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Purpose: To describe a case of central retinal vein occlusion (CRVO) in a young adult found to have elevated homocysteine after bariatric surgery and to review risk factors for CRVO in younger patients. Observations: An 18-year-old female presented with a CRVO and severe cystoid macular edema (CME). She was normotensive, not on medications, and without known heritable hypercoagulable disease. Her medical history was notable for bariatric surgery and subsequently she was found to have nutritional deficiency, anemia, and elevated homocysteine. Her elevated homocysteine may have induced a hypercoaguable state that predisposed her to developing a CRVO. Treatment with bevacizumab dramatically improved her macular edema and visual acuity. Nutritional supplementation was initiated. Conclusions: Elevated homocysteine in the setting of nutritional deficiency from prior bariatric surgery may cause a hypercoaguable state and is a potential risk factor for CRVO. Importance: With the increasing prevalence of obesity and bariatric surgery, it is important to consider associated nutrient deficiency as a potential cause of induced hypercoagulability and increased risk for CRVO. Identification of these at-risk patients is especially important given this condition is easily treatable and may be present in younger individuals. To the best of our knowledge, this is the first reported case of a CRVO with elevated homocysteine in the setting of nutrient deficiencies from laparoscopic sleeve gastrectomy.

Purpose: To describe a case of pronounced papillitis with diminished venous outflow and vitreous inflammation in a 50-year-old man who was later found to have clinical and serological manifestations of dermatomyositis. Observations: A 50-year-old man presented with papillitis associated with venous congestion and intraocular inflammation. He was normotensive, not on medications, and without known heritable hypercoagulable or inflammatory disease. Review of systems revealed axial and proximal muscle pain involving the lower back, hip, and thigh, and he developed a transient rash of the scalp. His evaluation including infectious, hypercoagulable, and inflammatory etiologies was negative except for a significantly elevated Mi-2 antibody titer. Treatment with intravenous and oral steroids improved the papillitis, visual acuity and visual field deficit. Conclusions: Significant papillitis and retinal venous stasis with intraocular inflammation may be associated with dermatomyositis. Importance: Rapidly progressive optic disc edema with associated inflammation and venous stasis requires a broad work up for infectious, hypercoagulable, and autoimmune etiologies for targeted therapy and visual preservation. To the best of our knowledge, this may be the first reported clinical presentation of dermatomyositis manifesting initially with papillitis and retinal venous congestion, based upon elevated Mi-2 antibodies and additional clinical features.

Purpose: To describe the frequency and variation of intravitreal bevacizumab and ranibizumab use for branch retinal vein occlusion (BVO) in the United States (US). Methods: We obtained a 5% random sample of Medicare beneficiaries from the Medicare Denominator and Physician/Supplier Part B claims files from 2010 to 2013 and identified all beneficiaries with an ICD-9-CM code for branch retinal vein occlusion (BVO, 362.36). Patient age, gender, race, state of residence and Charlson Comorbidity Index (CCI) scores were collected. Healthcare Common Procedure Coding System (HSCPS) codes for bevacizumab (J3590, J9035, and J3490) and for ranibizumab (J2778) were used to identify the mode of treatment for each patient. Patients who met the following criteria were excluded from this study: (1) under 65 years of age; (2) residence outside of the 50 United States or the District of Columbia; (3) no Part-B coverage or with HMO coverage that was not processed by Centers for Medicare & Medicaid Services (CMS); (4) concomitant diagnosis of diabetic edema (ICD-9: 362.07) or central retinal vein occlusion (ICD-9: 362.35); and (5) received both or none of the above two treatments. Geographic variation was examined by comparing injection frequencies across the nine US census divisions using Chi-squared analysis. Results: During 2010–2013, a majority of the 3944 BVO patients who met the inclusion criteria received bevacizumab compared to ranibizumab (76.7% vs 23.3%). Most patients were aged 75–79 (22.0%) or 80–84 (22.0%), female (61.5%), white (88.3%), and had a CCI score of 1–2 (39.8%). The frequencies of bevacizumab and ranibizumab injections for BVO varied significantly between the US census divisions (p

Purpose. To evaluate the methodological quality of age-related macular degeneration (AMD) clinical practice guidelines (CPGs). Methods. AMD CPGs published by the American Academy of Ophthalmology (AAO) and Royal College of Ophthalmologists (RCO) were appraised by independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, which comprises six domains (Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence), and an Overall Assessment score summarizing methodological quality across all domains. Results. Average domain scores ranged from 35% to 83% for the AAO CPG and from 17% to 83% for the RCO CPG. Intraclass correlation coefficients for the reliability of mean scores for the AAO and RCO CPGs were 0.74 and 0.88, respectively. The strongest domains were Scope and Purpose and Clarity of Presentation. The weakest were Stakeholder Involvement (AAO) and Editorial Independence (RCO). Conclusions. Future AMD CPGs can be improved by involving all relevant stakeholders in guideline development, ensuring transparency of guideline development and review methodology, improving guideline applicability with respect to economic considerations, and addressing potential conflict of interests within the development group.