Tavé van Zyl

Identifying barriers to follow-up eye care for children after failed vision screening in a primary care setting

PURPOSE To identify barriers to follow-up eye care in children who failed a visual acuity screening conducted by their primary care provider. METHODS Children aged 3-14 years who failed a visual acuity screening were identified. A phone survey with the parent of every child was conducted 4 months after the screening. Family demographics, parental awareness of childhood eye diseases and eye care for children, and barriers to follow-up eye care were assessed. RESULTS Of 971 children sampled, 199 (20.5%) failed a visual acuity screening. The survey was completed by the parents of 58 children (29.1%), of whom 27 (46.6%) presented for follow-up examination. The most common reason for failure to follow-up was parental unawareness of screening results (29.3%). Follow-up rates were higher in children with previous eye examinations than in those without (81% versus 17%; P = 0.005) and in children who waited <2 months for a follow-up appointment than in those who had to wait longer (100% versus 63%; P = 0.024). Childs sex, ethnicity, and health insurance status, parents marital, education and employment status, household income, and transportation access were not associated with statistically significant different follow-up rates. CONCLUSIONS Parental unawareness of a failed visual acuity screening is an important barrier to obtaining follow-up. Strategies to improve follow-up rates after a failed visual acuity screening may include communicating the results clearly and consistently, providing education about the importance of timely follow-up, and offering logistic support for accessing eye appointments to families.

Identification of RUNX1 as a Mediator of Aberrant Retinal Angiogenesis

Proliferative diabetic retinopathy (PDR) is a common cause of blindness in the developed world’s working adult population and affects those with type 1 and type 2 diabetes. We identified Runt-related transcription factor 1 (RUNX1) as a gene upregulated in CD31+ vascular endothelial cells obtained from human PDR fibrovascular membranes (FVMs) via transcriptomic analysis. In vitro studies using human retinal microvascular endothelial cells (HRMECs) showed increased RUNX1 RNA and protein expression in response to high glucose, whereas RUNX1 inhibition reduced HRMEC migration, proliferation, and tube formation. Immunohistochemical staining for RUNX1 showed reactivity in vessels of patient-derived FVMs and angiogenic tufts in the retina of mice with oxygen-induced retinopathy, suggesting that RUNX1 upregulation is a hallmark of aberrant retinal angiogenesis. Inhibition of RUNX1 activity with the Ro5–3335 small molecule resulted in a significant reduction of neovascular tufts in oxygen-induced retinopathy, supporting the feasibility of targeting RUNX1 in aberrant retinal angiogenesis.

Molecular Classification and Comparative Taxonomics of Foveal and Peripheral Cells in Primate Retina

High acuity vision in primates, including humans, is mediated by a small central retinal region called the fovea. As more accessible model organisms lack a fovea, its specialized function and dysfunction in ocular diseases remain poorly understood. We used 165,000 single-cell RNA-seq profiles to generate and validate comprehensive cellular taxonomies of macaque fovea and peripheral retina. More than 80% of >65 cell types match between the two regions, but exhibit substantial differences in proportions and gene expression, some of which we relate to functional differences. Comparison of macaque retinal types with those of mice reveals that interneuron types are tightly conserved, but that projection neuron types and programs diverge, despite conserved transcription factor codes. Key macaque types are conserved in humans, allowing mapping of cell-type and region-specific expression of >190 genes associated with 6 human retinal diseases. Our work provides a framework for comparative single-cell analysis across tissue regions and species.

Case 8: Extracapsular Cataract Extraction Wound Rupture

An 84-year-old man with history of extracapsular cataract extraction (ECCE) in both eyes 30 years prior presented with a Zone II open globe injury of the left eye secondary to ECCE wound dehiscence following blunt trauma. The patient underwent repair of his open globe injury and required several secondary retinal surgeries. The patient achieved a post-operative visual acuity of 20/125; however, he subsequently developed a retinal detachment resulting in a visual acuity of counting fingers. This case illustrates the poor prognosis and multiple complications associated with open globe injury following ECCE surgery.

