveitis with significant macular edema and subretinal fluid in both eyes. Systemic and ocular findings were consistent with complete VKHD and the patient was put on oral glucocorticoids. At follow-up 2 weeks later, blood sugars were found to be severely elevated, and the patient was hospitalized. During hospitalization, the patient was taken off steroids. At follow-up, the uveitis appeared quiescent, but vision was still poor in the left eye. The patient reported a continued sense of pressure and now numbness around the left eye. An MRI revealed occult invasive fungal sinusitis and the patient was hospitalized for treatment. The patient recovered after surgery for debridement of the sinuses and several weeks of treatment with amphotericin B. At the most recent follow up, 18 months following the initial visit, the patient's visual acuity was 20/20 OD and 20/50 with eccentric viewing OS. Many forms of uveitis such as acute VKHD require use of oral glucocorticoids. However, proper use of glucocorticoids involves patient counseling on potential side-effects and the prescribing physician to identify potential life-threatening complications. In this case, failure to identify either the severely elevated blood sugars or occult fungal sinusitis could have resulted in significant patient morbidity or even mortality.

Purpose: To evaluate scenario of retinopathy of prematurity (ROP) in a tertiary eye care hospital. Methodology: This observational study was conducted at Department of vitreo retina in National Institute of Ophthalmology and Hospital (NIOH), Dhaka, from January 2023 to September 2023. Study population was taken among patients who had come for confirmation and treatment of ROP. The sampling method was purposive sampling. Inclusion criteria were preterm and low birth weight babies with confirmed ROP according to national guideline. Exclusion criteria was doubtful cases with peripheral avascular zone. Variables were age distribution, sex distribution, fetus count, gestational age, age during 1st examination in department of vitreo retina, birth weight, delivery place, oxygen intake, zone and stage of ROP and ROP treatment. A detailed history was taken. The clinical examination was performed and adequately recorded. A proforma was prepared to record the data on the particulars of the patients. Ethical principles were followed accordingly. Results: Maximum patients were male (62%). 25% babies were twins or triplets. Mean gestational age was 31.67 weeks. Mean birth weight was 1623 gm. Mean oxygen intake duration was 12.35 days. 81% babies had multiple complications. Maximum cases (30%) were APROP (Aggressive posterior retinopathy of prematurity ) followed by zone II stage 3 with plus disease (22%) and zone II stage 2 with plus disease (20%). Maximum patient were treated by injection Bevacizumab and ROP laser (46%) followed by ROP laser (28%) and observation (14%). Conclusion: ROP is one of the emerging causes of childhood blindness. Preterm and low birth weight babies with prolonged oxygen therapy in neonatal intensive care unit were the major cases of ROP in a tertiary eye care hospital. J.Natl.Inst.Ophthalmol. 2023; 6(2):24-31

Purpose: To investigate how home optical coherence tomography (OCT) influences the clinical decision-making of retina specialists for the management of neovascular age-related macular degeneration (nAMD). Methods: In this retrospective imaging review, 15 retina specialists each evaluated 10 home OCT data segments from 29 eyes being treated for nAMD. Based on OCT data, indications were identified for when eyes should be treated, which antivascular endothelial growth factor should be used, and the specific retinal fluid and time thresholds for notification. Results: Withholding treatment was recommended in 64 (42.7%) of 150 data segments (95% CI, 34.7-50.6), whereas 100% of eyes received treatment on the last day of each data segment. Treatment was recommended in 86 cases (57.3%), with treatment occurring 7 or more days before the actual treatment was advised in 52 (60.5%) of 86 data segments. This earlier treatment would have prevented the accumulation of intraretinal fluid (IRF), subretinal fluid (SRF), and total retinal fluid for 69.1 nL, 162.2 nL, and 231.2 nL days. Retina specialists chose a different type of treatment agent in 35 (40%) of 86 cases. The following notification values were set: IRF, mean 9.8 ± 14.9 nL (median, 5; IQR, 5); SRF, mean 10.2 ± 16.1 nL (median, 5.5; IQR, 5); total retinal fluid, mean 15.2 ± 24.0 nL (median, 10; IQR, 5). The time-based notification interval was set at a mean of 34.7 ± 21.9 days (median, 30; IQR, 2). Conclusions: Home OCT-based decision-making by retina specialists differed substantially from actual clinical care. Home OCT has the potential to facilitate personalized care in nAMD.

