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Purpose of review Prevention and management of postcataract endophthalmitis remain quite relevant for anterior segment and vitreoretinal surgeons. Although the Endophthalmitis Vitrectomy Study, published in 1996, remains the only level 1 evidence for the management of postcataract endophthalmitis, recent advances have resulted in an evolution of practice patterns. The aim of this review is to summarize the literature regarding postcataract endophthalmitis with a focus on the last 18 months. Recent findings The IRIS registry indicates the rates of endophthalmitis are decreasing in the United States, and the outcomes appear to be improving. Intracameral moxifloxacin has become more widely accepted and intracameral vancomycin has been shown to be associated with retinal vasculitis. The role of systemic antibiotics and vitrectomy is unclear and practice patterns vary widely. Summary Although practice patterns vary, prevention and treatment of endophthalmitis after cataract surgery continues to improve. More uniform guidelines regarding surgical and medical therapy are necessary but the standard of prompt referral to a vitreoretinal specialist for immediate intravitreal antibiotics remains the most important intervention in the management of postcataract endophthalmitis.

Lacrimal drainage apparatus melanoma is a rare entity that may arise primarily or, more commonly, as secondary involvement from melanoma originating elsewhere. Conjunctival melanoma may involve the lacrimal drainage apparatus (LDA) via spread along the canalicular epithelium, separate in situ processes, or direct invasion. Only seven cases exist in the literature where conjunctival melanoma remotely recurred in the LDA. We report three additional patients, two with invasive conjunctival melanoma and one with primary acquired melanosis (PAM) with severe atypia/melanoma in situ, who developed LDA melanoma at 5, 8, and 16 years after initial treatment of conjunctival melanoma. This report confirms the ability of conjunctival melanoma to give rise to spatially and temporally remote LDA melanoma despite adequate local treatment, and reviews the proposed mechanisms and associated characteristics of LDA recurrence in conjunctival melanoma.

Background: Planning and treatment of bone metastases with palliative radiotherapy often requires 1–3 weeks, resulting in patient inconvenience and delayed palliation. We developed an expedited workflow that delivers palliative stereotactic body radiation therapy (SBRT) to painful bone metastases in which CT, planning, quality assurance (QA), and initial treatment are performed one day. This prospective pilot clinical trial evaluates the feasibility, safety, efficacy, and patient satisfaction of this workflow. Methods: Patients with 1–3 painful bone metastases were prospectively enrolled and treated with 2–5 fractions of 5–10 Gy per fraction. Bone pain, opioid use, patient satisfaction, performance status, and quality of life were evaluated prior to and at 1, 4, 8, 12, 26, and 52 weeks post treatment. Outcomes and treatment-related toxicity were analyzed. Results: Twenty-eight patients were enrolled and 37 metastases treated, receiving an average of 21.6 Gy in 3.1 fractions. Median time from CT simulation to 1st treatment was 6.6 hours. Average worst pain scores were significantly lower at all post-treatment time points with maximal response noted at 3 months. Opioid use was not significantly different from baseline at any follow up. Performance status was significantly increased only at week 12. Bone pain quality of life was significantly increased at all time points except at 52 weeks while general quality of life was significantly increased at only weeks 8 and 26. Ninety-two percent of patients reported being mostly or completely satisfied with the treatment results from week 8 until the end of follow-up. There was no grade 3 or higher toxicities. Conclusions: Results demonstrate that treating bone metastases with palliative SBRT via a multi-fraction Scan-Plan-QA-Treat patient centric workflow is feasible and safe. Although performance status, general quality of life, and opioid use were not significantly altered, patient satisfaction was high with this same-day treatment workflow.

