Optical Coherence Tomographic Features and Prognostic Values of Macular Edema in Vogt-Koyanagi-Harada Disease

Purpose: To determine optical coherence tomographic (OCT) features of macular edema (ME) and identify potential prognostic values for ME and visual outcomes in Vogt-Koyanagi-Harada disease (VKH).Methods: In the retrospective case series, a total of 1,377 VKH patients who were seen in a tertiary uveitis center between September 2011 and January 2018 were reviewed on their demographics, visual acuity, ocular and extraocular manifestations, modes of treatment, and OCT examinations. Of these patients, 79 (5.7%) having ME were included for analysis of OCT features. Four patients were missed without ME resolution, and the remaining 75 patients who either had ME resolved or were followed up for 2 years were included for analysis of disease outcomes.Results: Of the 115 affected eyes in these 79 patients, 100 (87.0%) had cystoid ME (CME), accounting for the most common OCT feature of VKH-related ME. Disruption of the inner-segment/outer-segment junction (IS/OS) band seen in 33 (28.7%) affected eyes of 24 (30.4%) patients was found as a risk factor for the development of persistent ME [10 of 62 (16.1%) vs. 13 of 13 (100%); P < 0.001] and a poor visual outcome (1.16 ± 0.42 vs. 1.17 ± 0.46 in logMAR unit; P = 0.89). CME patients with a concurrent choroidal neovascular membrane often had a disrupted IS/OS band, thus becoming refractory cases. A 6-month well-controlled intraocular inflammation following standard treatment regimens was found to associate with complete resolution of the refractory edema [4 of 5 (80%) vs. 2 of 13 (15%); P = 0.02].Conclusions: Intraretinal cystoid changes are most commonly seen in the edematous macula of VKH patients. Disruption of the IS/OS band is a useful risk sign for poor ME and visual outcomes in VKH-related ME, and a long-term well-controlled intraocular inflammation may be critical for the resolution of refractory cases.

A Clinical Study on the Incidence and Visual Outcome after Surgical Management of Lens-Induced Glaucoma

Aims and Objectives: To determine 1) the incidence of lens-induced glaucoma. 2) the more prevalent type of LIG. and 3) Visual outcome following surgical management of LIG. Material and Methods: 50 patients of lens-induced glaucoma, who presented in OPD of Regional Institute of Ophthalmology, were included in the study. All patients were admitted and managed in indoor wards. Informed and written consents were taken. A detailed history and a thorough ocular examination was done. Surgical correction was done by SICS or Phacoemulsification or triple procedures operations. Results: A standardized proforma was used to compile data and it was analyzed statistically using Chi-square test and Probability value. The incidence of LIG was found to be 0.174 among all OPD attendees. Phacomorphic glaucoma (58%) was found to be the highest followed by phacolytic glaucoma (32%). No significant association with respect to sex and age of the cases was found. The presenting symptoms varied in severity and were directly proportional to the degree of rise of IOP. 38% of cases in our study achieved best corrected visual acuity of 6/9 and 28% achieved 6/12 acuity at the end of 6 weeks. Visual outcome was found to be better for cases with early detection and treatment. Conclusion: The mainstay to prevent and treat LIG is early diagnosis and treatment of cataract. Delayed treatment of LIG may result in poor visual outcome. Keywords: LIG, IOP, Phacomorphic glaucoma, Phacolytic glaucoma, SICS, Phacoemulsification.

PRO score: predictive scoring system for visual outcomes after rhegmatogenous retinal detachment repair

