Murtaza K. Adam

MINIMAL ENDOILLUMINATION LEVELS AND DISPLAY LUMINOUS EMITTANCE DURING THREE-DIMENSIONAL HEADS-UP VITREORETINAL SURGERY.

Purpose: To determine minimal endoillumination levels required to perform 3-dimensional heads-up vitreoretinal surgery and to correlate endoillumination levels used for measurements of heads-up display (HUD) luminous emittance. Methods: Prospective, observational surgical case series of 10 patients undergoing vitreoretinal surgery. Endoillumination levels were set to 40% of maximum output and were decreased at set intervals until the illumination level was 0%. Corresponding luminous emittance (lux) of the HUD was measured 40 cm from the display using a luxmeter (Dr. Meter, Model #LX1010BS). Results: In 9 of 10 cases, the surgeon felt that they could operate comfortably at an endoillumination level of 10% of maximum output with corresponding HUD emittance of 14.3 ± 9.5 lux. In the remaining case, the surgeon felt comfortable at a 3% endoillumination level with corresponding HUD emittance of 15 lux. Below this threshold, subjective image dimness and digital noise limited visibility. Endoillumination levels were correlated with luminous emittance from the 3-dimensional HUD (P < 0.01). The average coefficient of variation of HUD luminance was 0.546. There were no intraoperative complications. Conclusion: With real-time digital processing and automated brightness control, 3-dimensional HUD platforms may allow for reduced intraoperative endoillumination levels and a theoretically reduced risk of retinal phototoxicity during vitreoretinal surgery.

Quality and diagnostic utility of mydriatic smartphone photography: The smartphone ophthalmoscopy reliability trial

BACKGROUND AND OBJECTIVE Establish quality and diagnostic utility of mydriatic smartphone ophthalmoscopy (SO) fundus images compared to fundus camera (FC) images. PATIENTS AND METHODS In this prospective, cross-sectional study, 94 consecutive patients in an urban eye emergency department underwent SO and FC fundus imaging via one of three study arms: medical student 1 (MS1), medical student 2 (MS2), and ophthalmology resident (OR). Images of 188 eyes were graded for overall quality by two masked reviewers, and observed critical fundus findings were compared to dilated fundus examination documentation. RESULTS SO images were higher quality in the OR arm than in the MS1 and MS2 arms (P < .017). There were no differences in FC image quality between photographers (all P > .328). In the OR arm, SO images detected 74.3% of critical fundus findings, whereas FC images detected 77.1%. CONCLUSION SO produces fundus images approaching the quality and diagnostic utility of traditional FC photographs.

HEMORRHAGIC OCCLUSIVE RETINAL VASCULITIS AND NONHEMORRHAGIC VASCULITIS AFTER UNCOMPLICATED CATARACT SURGERY WITH INTRACAMERAL VANCOMYCIN.

Purpose: To describe two cases of vasculitis: one hemorrhagic and one nonhemorrhagic after uncomplicated cataract surgery with intracameral vancomycin. Methods: Retrospective case series. Results: A 74-year-old female and a 54-year-old female developed severe visual loss within 2 weeks of uncomplicated cataract surgery with intracameral vancomycin. The first patient developed a fulminant hemorrhagic vasculitis, whereas the second patient developed a less severe nonhemorrhagic vasculitis. Partial visual recovery and prevention of neovascular glaucoma was achieved using a combination of topical, oral, and intravitreal corticosteroids, along with intravitreal antivascular endothelial growth factor agents in the first patient and a combination of topical and oral corticosteroids alone in the second patient. Conclusion: Hemorrhagic occlusive retinal vasculitis and nonhemorrhagic vasculitis after uncomplicated cataract surgery with intracameral vancomycin have been rarely reported. Early recognition and treatment may prevent devastating visual outcomes.

