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Objective: To investigate the management impact of non‐mydriatic fundus photography (NMFP) implementation for appropriate ED patients; compare the diagnostic accuracy of direct ophthalmoscopy (DO) and NMFP, and determine the prevalence of fundus pathology in a regional Australian ED. Methods: This before/after crossover study prospectively enrolled patients presenting with headache, neurological deficit, visual disturbance and/or hypertensive urgency. Patients received DO examination, then separate NMFP examination. Emergency clinicians (ECs) were surveyed on their patient management plans following both DO examination and NMFP imaging. Telemedicine review of NMFP images was performed by an ophthalmologist within 48 h, and any additional management changes were documented. Results: The use of NMFP influenced changes in management in 52 (39%) of 133 enrolled patients (95% confidence interval 31–48%). Of these, 65% were escalations of management due to acute fundus pathology, while 35% were de‐escalating changes following normal fundus findings. ECs diagnostic accuracy for acute fundus pathology improved from 0% to 29% sensitivity, and 59% to 84% specificity using DO and NMFP respectively, and telemedicine registrar review increased this to 50% sensitivity and 86% specificity. The period prevalence of acute fundus pathology was 10.5% (95% confidence interval 6–17%). Conclusion: The addition of NMFP images can significantly impact the management of ED patients requiring fundus examination, facilitating expedited and optimised patient care. NMFP improves ECs diagnostic acumen for fundus pathology over DO examination and telehealth specialist review is important for diagnostic accuracy. There is a clinically important prevalence of fundus pathology in this regional ED setting. [ABSTRACT FROM AUTHOR]

A concussion occurs when a direct or indirect force is transmitted to the brain, causing a change in brain function. Given that approximately half the brain circuits are involved in vision and the control of eye movements, a concussion frequently results in visual symptoms. Ophthalmic abnormalities are helpful in the assessment of acute concussion, identified by rapid automized naming tasks and eye movement assessments. In particular, convergence, eye-tracking and the vestibular-ocular motor screening tool may be used. For patients suffering from post-concussion syndrome more than 3 months from the original injury, abnormalities may be found in convergence, accommodation and smooth pursuit. Orthoptic exercises are useful rehabilitation tools to allow patients to return to school, work and recreation. This article provides a brief overview of concussion as it relates to vision and ophthalmic practice. [ABSTRACT FROM AUTHOR]

Introduction: Ocular trauma can cause significant morbidity and is a leading cause of unilateral blindness. In multi-trauma, life- and sight-threatening injuries can co-occur causing increased complexity in the assessment and management of ocular injuries as the competing priorities in the severely injured must be balanced. We conducted a narrative review to determine how ophthalmology may be further integrated into a trauma service and/or the organisation of an ocular trauma service. Methods: The literature was reviewed via EMBASE, MEDLINE, CINAHL and Google Scholar utilising comprehensive search strategies and keyword searches. Our review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Results: The search yielded 437 articles, 30 studies met selection criteria and were included in the review. The included literature comprised guidelines, observational studies and reviews of registry data from Australia, England, the United States, Singapore, Iran and Israel. Conclusion: The Australian Trauma Model has clear guidelines for referral of trauma patients to ensure appropriate care of the severely injured. However, there are no clear guidelines for the integration of ophthalmology into trauma. Therefore, early referral to ophthalmology and streamlining of referral pathways of specialist care would improve the care of patients with ocular trauma. [ABSTRACT FROM AUTHOR]

