Nationwide Prevalence of Inherited Retinal Diseases in the Israeli Population

Importance

Data regarding the prevalence of various inherited retinal diseases (IRDs) are limited and vary across populations; moreover, nationwide prevalence studies may be limited to a specific IRD phenotype, potentially leading to inaccurate prevalence estimations. Therefore, nationwide prevalence data are needed.

Objective

To determine the prevalence of 67 IRD phenotypes in the Israeli population.

Design, Setting, and Participants

This cohort study collected nationwide data regarding the number of individuals affected with IRD phenotypes assessed in 10 clinical and academic centers in Israel as part of the research activity of the Israeli inherited retinal disease consortium. Data were collected in May 2023 on 9396 individuals residing in Israel who were diagnosed by an ophthalmologist with an IRD using either electroretinography or retinal imaging where included. Individuals with retinal diseases known to have a nonmendelian basis or without a clear genetic basis and those who were reported as deceased at the time of data collection were excluded from this study.

Main Outcomes and Measures

Prevalence of 67 IRD phenotypes.

Results

Among the 9396 participants in our cohort, the most common IRD in Israel was retinitis pigmentosa with a disease prevalence of approximately 1:2400 individuals, followed by cone-rod dystrophy (approximately 1:14 000), Stargardt disease (approximately 1:16 000), Usher syndrome (approximately 1:16,000), and congenital stationary night blindness (approximately 1:18 000). The prevalence of all IRDs combined was 1:1043 individuals.

Conclusions and Relevance

The current study provides large prevalence dataset of 67 IRD phenotypes, some of which are extremely rare, with only a single identified case. This analysis highlights the potential importance of performing additional nationwide prevalence studies to potentially assist with determining the prevalence of IRDs worldwide.

Reproducibility of manifest refraction in patients with keratoconus compared with healthy subjects: A prospective cohort study

PURPOSE

To measure and compare the inter- examiner reproducibility of manifest refraction in patients with keratoconus.

DESIGN

Prospective, inter-examiner reliability analysis comparing "cases and controls" METHODS: Patients with Keratoconus (KC) and healthy subjects had undergone manifest refraction by the same two skilled optometrists, each was masked to the refraction of the other, on the same day. The KC group was comprised of patients with KC, who were recruited from the cornea clinic. The control group consisted of healthy individuals who wore spectacles and did not have KC. Participants for the control group were recruited from the clinic's staff, including doctors, technicians, nurses, and medical students. The study took place in one tertiary medical center in Israel from April 2021 to May 2022. The results of the manifest refraction and achieved corrected distance visual acuity (CDVA) were compared between groups.

RESULTS

A total of 120 eyes of 60 patients were enrolled in the study; Thirty in the keratoconus group and 30 in the control group. A difference of 0.67±0.83 D and 0.19±0.21 D in the absolute manifest cylinder was observed between the optometrists in the keratoconus (95% LoA, -0.96, 2.30) and control group (95% LoA, -0.22, 0.61), respectively (p<0.001). Multivariate analysis revealed a 22-fold higher likelihood of an error exceeding 0.75 D in cylinder measurements (OR, 22.24; 95% CI, 2.39-206.95) and a tenfold likelihood of a difference of at least one row on the Snellen chart for CDVA (OR,10.32; 95% CI,2.39-44.44) in the KC group.

CONCLUSION

when compared to healthy subjects, patients with KC exhibit greater variability in manifest refraction. This discrepancy has the potential to influence the decision-making process when managing patients with KC.

Best Disease: Global Mutations Review, Genotype-Phenotype Correlation, and Prevalence Analysis in the Israeli Population

Purpose

To review all reported disease-causing mutations in BEST1, perform genotype-phenotype correlation, and estimate disease prevalence in the Israeli population.

Methods

Medical records of patients diagnosed with Best disease and allied diseases from nine Israeli medical centers over the past 20 years were collected, as were clinical data including ocular findings, electrophysiology results, and retina imaging. Mutation detection involved mainly whole exome sequencing and candidate gene analysis. Demographic data were obtained from the Israeli Bureau of Statistics (January 2023). A bibliometric study was also conducted to gather mutation data from online sources.