Background/aimsTo compare risk factors for poor visual outcomes in patients undergoing primary rhegmatogenous retinal detachment (RRD) repair and to develop a scoring system.MethodsAnalysis of the Primary Retinal detachment Outcomes (PRO) study, a multicentre interventional cohort of consecutive primary RRD surgeries performed in 2015. The main outcome measure was a poor visual outcome (Snellen VA ≤20/200).ResultsA total of 1178 cases were included. The mean preoperative and postoperative logMARs were 1.1±1.1 (20/250) and 0.5±0.7 (20/63), respectively. Multivariable logistic regression identified preoperative risk factors predictive of poor visual outcomes (≤20/200), including proliferative vitreoretinopathy (PVR) (OR 1.26; 95% CI 1.13 to 1.40), history of antivascular endothelial growth factor (VEGF) injections (1.38; 1.11 to 1.71), >1-week vision loss (1.17; 1.08 to 1.27), ocular comorbidities (1.18; 1.00 to 1.38), poor presenting VA (1.06 per initial logMAR unit; 1.02 to 1.10) and age >70 (1.13; 1.04 to 1.23). The data were split into training (75%) and validation (25%) and a scoring system was developed and validated. The risk for poor visual outcomes was 8% with a total score of 0, 17% with 1, 29% with 2, 47% with 3, and 71% with 4 or higher.ConclusionsIndependent risk factors were compared for poor visual outcomes after RRD surgery, which included PVR, anti-VEGF injections, vision loss >1 week, ocular comorbidities, presenting VA and older age. The PRO score was developed to provide a scoring system that may be useful in clinical practice.

Clinical Characteristics and Outcomes of Fungal Keratitis in the United Kingdom 2011-2020: A 10-Year Study

Fungal keratitis (FK) is a serious ocular infection that often poses significant diagnostic and therapeutic dilemmas. This study aimed to examine the causes, clinical characteristics, outcomes, and prognostic factors of FK in the UK. All culture-positive and culture-negative presumed FK (with complete data) that presented to Queen’s Medical Centre, Nottingham, and Queen Victoria Hospital, East Grinstead, between 2011 and 2020 were included. A total of 117 patients (n=117 eyes) with FK were included in this study. The mean age was 59.0±19.6 years (range, 4-92 years) and 51.3% patients were female. Fifty-three fungal isolates were identified from 52 (44.4%) culture-positive cases, with Candida spp. (33, 62.3%), Fusarium spp. (9, 17.0%), and Aspergillus spp. (5, 9.4%) being the most common organisms. Ocular surface disease (60, 51.3%), prior corneal surgery (44, 37.6%), and systemic immunosuppression (42, 35.9%) were the three most common risk factors. Hospitalisation for intensive treatment was required for 95 (81.2%) patients, with a duration of 18.9±16.3 days. Sixty-six (56.4%) patients required additional surgical interventions for eradicating the infection. Emergency therapeutic/tectonic keratoplasty was performed in 29 (24.8%) cases, though 13 (44.8%) of them failed at final follow-up. The final corrected-distance-visual-acuity (CDVA) was 1.67±1.08 logMAR. Multivariable logistic regression analyses demonstrated increased age, large infiltrate size (>3mm), and poor presenting CDVA (<1.0 logMAR) as significant negative predictive factors for poor visual outcome (CDVA of <1.0 logMAR) and poor corneal healing (>60 days of healing time or occurrence of corneal perforation requiring emergency keratoplasty; all p<0.05). In conclusion, FK represents a difficult-to-treat ocular infection that often results in poor visual outcome, with a high need for surgical interventions. Innovative treatment strategies are urgently required to tackle this unmet need.

Endophthalmitis following Intravitreal Injection, Cataract Surgery, and Vitrectomy: Clinical Features and Visual Outcomes

Purpose. To describe and compare the clinical features and visual outcomes of endophthalmitis following intravitreal injections (IVI), cataract surgery, and pars plana vitrectomy (PPV). Methods. This is a single-centre, retrospective study. All included patients had acute postoperative endophthalmitis secondary to one of these three procedures. Visual acuity (VA), comorbidities, time to presentation, and treatment were assessed. The primary outcome was visual outcome. A poor outcome was considered if final VA was worse than or equal to counting fingers (CF) and a good outcome was classified as VA better than CF. Results. Over 12 years, a total of 61 patients were included. Twenty-seven cases were post-cataract endophthalmitis; twenty-five were post-IVI and nine post-PPV. Endophthalmitis post-PPV had a worse visual outcome (88.9% of patients with VA worse than or equal to CF 95% CI 51.3 to 100.0%) than endophthalmitis following cataract surgery (25.9% of patients with VA worse than or equal to CF 95% CI 11.0 to 39.9%) and the IVI subgroup (44.0% of VA worse than or equal to CF 95% CI 24.0 to 67.0%) ( p = 0.001 and p = 0.047 ). There were no significant differences in the proportion of patients with a poor visual outcome between endophthalmitis following cataract surgery and IVI ( p = 0.171 ). Conclusions. The number of patients with poor visual outcomes following acute endophthalmitis was similar in endophthalmitis following IVI and cataract surgery, but better than endophthalmitis following vitrectomy.