Radial versus raster spectral-domain optical coherence tomography scan patterns for detection of macular fluid in neovascular age-related macular degeneration

Background/aims To compare the 12-line radial to the 25-line raster spectral-domain optical coherence tomography (SD-OCT) acquisition patterns at detecting intraretinal or subretinal fluid in eyes with neovascular age-related macular degeneration (AMD). Methods Retrospective cross-sectional analysis of 200 eyes with neovascular AMD. Sequential 12-line radial and 25-line raster scans were evaluated for the presence of intraretinal/subretinal fluid. Results A total of 394 SD-OCT scans were interpreted (1.97 scans per eye). The 12-line radial detected intraretinal/subretinal fluid in all but 7 of 394 scans (1.7%; 95% CI 0.7% to 3.6%), resulting in a sensitivity of 98.3%. The 25-line raster detected intraretinal/subretinal fluid in all but 10 of 394 scans (2.5%; 95% CI 1.2% to 4.6%), resulting in a sensitivity of 97.5%. This small difference in fluid detection between the two acquisition patterns for neovascular AMD was not found to be statistically significant (p=0.6276). Conclusions The 12-line radial scan is statistically comparable with the 25-line raster scan in detecting the presence of intraretinal/subretinal fluid in neovascular AMD. The 12-line radial SD-OCT pattern alone may be adequate to guide day-to-day clinical decisions in a more time-efficient manner.

Enhanced depth imaging optical coherence tomography of precursor cell leukemic choroidopathy before and after chemotherapy.

Serous retinal detachment (SRD) can be the initial manifestation of leukemia. Herein, we explore the retinal and choroidal features on enhanced depth imaging optical coherence tomography (EDI-OCT) of SRD in a patient with undiagnosed leukemia. A 23-year-old male developed blurred visual acuity of 20/200 in the right eye oculus dexter (OD) and 20/200 in the left eye oculus sinister (OS). Funduscopically, he manifested serous macular detachment in both eyes oculi uterque (OU) without hemorrhagic retinal abnormalities. EDI-OCT disclosed macular detachment OU and homogeneous, marked choroidal opacification with thickening to 724 ΅m OD and estimated >600 ΅m OS and with loss of choroidal detail OU. Peripheral blood smears revealed severe thrombocytopenia and normal leukocyte count. Peripheral cytochemisty, immunophenotyping, and bone marrow aspirate confirmed the presence of atypical lymphoblasts, fulfilling criteria for precursor cell leukemia. Following systemic chemotherapy, the visual acuity improved to 20/25 OD and 20/20 OS. On EDI-OCT, the choroidal thickening resolved to 431 um OD and 443 um OS, leaving a normal choroidal appearance. Massive choroidal infiltration with leukemic cells could be the cause of serous macular detachment found in patients with newly diagnosed leukemia.

25-gauge Trocar Cannula For Acute Endophthalmitis-related In-office Vitreous Tap And Injection: Patient Comfort and Physician Ease of Use.

Purpose: To assess comfort and procedural facility using a 25-gauge trocar cannula as a port to diagnose and treat acute endophthalmitis compared with a standard vitreous tap and injection technique. Methods: Eighteen consecutive patients with acute endophthalmitis were randomized into two treatment arms: 1) Standard vitreous tap and injection technique, and 2) A technique where a valved 25-gauge trocar cannula is inserted through the pars plana as done in sutureless vitrectomy surgery and subsequent vitreous sampling and injections are performed through the port. A standardized anesthetic protocol was used and subjects were masked to the technique performed. Primary outcomes measured were patient comfort using a Wong–Baker pain scale and standardized physician ease-of-use scoring scale. Secondary outcomes included vitreous sampling success rate and volume of vitreous sample. Results: No significant differences were found when comparing patient comfort (P = 0.340), physician ease-of-use scores (P = 0.796), vitreous sample volume (P = 0.149), successful vitreous taps (P = 0.620), and microbiologic yield (P = 1.000) between treatment arms. There were no adverse events. Conclusion: The 25-gauge trocar technique provides a safe, well-tolerated, and equally effective alternative to the standard vitreous tap and injection technique for delivery of intravitreal antibiotics, and procuring of vitreous sample, requiring a single sharp penetration.

Optical Coherence Tomography Findings in Endogenous Fungal Chorioretinitis, Retinitis, and Endophthalmitis

BACKGROUND AND OBJECTIVE To describe spectral-domain optical coherence tomography (SD-OCT) findings in eyes with endogenous fungal chorioretinitis and endophthalmitis. PATIENTS AND METHODS Retrospective, observational case series of subjects at Wills Eye Hospital and William Beaumont Hospital were identified by screening OCT billing data and cross-referencing with patient charts. Clinical and imaging data were collected for each patient and reviewed. RESULTS Twelve eyes of seven consecutive patients were identified, demonstrating two patterns of posterior ocular involvement: chorioretinal infiltration and superficial retinal/retinal vascular infiltration without choroidal involvement. Six of 12 eyes had follow-up imaging performed after antifungal treatment, which demonstrated decreased size of choroidal and/or retinal infiltrates. CONCLUSIONS All patients with follow-up imaging had anatomic improvement by OCT of the lesions with treatment. In the future, OCT imaging may provide a method to assess therapeutic response and prognosis for visual recovery in patients with endogenous fungal ocular disease. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:894-901.].