Purpose To investigate the effect of the coronavirus disease 2019 (COVID-19) pandemic on the clinical presentation of acute, primary rhegmatogenous retinal detachment (RRD). Design Single-center, consecutive case series with historical controls. Participants Consecutive patients seeking treatment for primary RRD in a 50-day period during the COVID-19 pandemic (March 9–April 27, 2020) and the corresponding 50-day period during the previous year (March 4–April 22, 2019) in the United States. Methods The cohorts were compared to assess demographic variables and clinical presentations. Multivariate logistic regression was used to identify factors predictive of presenting macular attachment status. Main Outcome Measures The primary outcome was the proportion of patients with macula-on RRD at presentation. Secondary outcomes included visual acuity (VA), duration of symptoms before presentation, proportion seeking treatment within 1 day of symptom onset, and presence of primary proliferative vitreoretinopathy (PVR). Results Eighty-two patients were included in the 2020 cohort compared with 111 patients in the 2019 primary control cohort. Demographic factors were similar between the groups. Significantly fewer patients demonstrated macula-on RRD in the 2020 cohort (20/82 patients [24.4%]) than in the 2019 cohort (55/111 patients [49.5%]; P = 0.001). Patients in the 2020 cohort showed worse median VA at presentation (1.00 logarithm of the minimum angle of resolution [logMAR; Snellen equivalent, 20/200] in 2020 vs. 0.48 logMAR [Snellen equivalent, 20/60] in 2019; P = 0.008), fewer patients sought treatment within 1 day of symptoms (16/80 patients [19.5%] in 2020 vs. 41/106 patients [36.9%] in 2019; P = 0.005), and a greater proportion demonstrated primary PVR (11/82 patients [13.4%] in 2020 vs. 5/111 patients [4.5%] in 2019; P = 0.03). In multivariate analysis, younger age (P = 0.03) and established patient status (P = 0.02) were independent predictors of macula-on status in the 2020 cohort. Conclusions Patients with primary RRD during the 2020 COVID-19 pandemic were less likely to have macula-on disease and more likely to delay seeking treatment and to show worse vision and PVR.

To identify geographic and socioeconomic variables predictive of residential proximity to diabetic eye disease clinical trial locations.Cross-sectional, retrospective study.De-identified census tract-level data from public datasets and trial-level data from ClinicalTrials.gov.Using public data from ClinicalTrials.gov, we identified all active interventional clinical trials in diabetic eye disease since 2017. After geolocating every trial site, we used an origin-destination cost-matrix to calculate the driving distance and travel time from the population-weighted United States census tract centroid to the nearest site. We then used public databases to identify census tract-level socioeconomic factors predictive of driving distance and time.Driving distance60 miles and time traveled60 minutes to the nearest clinical trial site.In a multivariate model, driving distance of more than 60 miles had a significant association with rural versus urban location (adjusted odds ratio, 5.22; 95% confidence interval [CI], 3.75-7.26; P0.001), percentage of population at less than 200% of federal poverty level compared with the fourth quartile (first quartile: adjusted odds ratio, 0.40 [95% CI, 0.29-0.55]; second quartile: adjusted odds ratio, 0.60 [95% CI, 0.47-0.77]; third quartile: adjusted odds ratio, 0.76 [95% CI, 0.63-0.91]; P 0.001) and the Midwest (adjusted odds ratio, 2.15; 95% CI, 1.13-4.07; P = 0.02), South (adjusted odds ratio, 2.71; 95% CI, 1.23-5.99; P = 0.01), and West (adjusted odds ratio, 3.01; 95% CI, 1.21-7.54; P = 0.02) regions as compared with the Northeast. Driving distance was associated with county-level prevalence of diabetes in the univariate model (odds ratio, 1.12; 95% CI, 1.06-1.19; P0.001), although it was nonsignificant in the multivariate model. Similar predictors were found for time traveled in minutes.Geographic maldistributions of clinical trial sites exist for diabetic eye disease in the United States. Those with higher travel burden are more likely to reside in a census tract that is rural, low income, and from areas outside the Northeast.

