Search

Amir Akhavanrezayat,1 Wataru Matsumiya,1,2 Prapatsorn Ongpalakorn,1 Hashem H Ghoraba,1 Chris Or,1 Hassan Khojasteh Jafari,1 Gunay Uludag Kirimli,1 Cigdem Yasar,1 Ngoc Trong Tuong Than,1 Irmak Karaca,1 Moosa Zaidi,1 Azadeh Mobasserian,1 Negin Yavari,1 Vahid Bazojoo,1 Yong Un Shin,1 Albert John Bromeo,1 Quan Dong Nguyen1 1Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA; 2Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, JapanCorrespondence: Quan Dong Nguyen, Spencer Center for Vision Research, Byers Eye Institute at Stanford University, 2452 Watson Court, Suite 200, Palo Alto, CA, 94303, USA, Tel +1 650 723 9386, Email ndquan@stanford.eduPurpose: To report a case of neurosarcoidosis (NS) who was initially diagnosed as Coccidioidomycosis immitis (CI) infection.Observations: A 57-year-old diabetic man presented with sudden painless diminution of vision, metamorphopsia, and color vision deficits in the left eye (OS) for one month. His vision was 20/20 in the right eye (OD) and 20/40 OS. Ophthalmic examination revealed left relative afferent pupillary defect, blurred optic nerve margin, creamy chorioretinal infiltration around the optic disc, and mild macular edema. OD examination was non-revealing. Chest CT scan with contrast showed calcified mediastinal lymph nodes, but biopsy of the lymph nodes was normal. Brain and orbit MRI demonstrated soft tissue abnormality with enhancement in left orbital apex with involvement of the extraocular muscles. CSF culture was negative, but complement fixation had positive titer of 1:2 for CI. The patient was diagnosed with CI meningitis, and antifungal therapy was initiated. Slight visual and symptomatic improvement was observed, which was not completely satisfactory. Biopsy of extraocular orbital muscle five months later revealed non-caseating granulomatous inflammation, leading to initiation of prednisone trial therapy. Nine months later, the patient was referred to a tertiary center owing to persistence of optic disc edema OS. PET CT was consistent with a diagnosis of sarcoidosis. Antifungal treatment was discontinued, and oral prednisone with methotrexate was initiated. Subsequently, methotrexate was replaced by infliximab to further manage ocular inflammation and neurologic symptoms which was effective. Vision was 20/20 OD and 20/30 OS at the most recent visit.Conclusion and Importance: Signs and symptoms of neurosarcoidosis and coccidioidomycosis can be similar and deceiving. The index case underscores importance of considering appropriate differential diagnoses in patients with similar symptoms and signs who may respond to preliminary designated treatment but not to the optimal extent. Considering such possibility could assist clinicians in managing the patients timely and efficiently.Keywords: neurosarcoidosis, coccidioidomycosis, sarcoidosis, ocular involvement

Albert John Bromeo,1 Patricia Grulla-Quilendrino,1 Sweet Jorlene Lerit,1 Myron Carlo Gomez,1 Cheryl A Arcinue,1,2 Ralph Anthony De Jesus,1 Amadeo Veloso Jnr1 1Asian Eye Institute, Makati, Philippines; 2Department of Ophthalmology and Visual Sciences, Philippine General Hospital, University of the Philippines - Manila, Manila, PhilippinesCorrespondence: Albert John BromeoAsian Eye Institute, 9th Floor, PHINMA Plaza, Rockwell Center, Makati, PhilippinesTel + 63 02 8898 2020Email albert.bromeo@gmail.comPurpose: The aim of this study was to assess the changes in clinical practice patterns among retina specialists in the Philippines in response to the coronavirus disease 2019 (COVID-19) pandemic.Materials and Methods: This was a multi-center cross-sectional study based on a self-reported online survey. An online questionnaire was distributed among practicing retina specialists in the Philippines as listed in the database of the Vitreo-Retina Society of the Philippines using a combination of convenience and snowball sampling. The questionnaire contained questions regarding changes in clinic set-up, laser procedures, intravitreal injections, vitreoretinal surgery, and long-term outlooks.Results: A total of 48 responses were recorded and analyzed with a view rate of 41.7%. There was a decrease in the number of clinic consults, laser procedures, intravitreal injections, and vitreoretinal procedures with most reporting only 1– 25% of their usual patient load. Several modifications in clinic protocols have been made, including use of personal protective equipment, adjustments in clinic hours, and scheduling of only urgent cases. The adjustments implemented during the pandemic are expected by most respondents to be long-term changes.Conclusion: Retina specialists in the Philippines have implemented changes in their practices to combat COVID-19, following guidelines issued by the local and international governing bodies on health.Keywords: COVID-19, pandemic, practice patterns, retina, vitreoretinal surgery