Fluorescein angiographic findings and Behcet's disease ocular attack score 24 (BOS24) as prognostic factors for visual outcome in patients with ocular Behcet's disease

Purpose To determine the application of fluorescein angiographic (FA) findings and Behcet’s disease ocular attack score 24 (BOS24) scoring system in predicting poor visual outcome in patients with ocular Behcet’s disease. Study design Retrospective cohort study. Methods We included 73 eyes of 38 patients with ocular Behcet’s disease who underwent FA and reviewed FA images, anterior chamber cells, vitreous opacity, retinal and optic disc lesions, which are parameters in BOS24. The correlation between FA findings, BOS24, and visual acuity was assessed. Results Optic disc hyperfluoresence (74%), diffuse posterior pole leakage (52%) and diffuse peripheral leakage (52%) were the three most common findings. Common complications were peripheral capillary nonperfusion (29%), arterial narrowing (22%), and macular ischemia (19%). BOS24 scores of ≥ 6 (p < 0.0001), arterial narrowing (p < 0.0001), and severe posterior pole leakage (p = 0.004) were significantly associated with poor visual outcome. Combining significant FA findings: arterial narrowing and severe posterior pole leakage, to BOS24 ≥ 6 results in an increased relative risk of developing poor visual acuity from 7.30 to 10.43 and 1.89 to 2.02 respectively. Conclusion Fluorescein angiography is an important investigation for predicting poor visual outcome. BOS24 may be a useful alternative when fluorescein angiographic is unavailable.

Risk Factors, Clinical Outcomes, and Prognostic Factors of Bacterial Keratitis: The Nottingham Infectious Keratitis Study

Background/Aim: To examine the risk factors, clinical characteristics, outcomes, and prognostic factors of bacterial keratitis (BK) in Nottingham, UK.Methods: This was a retrospective study of patients who presented to the Queen's Medical Centre, Nottingham, with suspected BK during 2015–2019. Relevant data, including the demographic factors, risk factors, clinical outcomes, and potential prognostic factors, were analysed.Results: A total of 283 patients (n = 283 eyes) were included; mean age was 54.4 ± 21.0 years and 50.9% were male. Of 283 cases, 128 (45.2%) cases were culture-positive. Relevant risk factors were identified in 96.5% patients, with ocular surface diseases (47.3%), contact lens wear (35.3%) and systemic immunosuppression (18.4%) being the most common factors. Contact lens wear was most commonly associated with P. aeruginosa whereas Staphylococci spp. were most commonly implicated in non-contact lens-related BK cases (p = 0.017). At presentation, culture-positive cases were associated with older age, worse presenting corrected-distance-visual-acuity (CDVA), use of topical corticosteroids, larger epithelial defect and infiltrate, central location and hypopyon (all p &lt; 0.01), when compared to culture-negative cases. Hospitalisation was required in 57.2% patients, with a mean length of stay of 8.0 ± 8.3 days. Surgical intervention was required in 16.3% patients. Significant complications such as threatened/actual corneal perforation (8.8%), loss of perception of light vision (3.9%), and evisceration/enucleation (1.4%) were noted. Poor visual outcome (final corrected-distance-visual-acuity of &lt;0.6 logMAR) and delayed corneal healing (&gt;30 days from initial presentation) were significantly affected by age &gt;50 years, infiltrate size &gt;3 mm, and reduced presenting vision (all p &lt; 0.05).Conclusion: BK represents a significant ocular morbidity in the UK, with ocular surface diseases, contact lens wear, and systemic immunosuppression being the main risk factors. Older age, large infiltrate, and poor presenting vision were predictive of poor visual outcome and delayed corneal healing, highlighting the importance of prevention and early intervention for BK.