Asima Bajwa,1 Travis Peck,1 Ashvini K Reddy,2 Peter A Netland,1 Yevgeniy Shildkrot1 1Department of Ophthalmology, University of Virginia, Charlottesville, VA, USA; 2Johns Hopkins Wilmer Eye Institute, Baltimore, MD, USA Purpose: To evaluate the long-term efficacy of the 0.70 mg dexamethasone (DEX) intravitreal implant in patients with birdshot chorioretinopathy (BSCR).Methods: Retrospective descriptive case series of BSCR patients treated with DEX implant (DEX implant 0.70 mg, DEX). Patients receiving treatment between September 2013 and November 2016 with a minimum follow-up (FU) of 12 months were included. The outcomes of primary interest were vision-related functioning, Snellen visual acuity, ocular inflammation status, presence or absence of vasculitis, change in central macular thickness, and development of glaucoma and/or cataract. Change in vision-related functioning was evaluated by comparing the National Eye Institute Visual Function Questionnaire-25. The outcomes were assessed at baseline, after DEX implant, at time of relapse, and at last FU.Results: Three patients (six eyes) were included in the study and were followed for 1–3 years. They received 1–4 DEX implants OU. All patients demonstrated improvement in National Eye Institute Visual Function Questionnaire-25 scores. Mean Snellen visual acuity better than or equal to 20/40 was seen in three eyes at baseline and five eyes at last FU. At induction, all of the patients (six eyes) had active vitritis and two (four eyes) had retinal vasculitis. All three patients (six eyes) were quiet at last FU. One patient (two eyes) developed bilateral ocular hypertension requiring topical therapy and discontinuation of DEX implants. Two patients (three eyes) developed posterior subcapsular cataract during therapy. Two patients (four eyes) showed progression of disease while on DEX therapy. All patients were eventually transitioned to systemic immunosuppressive drug therapy.Conclusion: BSCR patients receiving DEX implant experienced clinically meaningful improvements in patient-reported visual function as well as ocular inflammation. However, patients in this study required repeat implantation and were unable to be maintained on DEX implant long term due to development of adverse effects or progression of disease. Eventually, it was necessary to transition to systemic immunosuppressive therapy in all patients. Keywords: birdshot chorioretinopathy, dexamethasone implant, inflammation, uveitis&nbsp

Although the connection is not often apparent, hepatic pathology may be associated with ophthalmic disease. We review the literature concerning the periocular, periorbital, and orbital manifestations of various hepatic disorders. This includes periocular or periorbital jaundice, the impact of hepatitis B and C, eyelid changes in cirrhosis, orbital mass lesions in hepatocellular carcinoma, and cutaneous vascular malformations as they are related to liver disease. The motility disorders associated with Wilson disease, the ophthalmic manifestations of Alagille syndrome, and the effects of liver transplantation are also discussed.

Purpose. To report a case of closed-eye visualizations and to clarify the different types of hallucinations and their etiologies. Methods. Retrospective case report of a patient with closed-eye visualizations secondary to hyponatremia. Clinical findings, physical exam, laboratory assessment, treatment, and disease course from the patient’s hospitalization were used in creating this report. Follow-up data after discharge were also obtained. Results. Closed-eye visualizations were diagnosed as secondary to hyponatremia, as they did not occur with the eyes open, and potential alternate causes were excluded. Serum sodium nadir was 119 mEq/L. Symptoms resolved with correction of hyponatremia via fluid resuscitation and electrolyte replenishment. There has been no recurrence of the symptoms. Conclusion. This patient had hallucinations exclusively with the eyes closed, which must be differentiated from the release hallucinations seen with the eyes open in Charles Bonnet syndrome. This patient had no visual loss or retinal disease, which should be suspected in open eye hallucinations.

Langerhans cell histiocytosis (LCH) is a clonal neoplastic proliferation of Langerhans-type cells. Orbital LCH is infrequent, typically manifesting as an isolated lytic bony lesion with an adjacent soft tissue mass in a child. Isolated lacrimal gland involvement by LCH is extremely rare, with only 2 previously reported cases. The authors describe a 37-year-old woman with a 6-month history of painless right upper eyelid swelling and diffuse right lacrimal gland enlargement without bony changes on computed tomography scan. Excisional biopsy of the lacrimal gland demonstrated concurrent LCH, extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue, and increased IgG4-expressing plasma cells. Work-up was negative for systemic hematolymphoid malignancy and IgG4-related disease. This case illustrates the association between LCH, mucosa-associated lymphoid tissue lymphoma, and elevated IgG4 plasma cells in the lacrimal gland, and we review the emerging theories proposed to explain this phenomenon.