Results

A total of 134 patients were clinically diagnosed with Best disease and related conditions. The estimated prevalence of Best disease was calculated to be 1 in 127,000, with higher rates among Arab Muslims (1 in 76,000) than Jews (1 in 145,000). Genetic causes were identified in 76 individuals (57%), primarily showing autosomal-dominant inheritance due to BEST1 mutations (58 patients). Critical conserved domains were identified consisting of a high percentage of dominant missense mutations, primarily in transmembrane domains and the intracellular region (Ca2+ binding domain) of the BEST1 protein.

Conclusions

This study represents the largest cohort of patients with Best disease reported in Israel and globally. The prevalence in Israel is akin to that in Denmark but is lower than that in the United States. Critical conserved domains within the BEST1 protein are pivotal for normal functioning, and even minor missense alterations in these areas lead to a dominant disease manifestation. Genetic testing is indispensable as the gold standard for Best disease diagnosis due to the variable clinical presentation of the disease.

Treatment of Rapid Progression of Myopia: Topical Atropine 0.05% and MF60 Contact Lenses

This retrospective study evaluates the effectiveness of combining 0.05% atropine with MF60 contact lenses in managing rapid myopia progression in children over one year. The study involved three groups: the treatment group (TG) with 15 children (53% male, average age 12.9 ± 1.04), the MF group (MF) with 12 children (50% male, average age 12.8 ± 0.8) using only MF60 lenses, and the control group (CG) with 14 children (43% male, average age 12.1 ± 0.76). Baseline myopia and axial length (AL) were similar across groups, with the TG, MF, and CG showing -4.02 ± 0.70 D, -4.18 ± 0.89 D, -3.86 ± 0.99 D, and 24.72 ± 0.73 mm, 24.98 ± 0.70 mm, 24.59 ± 1.02 mm, respectively. Prior to the study, all groups exhibited significant myopia and AL progression, with no previous myopia control management. The treatment involved daily 0.05% atropine instillation, the use of MF60 lenses and increased outdoor activity. Biannual cycloplegic refraction and slit lamp evaluations confirmed no adverse reactions. After one year, the TG showed a significant reduction in myopia and AL progression (-0.43 ± 0.46 D, p < 0.01; 0.22 ± 0.23 mm, p < 0.01), whereas the CG showed minimal change (-1.30 ± 0.43 D, p = 0.36; 0.65 ± 0.35 mm, p = 0.533). The MF group also exhibited a notable decrease (-0.74 ± 0.45 D, p < 0.01; 0.36 ± 0.23 mm). Increased outdoor activity during the treatment year did not significantly impact myopia control, suggesting its limited additional effect in this cohort. The study concludes that the combination of 0.05% atropine and peripheral defocus soft contact lenses effectively controls myopia progression in children.

Between-eye correlation of ocular parameters

OBJECTIVE

It is accepted that ocular parameters are more correlated with the fellow eye. This poses a challenge in ophthalmic research. There is a relative scarcity of data concerning the extent of correlation. The aim of this study was to analyze and quantify the correlation of different ocular parameters.

DESIGN

Historical registry analysis.

PARTICIPANTS

All patients examined in a 10-year period (2011-2021) in one academic tertiary medical centre in central Israel.

METHODS

Data from optical coherence tomography examinations and biometry of a single examination of both eyes taken at the same time from each patient was included. Pearson's r values were calculated to estimate the extent of correlation.

RESULTS

A total of 17,212 patients were included. Mean age was 73 ± 12.7 years, and 54.5% were female. All examined parameters were highly statistically significantly correlated between eyes (all with p < 0.1 × 10-36), whereas the strength of correlation differed. Very weak correlation was seen in central macular thickness (r = 0.189), and a weak correlation was seen in anterior-chamber depth (r = 0.379) and retinal nerve fibre layer thickness (r = 0.479). A strong correlation was seen in central corneal thickness (r = 0.754), and a very strong correlation was seen in axial length (r = 0.900).