Three-Layered Optic Disc Hemorrhages in Idiopathic Intracranial Hypertension

Papilledema related to idiopathic intracranial hypertension (IIH) may present with optic disc hemorrhaging. The significance and characteristics of these hemorrhages still remains to be clarified. Here, we present 2 unique cases with severe unilateral optic disc hemorrhaging in all 3 retinal layers (preretinal, intraretinal, and subretinal) and a good visual outcome. A 42- and a 44-year-old woman presented with signs and symptoms of raised intracranial pressure. Visual acuity was normal and Humphrey visual field testing showed only mild vision loss with enlarged blind spots. Dilated fundus examination revealed moderate papilledema in both eyes with severe optic disc hemorrhaging in the left eye in the first patient and the right eye in the second patient. The optic disc hemorrhaging occurred in all 3 retinal layers (preretinal, intraretinal, and subretinal), and the fellow eyes had only minimal hemorrhage. All patients had normal magnetic resonance imaging/magnetic resonance venography, and lumbar punctures revealed elevated opening pressures and normal cerebrospinal fluid contents. The papilledema resolved after 4 months in both cases with medical therapy. Optic disc hemorrhaging may be severe in patients with IIH, but this does not necessarily confer a poor visual outcome. The differential diagnosis of hemorrhages in all 3 retinal layers may be expanded to include IIH.

Risk Factors, Clinical Outcomes and Prognostic Factors of Bacterial Keratitis: The Nottingham Infectious Keratitis Study

Background/aim: To examine the risk factors, clinical characteristics, outcomes and prognostic factors of bacterial keratitis (BK) in Nottingham, UK. Methods: This was a retrospective study of patients who presented to the Queens Medical Centre, Nottingham, with suspected BK during 2015-2019. Relevant data, including the demographic factors, risk factors, clinical outcomes, and potential prognostic factors, were analysed. Results: A total of 283 patients (n=283 eyes) were included; mean age was 54.4+/-21.0 years and 50.9% were male. Of 283 cases, 128 (45.2%) cases were culture-positive. Relevant risk factors were identified in 96.5% patients, with ocular surface diseases (47.3%), contact lens wear (35.3%) and systemic immunosuppression (18.4%) being the most common factors. Contact lens wear was most commonly associated with P. aeruginosa whereas Staphylococci spp. were most commonly implicated in non-contact lens-related BK cases (p=0.017). At presentation, culture-positive cases were associated with older age, worse presenting corrected-distance-visual-acuity (CDVA), larger epithelial defect and infiltrate, central location and hypopyon (all p<0.01), when compared to culture-negative cases. Hospitalisation was required in 57.2% patients, with a mean length of stay of 8.0 +/- 8.3 days. Surgical intervention was required in 16.3% patients. Significant complications such as threatened/actual corneal perforation (8.8%), loss of perception of light vision (3.9%), and evisceration/enucleation (1.4%) were noted. Poor visual outcome (final corrected-distance-visual-acuity of <0.6 logMAR) and delayed corneal healing (>30 days from initial presentation) were significantly affected by age >50 years, infiltrate size >3mm, and reduced presenting vision (all p<0.05). Conclusion: BK represents a significant ocular morbidity in the UK. Culture positivity is associated with more severe disease at presentation but has no significant influence on the final outcome. Older age, large infiltrate, and poor presenting vision were predictive of poor visual outcome and delayed corneal healing, highlighting the importance of primary prevention and early intervention for BK.

Early postoperative infection following lamellar keratoplasty: a review

With the growing popularity of lamellar keratoplasty for selective replacement of diseased corneal tissue, it is important to understand the risk of developing an infection after the procedure. Although lesser than that postpenetrating keratoplasty, the reports on post lamellar keratoplasty infectious keratitis are not negligible. Trends of acute infections arising within 2 months of surgery are a subject of interest. Most of these infections are reported post Descemet’s stripping endothelial keratoplasty with a preponderance of Candida species. A donor to host transmission of infection is not uncommon. Among the Candida cases, about 80% seem to occur due to a donor to host transmission. Infections presenting as or progressing to endophthalmitis lead to a poor visual outcome. Strict aseptic measures and protocols during corneal tissue harvesting, tissue processing, tissue storage and surgery are essential to prevent occurrence of these infections. After the infection has occurred, determining the aetiology and drug susceptibility through microbiological testing is vital. This helps to guide treatment protocols and hence determines final outcome of these cases. Most cases require some form of surgical management for resolution of infection, most often a graft removal and therapeutic keratoplasty. Secondary surgical interventions are performed to restore graft clarity and achieve a good final visual outcome.