Purpose. We present a case of a patient with Soemmering ring after cataract surgery and a potential complication that can arise as a result of its presence. Observations. A patient with history of ruptured globe status after repair and lensectomy, complicated by aphakic secondary open angle glaucoma, was referred for management of second injury to the same eye. This injury resulted in Soemmering ring dislocation into the anterior chamber. The cortical material caused a significant increase in intraocular pressure and corneal decompensation. Surgical removal of the Soemmering ring and Ahmed glaucoma tube implant was performed with control of intraocular pressures; however corneal edema could not be reversed. Conclusions and Importance. This case report illustrates the serious consequences that can be caused by Soemmering rings without early surgical intervention. Care must be taken to completely remove cortical material during cataract surgery to prevent their formation.

Objective Evaluate associations between TV viewing and weight status in children from kindergarten to first grade. Methods Linear and logistic regression was used to evaluate associations of TV-viewing time on BMI-z-score cross-sectionally at kindergarten and first grade and longitudinally in between, among a nationally representative sample of 14,645 children from the Early Childhood Longitudinal Study-Kindergarten Cohort 2011. All analyses were adjusted for sex, race/ethnicity, parental education, and household income. Results Weekday TV-viewing time was correlated with BMI-z-score (P

A 69-year-old man, previously treated with pyridostigmine for myasthenia gravis (manifesting as ptosis and diplopia) was evaluated for several concomitant bilateral anterior orbital masses. Imaging revealed 3 discrete, solid masses within and around the orbits. An incisional biopsy demonstrated atypical lymphocytes positive for CD20 and Cyclin-D1, consistent with mantle cell lymphoma. The patient received induction chemotherapy with a rituximab-based regimen. He experienced resolution of his diplopia and ptosis after one cycle of chemotherapy and achieved complete remission of the orbital masses and myasthenia symptoms after 6 cycles. Myasthenia gravis is most commonly associated with thymoma, but may also be observed with other malignancies. Recognition that orbital lymphoma may coexist with myasthenia gravis will help in expediting the diagnosis of future cases and in guiding treatment decisions.

OBJECTIVEEmbolization of brain arteriovenous malformations (AVMs) prior to stereotactic radiosurgery (SRS) has been reported to negatively affect obliteration rates. The goal of this systematic review and meta-analysis was to compare the outcomes of AVMs treated with embolization plus SRS (E+SRS group) and those of AVMs treated with SRS alone (SRS group).METHODSA literature review was performed using PubMed to identify studies with 10 or more AVM patients and obliteration data for both E+SRS and SRS groups. A meta-analysis was performed to compare obliteration rates between the E+SRS and SRS groups.RESULTSTwelve articles comprising 1716 patients were eligible for analysis. Among the patients with radiological follow-up data, complete obliteration was achieved in 48.4% of patients (330/681) in the E+SRS group compared with 62.7% of patients (613/978) in the SRS group. A meta-analysis of the pooled data revealed that the obliteration rate was significantly lower in the E+SRS group (OR 0.51, 95% CI 0.41–0.64, p < 0.00001). Symptomatic adverse radiation effects were observed in 6.6% (27/412 patients) and 11.1% (48/433 patients) of the E+SRS and SRS groups, respectively. The annual post-SRS hemorrhage rate was 2.0%–6.5% and 0%–2.0% for the E+SRS and SRS groups, respectively. The rates of permanent morbidity were 0%–6.7% and 0%–13.5% for the E+SRS and SRS groups, respectively.CONCLUSIONSArteriovenous malformation treatment with combined embolization and SRS is associated with lower obliteration rates than those with SRS treatment alone. However, this comparison does not fully account for differences in the initial AVM characteristics in the E+SRS group as compared with those in the SRS group. Further studies are warranted to address these limitations.