Albert John Bromeo, Nilo Vincent FlorCruzDepartment of Ophthalmology and Visual Sciences, Philippine General Hospital, University of the Philippines Manila, Manila, PhilippinesCorrespondence: Albert John BromeoSentro Oftalmologico Jose Rizal, Philippine General Hospital, Taft Avenue, Manila, PhilippinesTel/fax +63 02 554 8400Email albert.bromeo@gmail.comPurpose: To determine the incidence of ocular hypertension following surgery for rhegmatogenous retinal detachment in the first 3 months postoperatively and to determine their outcomes in terms of visual acuity, control of IOP, and changes in cup:disc ratio.Patients and methods: A single center prospective cohort study was done involving patients who underwent retinal surgery for rhegmatogenous retinal detachment. The patients were followed up for 3 months postoperatively and were monitored for development of ocular hypertension. The primary outcome measures were changes in IOP, visual acuity, and cup:disc ratio.Results: Of the 52 eyes enrolled in the study, 19 eyes developed ocular hypertension in the first 3 months postoperatively, giving an incidence rate of 36.5% (95% CI, 48.9–76.0%). Analysis of mean IOP trends shows that most cases of IOP elevations occur in the first day postoperatively with a sustained elevation up to the first month and then returning to normal levels by the 3rd month. There is a significant increase in mean cup:disc ratio among patients who developed ocular hypertension (p=0.047). Visual acuity trends show that mean visual acuity significantly improved from baseline among cases who maintained normal IOP (p=0.002) as compared to those who developed ocular hypertension (p=0.97), although the difference in final visual acuity at the end of 3 months between groups was not statistically significant (p=0.30).Conclusion: Ocular hypertension may complicate retinal reattachment surgery. Control of IOP in the acute setting is essential to prevent development of secondary glaucoma.Keywords: intraocular pressure, ocular hypertension, retinal detachment surgery, secondary glaucoma

Purpose: To evaluate risk factors associated with development of anti-adalimumab antibodies (AAA) in patients with non-infectious uveitis treated with adalimumab., Methods: A retrospective, cross-sectional, case-control study was done evaluating patients with non-infectious uveitis treated with adalimumab for at least 12 months and have undergone testing for AAA levels. Demographics, clinical characteristics, grading of ocular inflammation, and previous and concomitant immunomodulatory therapy were assessed. Univariate and multivariate analysis were done to estimate odds ratio (OR) with 95% confidence intervals for the various risk factors., Results: A total of 31 patients were included in the analysis, in which 12 patients who tested positive (Group 1) were matched with 19 patients who tested negative for AAA (Group 2). The groups differed significantly in terms of sex (female) (91.7% vs 52.6%, p = 0.046), presence of systemic disease (91.7% vs 42.1%, p = 0.008), and presence of anterior chamber inflammation at baseline (100% vs 63.2%, p = 0.026). A history of interruption in anti-TNF therapy prior to starting or restarting adalimumab was found to have an increased odds for development of AAA (OR 16.89 [2.92, 107.11], p = 0.008), as well as flare-ups (reactivation of disease) during adalimumab therapy (OR 6.77 [1.80, 61.80], p = 0.027). Weekly dosing of adalimumab was shown to decrease odds of AAA development (OR 0.34 [0.02, 0.70], p = 0.040), while concomitant anti-metabolite therapy was not shown to be a statistically significant protective factor (OR 2.22 [0.50, 9.96], p = 0.148)., Conclusions: History of interruption in anti-TNF therapy and flare during adalimumab were associated with development of AAA, while weekly dosing of adalimumab was protective against AAA. Identification of those with higher risk of developing AAA may guide in clinical decision making to optimize management for these patients., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Published by Elsevier Ltd.)