Background: Weight loss is important in the management of idiopathic intracranial hypertension (IIH); however, extremely caloric restrictive diets have been used in published studies, which may not be practical for all patients. We aim to review the weight loss outcomes of IIH patients and weight loss methods used by patients who achieve clinical remission (CR) in a standard clinical setting. Methods: The medical records of IIH patients were retrospectively reviewed. Measures evaluated included: reported symptoms, visual acuity, retinal nerve fiber layer analysis, automated visual fields, optic disc appearance, and cessation of medications. Patients were divided into different outcome groups and weight changes were compared. Patients who achieved CR were contacted to assess weight loss methods used. Results: Of the 39 patients included in the analysis, 28 patients (71.8%) achieved CR with concomitant weight loss, 6 patients (15.4%) improved clinically with concomitant weight loss but did not achieve CR. Among the patients with CR, 10 patients (35.7%) were successfully weaned off their medications completely, whereas another 10 patients (35.7%) are in the process of this. Median weight loss from baseline to lowest weight for this group was 10.5 kg (11.5%) achieved using self-directed methods. Conclusion: This study demonstrated that a large proportion of IIH patients were able to achieve CR or improvement with self-directed weight loss regimens, reinforcing the evidence and the practicality of weight loss in the management of IIH in the clinical setting. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: In recent years, CTLA-4 and PD-1/PD-L1 checkpoint inhibitors have proven to be effective and have become increasingly popular treatment options for metastatic melanoma and other cancers. These agents work by enhancing autologous antitumor immune responses. Immune-related ophthalmologic complications have been reported in association with checkpoint inhibitor use but remain incompletely characterized. This study seeks to investigate and further characterize the neuro-ophthalmic and ocular complications of immune checkpoint blockade treatment. Methods: A survey was distributed through the secure electronic data collection tool REDCap to neuro-ophthalmology specialists in the North American Neuro-Ophthalmology Society listserv. The study received human subjects approval through the University of California at Los Angeles Institutional Review Board. The survey identified patients sent for neuro-ophthalmic consultation while receiving one or more of a PD-1 inhibitor (pembrolizumab, nivolumab, or cemiplimab); PD-L1 inhibitor (atezolizumab, avelumab, or durvalumab); or the CTLA-4 inhibitor ipilimumab. Thirty-one patients from 14 institutions were identified. Patient demographics, neuro-ophthalmic diagnosis, diagnostic testing, severity, treatment, clinical response, checkpoint inhibitor drug used, and cancer diagnosis was obtained. Results: The checkpoint inhibitors used in these patients included pembrolizumab (12/31), nivolumab (6/31), combined ipilimumab with nivolumab (7/31, one of whom also received pembrolizumab during their course of treatment), durvalumab (3/31), ipilimumab (2/31), and cemiplimab (1/31). Malignant melanoma (16/31) or nonsmall cell lung carcinoma (6/31) were the most common malignancies. The median time between first drug administration and the time of ophthalmological symptom onset was 14.5 weeks. Eleven patients had involvement of the optic nerve, 7 patients had inflammatory orbital or extraocular muscle involvement, 6 patients had ocular involvement from neuromuscular junction dysfunction, 4 patients had cranial nerve palsy, and 4 patients had non neuro-ophthalmic complications. Use of systemic corticosteroids with or without stopping the checkpoint inhibitor resulted in improvement of most patients with optic neuropathy, and variable improvement for the other ophthalmic conditions. Conclusion: This study describes the variable neuro-ophthalmic adverse events associated with use of immune checkpoint inhibitors and contributes a more thorough understanding of their clinical presentations and treatment outcomes. We expect this will increase awareness of these drug complications and guide specialists in the care of these patients. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 79-year-old woman with gradual onset bilateral temporal headache of moderate severity. Topics include identifying secondary headaches of significant morbidity and mortality in all ages; and containing giant cell arteritis (GCA), cerebral ischaemia, infection (meningitis, encephalitis), intracranial haemorrhage, or neoplasm cardiac cephalalgia and acute glaucoma.

X‐linked retinitis pigmentosa (XLRP) accounts for a significant proportion of certifiable blindness in working‐age adults. The objectives of this study were to: (1) synthesize the best available evidence regarding the natural history of disease progression and (2) identify the best current clinical biomarkers for monitoring disease progression, which will be important in planned gene therapy trials for this condition. Patient population: XLRP affected males. Main outcomes: A systematic review of the literature was undertaken with data sought on overall annual progression for clinical biomarkers using optical coherence tomography (OCT), fundus autofluorescence (FAF), visual acuity, electroretinography and visual fields. To assess which outcome was best for monitoring progression, data on reliability, interocular correlation and structure‐function correlation were extracted. A total of 17 studies met the inclusion criteria. Studies estimated progression at between 4% to 19% per year with longitudinal data. Where an overall model was produced with cross‐sectional data, the trend was usually best fit by a logarithmic function with an annual exponential decline rate between 4.7% and 8.0%. The evidence suggested the ellipsoid zone (EZ) width on OCT and outer ring area (ORA) on FAF as the most useful biomarkers having excellent interocular symmetry, reproducibility and functional correlation. Using different clinical biomarkers, XLRP progresses at a rate of 4 to 19% per year. Ellipsoid zone (EZ) width and ORA are the most robust biomarkers with the potential to be used in trials where one eye serves as a control for the other. [ABSTRACT FROM AUTHOR]