To determine the outcomes of early (less than 7 inter-operative days) versus late (7 or greater inter-operative days) vitrectomy in patients with retained lens fragments in the posterior segment after cataract surgery. This was a retrospective review of all patients underwent pars plana vitrectomy for retained lens fragments at the University of Virginia Hospital from 2002 to 2015. Forty-one eyes were included in the analysis. Mean follow-up time was 25.3 months (range 3.2 months-13 years). Patients in the early vitrectomy group had poorer baseline visual acuity than those in the late vitrectomy group (mean logMAR, 1.10 vs. 0.53, p = 0.030). No other pre-operative differences existed between the two groups. At the final follow-up, there was no significant difference in visual acuity between the early (mean logMAR, 0.41) and the late (mean logMAR, 0.45) vitrectomy groups. There were no differences in rates of glaucoma, retinal detachment, or cystoid macular edema between the groups. Factors associated with final visual acuity of worse than 20/40 were diabetes mellitus, placement of anterior chamber intraocular lens at cataract surgery, cortical as opposed to nuclear retained lens fragments, post-cataract extraction complications, need for glaucoma medications, and additional surgery after vitrectomy. Separate analysis was done for patients with pre-existing eye disease resulting in worse than 20/40 vision, which showed. Clinical outcomes were similar in patients undergoing early and late vitrectomy. Patients with poorer baseline visual acuity were more likely to receive early vitrectomy. Worse final visual acuity was seen in patients with baseline diagnosis of diabetes and in those who experienced post-operative complications.

Macular corneal dystrophy is a corneal stromal dystrophy which leads to progressive vision loss. Macular corneal dystrophy is an autosomal recessive condition in which there is abnormality of proteoglycan synthesis. Mutations in the carbohydrate sulfotransferase gene prevent normal sulfation of corneal keratan. Different immunophenotypes have been described depending on the presence of keratan sulfate in cornea and/or serum. The deposition of abnormal proteoglycans leads to loss of corneal transparency and decreased vision. Imaging techniques such as in vivo confocal microscopy and anterior segment ocular coherence tomography have helped enhance our understanding of the corneal ultrastructural changes in this condition. These imaging modalities provide additional information without the need for a tissue biopsy or excision. Traditionally, full-thickness penetrating keratoplasty to replace the opacified cornea has remained the standard of treatment to improve vision. However, newer surgical interventions such as deep anterior lamellar keratoplasty and phototherapeutic keratectomy have also been shown to play a role in the treatment. Disease recurrence remains a challenge and the reason for poor visual prognosis. Newer techniques such as gene-targeting therapies and enzyme replacement therapies are being studied for a potential permanent solution in macular corneal dystrophy. Recent research is directed toward development of genetically modified products to integrate into host corneal DNA and block the mutant genes and hence overcome the underlying pathophysiology. Enzyme replacement therapy is another intervention with potential to treat macular corneal dystrophy. Animal studies show clearance of accumulated keratan sulfate from the body tissues in the treatment of systemic mucopolysaccharidosis by long-term enzyme replacement therapy. Future research should be directed toward elucidation of the relationship between the mutated carbohydrate sulfotransferase gene, the mechanism of deposit formation, and the development of pharmaceutical agents based on gene therapy.

Dry eye disease (DED) is a multifactorial ocular surface disease that causes symptoms of ocular pain, discomfort, and decreased visual acuity. It significantly affects quality of life of patients. It is more prevalent in the females and is being specifically in the menopausal and postmenopausal age group. This is believed to be due to the changes in balance of sex hormones. Sex hormones – estrogens and androgens – influence production of all components of the tear film including aqueous layer, lipid, and mucin. Various mechanisms such as decrease in hormonal levels, shift in feedback mechanisms, and changes in receptor receptivity interplay to alter the ocular surface homeostasis and subsequently result in DED. Several studies have suggested potential role of hormone replacement therapy in menopause-associated dry eye symptoms. The purpose of this review is to help the non ophthalmic physicians about DED encountered commonly in menopausal age group. It is important for primary care physicians to understand DED due to its high prevalence, often debilitating symptoms and the potentially preventable and treatable nature of the condition.