Background: To analyze the changes in foveal avascular zone (FAZ) area, perimeter, and circularity in the superficial (SCP) and deep (DCP) capillary plexuses in eyes with diabetic macular edema (DME) treated with intravitreal anti-VEGF using optical coherence tomography angiography (OCTA)., Methods: This prospective observational study included 56 eyes from 32 patients with DME that received intravitreal anti-VEGF. OCTA images were obtained at baseline and 1, 3, and 6 months of follow-up. The outcome measures were FAZ area, perimeter, and circularity in both the SCP and DCP, as well as central subfield thickness (CST) and best-corrected visual acuity (BCVA)., Results: The mean number of intravitreal anti-VEGF injections received during the observation period was 4.60 ± 0.82 (range: 3-6). The FAZ area, perimeter, and circularity were statistically unchanged at all observation points in both the SCP (p = 0.772, p = 0.405, p = 0.157, respectively) and the DCP (p = 0.620, p = 0.769, p = 0.481, respectively). Despite having no change in the FAZ parameters, there was still a statistically significant decrease in CST (p < 0.001) as well as a statistically significant increase in BCVA (p = 0.004) during the observation period., Conclusions: The FAZ area, perimeter, and circularity in the SCP and DCP as measured by OCTA remained stable during the first 6 months of intravitreal anti-VEGF therapy in eyes with DME. While there were no significant changes in the FAZ, treatment with intravitreal anti-VEGF still resulted in decreased CST and improved BCVA., (© 2022. The Author(s).)

Retinitis pigmentosa can be associated with exudative vasculopathy in rare instances, which can manifest as retinal vasoproliferative tumours. We present the case of a 33-year-old woman previously diagnosed with retinitis pigmentosa sine pigmentosa in both eyes. She was asymptomatic and just came in for a routine follow-up eye examination. Thorough examination of the peripheral retina on the right eye revealed a dome-shaped retinal tumour with a feeder vessel and surrounding exudative changes at the superotemporal periphery, consistent with a secondary retinal vasoproliferative tumour from retinitis pigmentosa. She subsequently underwent focal laser photocoagulation of the tumour which resulted in tumour stabilisation. While exudative vasculopathy is very uncommon in retinitis pigmentosa, ophthalmologists need to be aware of its occurrence in such patients. Vision loss may occur from exudation, haemorrhage, retinal detachment and neovascularisation. A thorough examination of the peripheral retina is warranted in these cases., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Tractional retinal detachment is an uncommon complication of intravitreal anti-vascular endothelial growth factor (VEGF) injection wherein the drug triggers tractional retinal detachment as a result of fibrovascular membrane contraction. We present a case of a 42-year-old hypertensive woman diagnosed with chronic central retinal vein occlusion on both eyes. The right eye had total retinal detachment and neovascular glaucoma, while the left eye had retinal neovascularisation. Panretinal photocoagulation and intravitreal anti-VEGF injection was started on the left eye. However, she was lost to follow-up. She returned 4 months later with extensive tractional retinal detachment involving the macula on the left eye. She subsequently underwent vitrectomy with endolaser and silicone oil tamponade on the left eye. The anti-VEGF 'crunch' results from regression of fibrovascular proliferation with a concurrent increase in fibrosis, resulting in worsening retinal traction. With the widespread use of anti-VEGF agents, ophthalmologists need to be aware of this vision-threatening complication., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

A 36-year-old woman presented with eye pain and blurring of vision in her right eye. On eye examination, it was noted that there were angle-closure glaucoma and anterior uveitis in both eyes. Ocular ultrasound showed short axial lengths as well as a choroidal thickening in both eyes, confirming the diagnosis of nanophthalmos. Nanophthalmos is a condition where the eye is abnormally short, resulting in axial hyperopia and predisposing it to angle-closure glaucoma. The patient was initially managed medically, but the glaucoma was intractable. The patient underwent repeated sessions of transscleral cyclophotocoagulation which eventually lowered the intraocular pressure. The management of nanophthalmic eyes can be quite challenging due to the risk of inciting uveal effusion syndrome with any form of intraocular surgery. Controlled and repeated sessions of transscleral cyclophotocoagulation may be considered as a viable management option in these cases., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

A 3-year-old woman presented with a large ulcerated lesion involving the left upper eyelid and left earlobe with erythematous, swollen, undermined and advancing borders. Culture of the ulcer showed no growth of organisms. Treatment with empiric intravenous and topical antibiotics showed no improvement. Workup revealed an elevated white blood cell count with elevated neutrophil count, elevated erythrocyte sedimentation rate and C reactive protein and positive antinuclear antibody. A skin biopsy showed a neutrophilic dermatitis with vasculitis. The patient was started on oral prednisone, which resulted in halting of the progression of ulceration and clinically decreased skin inflammation. The skin biopsy and positive response to corticosteroids confirmed the diagnosis of pyoderma gangrenosum. Pyoderma gangrenosum is a rare inflammatory skin condition and rarely presents as lesions of the eyelid. Early initiation of immunosuppressive therapy prevents disfigurement. Eyelid reconstruction in these cases may prove to be difficult., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)