CONCLUSIONS

In a retrospective analysis of optical coherence tomography and biometry measurements of >10,000 patients, all examined parameters were highly statistically significantly correlated. Correlation magnitude varied, with structural characteristics more correlated than functional ones. Including both eyes in an outcome analysis likely will introduce bias. We recommend adjusting for inter-eye correlation in all studies assessing ocular outcome measures.

Diagnostic capabilities of ChatGPT in ophthalmology

PURPOSE

The purpose of this study is to assess the diagnostic accuracy of ChatGPT in the field of ophthalmology.

METHODS

This is a retrospective cohort study conducted in one academic tertiary medical center. We reviewed data of patients admitted to the ophthalmology department from 06/2022 to 01/2023. We then created two clinical cases for each patient. The first case is according to the medical history alone (Hx). The second case includes an addition of the clinical examination (Hx and Ex). For each case, we asked for the three most likely diagnoses from ChatGPT, residents, and attendings. Then, we compared the accuracy rates (at least one correct diagnosis) of all groups. Additionally, we evaluated the total duration for completing the assignment between the groups.

RESULTS

ChatGPT, residents, and attendings evaluated 126 cases from 63 patients (history only or history and exam findings for each patient). ChatGPT achieved a significantly lower accurate diagnosis rate (54%) in the Hx, as compared to the residents (75%; p < 0.01) and attendings (71%; p < 0.01). After adding the clinical examination findings, the diagnosis rate of ChatGPT was 68%, whereas for the residents and the attendings, it increased to 94% (p < 0.01) and 86% (p < 0.01), respectively. ChatGPT was 4 to 5 times faster than the attendings and residents.

CONCLUSIONS AND RELEVANCE

ChatGPT showed low diagnostic rates in ophthalmology cases compared to residents and attendings based on patient history alone or with additional clinical examination findings. However, ChatGPT completed the task faster than the physicians.

The outcomes of postoperative eye patching after cataract surgery in patients with Fuchs' endothelial corneal dystrophy

PURPOSE

To investigate the influence of post-operative eye patching on corneal thickness, endothelial cells' loss and visual acuity in patients diagnosed Fuchs' endothelial corneal dystrophy (FECD).

SETTING

Public healthcare centre, Shamir Medical Centre, Israel.

METHODS

This randomized controlled trial included patients with FECD undergoing routine cataract surgery in a public medical centre. Patients were randomly assigned to 2 groups: the eye undergoing surgery was covered with a patch for 24 h in the first group (patched group), and a plastic shield was used in the second (non-patched group). Both groups received a unique dose of a local steroid and antibiotic post-operatively. The eyes were examined pre-operatively, and on days 1, 7 and 30 post-surgery . Examination included: best corrected visual acuity (BCVA), comeplete slit lamp examination, intra ocular pressure (IOP), anterior chamber depth (ACD), central corneal thickness (CCT) using the IOL Master 700 (Zeiss, Germany) and endothelial cell density (ECD) using Specular microscopy. Cumulative dissipated energy (CDE) and operation time were recorded for all cases.

RESULTS

The study included 46 eyes of 46 patients diagnosed with FECD. Twenty-three eyes in the patched group, and 23 eyes in the non-patched group . Thirty days post-operatively the CCT in the patched group decreased by 60 ± 38 mµ (9%) compared to 92 ± 80 mµ (13.5%) in the non- patched group (p = 0.04). Seven days post-operatively the CCT in the patched group decreased by 31 ± 35 mµ (5%) compared to 58 ± 76 (8%) in the non-patched group, but this difference did not reach statistical significance (p = 0.081). There was no statistically significant difference in endothelial cells loss as well as BCVA at 1, 7 and 30 days post-operatively between the study groups.

CONCLUSIONS

Avoiding eye patch post-operatively after cataract surgery in patients with FECD results in better corneal clarity recovery and reduced corneal edema one month post-operatively. Visual acuity and endothelial cell's loss were not influenced by patching.

RATES OF RECURRENT RETINAL DETACHMENT AFTER VAGINAL VERSUS CESAREAN DELIVERIES: A Retrospective Analysis and Review of the Literature

PURPOSE

To evaluate the risk of a retinal redetachment in women after vaginal delivery versus cesarean delivery.