Purpose: To review the first Research and Safety in Therapeutics (ReST) Committee webinar and summarize the most current recommendations regarding diagnosis and management. Methods: The ReST Committee is comprised of members of the American Society of Retina Surgeons (ASRS). At regular internal meetings, safety issue reports from the website are reviewed. A webinar series was started in 2021 to update members on multiple relevant potential safety events. Results: Topics reviewed in the webinar included pentosan polysulfate sodium (Elmiron) maculopathy, intraocular pressure elevation reported with the aflibercept prefilled syringe (PFS), and brolucizumab-associated inflammation with occlusive retinal vasculitis. Retinal toxicity related to intraoperative medications was reviewed, including hemorrhagic occlusive retinal vasculitis after intraocular vancomycin, dilution errors with intravitreal aminoglycosides, inadvertent overdoses of cefuroxime after cataract surgery, and toxic posterior segment syndrome after dropless cataract surgery using compounded triamcinolone-moxifloxacin. Indocyanine green toxicity has been reported after its use as an adjuvant during macular hole surgery. Conclusions: The past decade has seen advances in retinal pharmaceuticals and drug-delivery devices. The ASRS ReST Committee collects data from its website reporting system to inform members about up-to-date pharmaceutical and device safety concerns. Recently, a webinar was used to inform members of pigmentary maculopathy associated with pentosan polysulfate sodium, safety regarding the aflibercept PFS, intraocular inflammation and occlusive retinal vasculitis secondary to brolucizumab, and retinal toxicity from intraoperative ocular medications.

The pending introduction of home-based optical coherence tomography (OCT) in managing neovascular age-related macular degeneration (nAMD) has sparked interesting debates. Advocates assert that home-based OCT will revolutionize care of patients with nAMD, while skeptics question its real-world viability and point out its potential drawbacks. This article delves into the dichotomy, presenting the "pro" argument highlighting the transformative potential of home OCT and the "con" perspective, which scrutinizes the limitations and challenges to adapting the technology to the real-world setting. By exploring both sides of the discourse, we aim to address the promises and complexities surrounding the role of home OCT in the management of nAMD.

Until recently, metastatic uveal melanoma was associated with essentially uniform fatality within months. However, recent developments in screening, improved understanding of the genetic underpinnings of metastatic disease, and pivotal medication approvals have improved the disease's rate of fatality. Routine implementation of genetic testing at the time of primary tumor treatment via gene expression profiling or chromosomal analysis has identified patients who are at high risk for metastatic disease. Enhanced screening with imaging directed at the liver and lungs has allowed for identification of early disease and lower tumor burden. Significant work on improved liver directed therapy along with systemic chemotherapy and immunotherapy has improved life expectancy. The first systemic immunotherapy specifically for metastatic uveal melanoma was approved this year. This medication, tebentafusp, is likely to improve life expectancy for all patients with metastatic melanoma assuming they have appropriate human leukocyte antigen (HLA) markers. Multiple clinical trials with novel immunotherapeutic agents are promising as well. The prognosis for patients with uveal melanoma is far better than ever before because of recent developments in the understanding and treatment of metastatic disease.

Purpose:To comparatively evaluate in Indian eyes with coexisting cataract and primary open-angle glaucoma the outcome of mitomycin C (MMC) and Ologen implant as adjunctives in combined phacoemulsification with trabeculectomy.Methods:Eyes with primary open-angle glaucoma that underwent trabeculectomy and phacoemulsification with IOL implantation with either MMC application or Ologen implant between June 2019 and February 2020 were followed up for 12 months. Thirty-four eyes of 34 participants were studied. The primary outcome was intraocular pressure (IOP), and the secondary outcomes were the number of ocular hypotensives, best distance visual acuity (BDVA), and bleb morphology.Results:In 16 eyes treated with MMC and 18 eyes treated with Ologen implant, it was observed that the mean postoperative IOP (14.62 ± 2.89 mm Hg with MMC and 14.56 ± 4.14 mm Hg with Ologen implant) was not significantly different in both groups (P = 0.47). Number of ocular hypotensives and BDVA were also comparable between the two groups. However, bleb morphology was better with Ologen implantation. One eye in the MMC group developed hypotony which was conservatively managedConclusion:MMC and Ologen are both effective adjunctives in combined phaco-trabeculectomy. However, the Ologen implant provides better bleb health and safety.