Funduscopic Screening of Fungemic Patients: where we Stand

Candida and other fungal species account for approximately 9.5% of nosocomial bloodstream infections in the United States, with an incidence of 4.6 per 10,000 admissions [1]. Patients with a history of diabetes, indwelling lines/catheters, hyperalimentation, and immunocompromise are at increased risk for fungal bloodstream infections [2-5]. Dissemination of fungal organisms to the eye can occur via hematogenous seeding of small retinal and choroidal capillaries. Localized ocular fungal proliferation can progress to focal or multifocal inflammatory lesions manifesting as chorioretinitis and subsequent abscess formation and vitreous seeding can then lead to frank endophthalmitis. Fungal chorioretinitis and endophthalmitis carry the potential to cause devastating vision loss. Early recognition and prompt treatment can confer more favorable outcomes [6]. Previous studies in a variety of clinical settings not necessarily applicable to the modern tertiary care hospital demonstrated that patients with fungemia developed ocular involvement in 10% to 45% of cases [7-10]. These historically high rates have justified routine funduscopic screening of inpatients for ocular fungal involvement.

Optical Coherence Tomography and Management of a Retinal Granuloma in Presumed Ocular Sarcoidosis

ABSTRACT Purpose: To highlight the utility of EDI-OCT and periocular steroid administration for the treatment of a retinal granuloma due to presumed ocular sarcoidosis. Methods: Retrospective case-study of a single patient. Results: A 45-year-old African-American male with blurred vision in the right eye was found to have a macula-involving retinal granuloma. Laboratory, imaging, and clinical findings were consistent with a diagnosis of presumed ocular sarcoidosis. Optical coherence tomography (OCT) and fundus photographs were used to document granuloma evolution. Oral prednisone 60mg was initiated and tapered to 10mg within 2 months. Due to systemic side-effects and inadequate treatment response with prednisone, 5 sub-Tenon’s triamcinolone acetonide (PSTA) injections were then administered over 7 months, and oral prednisone was discontinued at 6 months. Conclusion: This case demonstrated marked granuloma regression occurring with improvement in visual acuity, highlighting the utility of OCT and PSTA in managing retinal sarcoid granulomas.

Optical Density of Subretinal Fluid as a Predictive Biomarker for Eyes With Chronic Central Serous Retinopathy Treated With Eplerenone

Purpose: To investigate how the optical density ratio (ODR) of subretinal fluid (SRF) obtained by optical coherence tomography (OCT) in eyes with chronic central serous retinopathy (CSR), defined as symptoms >3 months, treated with eplerenone correlates with treatment response and visual outcomes. Methods: This retrospective, single-center observational study included patients with chronic CSR treated with eplerenone who had at least 6 weeks of follow-up. Eyes with poor-quality OCT scans, shallow SRF precluding sampling of optical density (OD), and macular pathology other than CSR were excluded. Optical density of the vitreous and SRF was measured using ImageJ and used to calculate ODR (ODR = ODSRF/ODVIT). Peak SRF height, foveal SRF height, central macular thickness (CMT), and Snellen visual acuity (VA) were measured. The Mann-Whitney U test was used to compare continuous variables. Pearson correlation coefficient was used to determine the statistical significance of applied linear regressions. Results: Twenty-three eyes of 23 patients met the inclusion criteria. Six (26%) eyes had complete resolution of foveal SRF (resolvers) with eplerenone treatment, and the remainder of patients had worsening or incomplete resolution (nonresolvers). Resolvers had significantly lower baseline logarithm of the minimum angle of resolution (logMAR) VA (P < .01) than nonresolvers. There was a positive linear correlation between ODR and logMAR VA at baseline (R 2 = 0.208; P = .03) and follow-up (R 2 = 0.206; P = .03). A significant correlation between ODR and percentage change in CMT was found (R 2 = 0.263; P = .01). Linear correlations were not found between ODR and age, peak SRF height, and foveal SRF height (all P > .125). Conclusion: Lower baseline ODR was associated with improved percentage change in CMT and VA in patients treated with eplerenone for chronic CSR. Optical density ratio may represent a novel prognostic biomarker that may help determine which eyes with chronic CSR may respond better to eplerenone.