Case 15: Zone II/III Open Globe due to Stab Wound from Knife Assault During Intimate Partner Violence

A healthy woman in her 40s presented with an open globe injury (OGI) of the left eye due to a penetrating stab wound inflicted by her domestic partner. Exam was significant for a laceration above the left eyebrow, CF vision, no obvious corneal or conjunctival lacerations, a deep anterior chamber compared to fellow eye, a pupil peaked superonasally, vitreous hemorrhage (VH) and retinal elevations concerning for retinal detachment. Surgical exploration confirmed a Zone II-III scleral laceration and a subfascial communication between the periocular space and the supra-brow laceration, which was felt to be the entry site. Social services and intimate partner violence resources were mobilized prior to discharge. Two weeks following the initial OGI repair, she underwent uncomplicated pars plana vitrectomy to clear the VH. No retinal detachments or tears were noted intraoperatively. Her final uncorrected visual acuity was 20/30.

Case 18: Delayed Presentation Zone I Open Globe Injury with Traumatic Cataract

A 63-year-old man presented 10 days following penetrating wood injury to right eye. Exam confirmed a Zone I open globe with lens violation. He underwent primary globe closure immediately. Lens extraction was delayed due to the poor intraocular view from significant corneal edema. Inflammation was controlled medically and cataract extraction without insertion of intraocular lens was performed one month later with the corneal sutures still in place. Secondary intraocular lens implantation versus an aphakic contact lens was offered after the corneal sutures were removed; the patient deferred additional surgery and elected to seek follow-up locally. The patient’s final visual acuity was 20/50 with a +11 diopter lens and pinhole occluder.

Case 36: Bilateral Open Globe Injury Stemming from an Assault

A 53 year-old male was assaulted resulting in bilateral open globe ruptures. Post-operatively the left eye remained no light perception and the right eye remained light perception only; at 4 weeks after the initial injury, vitrectomy was attempted to reattach the retina but it was found intraoperatively to be inoperable. The patient expired 3 months later due to unrelated causes.

Case 12: Zone III Rupture Requiring Muscle Take-Down After Hockey Stick Injury

A 31-year-old man presented with a Zone III open globe injury of the left eye following severe blunt trauma from a hockey stick. The vision was hand motions (HM), intraocular pressure (IOP) was 5, and there was an afferent pupillary defect (APD) by reverse. During surgical exploration, the rupture was identified at the equator, approximately 15 mm posterior to the limbus. The wound ran posterior to the lateral rectus muscle insertion, which was temporarily disinserted to provide adequate exposure for wound closure. Postoperative B-scan revealed a funnel retinal detachment (RD), for which he underwent complex repair with 360 relaxing retinectomy and silicone oil tamponade. On the most recent follow-up, 8 months after injury, his vision was HM, IOP 14, and his remaining retina remained attached under oil.

Case 39: Delayed Presentation Zone I Open Globe Injury at Site of Previous Trauma

A 31-year-old man presented with a Zone I open globe injury 2 days after blunt head trauma. Initial exam was significant for a 6.5 mm full thickness corneal wound, Seidel positive without provocation, and ingrowth of blood vessels from the limbus into the wound and surrounding corneal whitening. There were also posterior synechiae and sectoral iris atrophy inferior and posteriorly to the corneal wound suggesting a previous corneal injury at the site of new acute rupture. Intraoperatively the wound bled while suturing and the corneal tissue in this area was friable, consistent with delayed presentation and possible chronic intermittent low-grade inflammation or infection from a previous trauma. Post-operatively, the patient underwent staged suture removal at 6 and 8 weeks, respectively. His final best-corrected visual acuity was 20/20.

Case 44: Severe Zone I/II Open Globe Injury with Stellate Wound Repair Followed by Enucleation

A 22-year-old man presented with a severe, complex Zone I-II open globe injury of the left eye after a fall. The patient underwent repair of this open globe injury in addition to associated facial lacerations. The patient’s postoperative course was complicated by a funnel retinal detachment and significant post-operative pain. The patient was offered further surgical intervention for the retinal detachment as well as the possibility of a corneal transplant in the future, but the patient was not interested in further surgical intervention and ultimately underwent enucleation.