METHODS

Retrospective cohort analysis of patients diagnosed with retinal detachment (RD) who had later delivered in one tertiary medical center. Recurrence rates of RD were obtained from medical charts.

RESULTS

A total of 967 women with RDs were evaluated, and 66 patients met the inclusion criteria. The mean age at the time of RD was 22.64 ± 5.81 SD years and 21.75 ± 5.47 SD years in the vaginal delivery group and the cesarean section group, respectively. None of the patients had a history of eye surgery or traumatic eye injury before the event of RD. In all patients, the detached retina was surgically reattached. Retinal detachment was not recorded in the fellow eye during follow-up. We report four cases of redetachment after birth in four women. In our study, there was a 5% rate (n = 2) of RD after a vaginal delivery as compared with a 7.5% (n = 2) redetachment rate for patients after a cesarean delivery ( P = 0.654).

CONCLUSION

The risk of a redetachment of the retina in women is not increased after a vaginal delivery as compared with a cesarean delivery. Therefore, in our opinion, there is no ophthalmic benefit in a cesarean section for a woman with prior RD.

Quantum Molecular Resonance Effects on Patients With Dry Eye Disease: A Randomized Controlled Trial

PURPOSE

The aim of the study was to evaluate the efficacy and safety of quantum molecular resonance in the treatment of dry eye disease.

METHODS

This study was a double-blind randomized control trial in 1 academic medical center, for 2 years. Participants received treatment or a placebo with the Rexon-Eye device, once per week for 4 weeks. The primary outcome was the change in dry eye symptoms assessed by the Ocular Surface Disease Index (OSDI). Secondary outcomes were clinical findings associated with the dry eye such as meibomian gland dysfunction (MGD) score, tear break-up time (TBUT), corneal fluorescein staining, Schirmer test, and best-corrected visual acuity (BCVA).

RESULTS

Forty patients were recruited, 20 in each arm. The mean age was 63.5 ± 15.1 years and 27 (67.5%) were female. The mean OSDI score significantly improved in the intervention group from 19.15 ± 10.3 to 10.5 ± 7.0 (P < 0.001), whereas the control group showed no significant change (14.4 ± 8.4 to 15.5 ± 8.6, P = 0.830). MGD scores significantly improved in the intervention group (1.57 ± 1.2 to 0.8 ± 0.9, P = 0.006), whereas showing no significant change in the control group (1.60 ± 0.9 to 1.99 ± 1.0, P = 0.244). The corneal staining score also showed significant improvement in the intervention group (P = 0.045) and a nonsignificant decline in the placebo group (P = 0.50). No significant difference was seen in TBUT, visual acuity, and Schirmer scores between groups. No harm resulting from treatment was reported during the duration of the trial.

CONCLUSIONS

High-frequency electrotherapy may have a positive effect on symptoms and signs of dry eye. This emerging technology may become part of the arsenal of therapeutic modalities for this condition.

Effective Decrease in Myopia Progression With Two Mechanisms of Management

PURPOSE

To ascertain the effectiveness of 0.01% atropine treatment to inhibit myopia progression and the possible additive potency with peripheral defocus contact lenses over 3 years and the rebound effect 1 year after cessation of treatment.

METHODS

This prospective study included 127 children aged 8 to 5 years, divided into three treatment groups: 0.01% atropine and single-vision spectacles (At+SV, n = 36), 0.01% atropine and peripheral defocus contact lens (At+PDCL, n = 30), and 0.01% atropine and dual-focus contact lens (At+DF, n = 25). A control group was prescribed single-vision spectacles (n = 36). Cycloplegic spherical equivalence refraction was measured every 6 months during 3 years of treatment and 1 year after cessation.

RESULTS

Myopia progression decreased over 3 years of treatment, more during the second and third years than the first year, to a statistically significant degree in the atropine groups (P < .01): in the first, second, and third years, respectively, -0.42 ± 0.34, -0.19 ± 0.18, -0.22 ± 0.19 diopters (D) in the At+SV group, -0.26 ± 0.21, -0.14 ± 0.37, and -0.15 ± 0.31 D in the At+PDCL group, and -0.22 ± 0.15, -0.15 ± 0.22, and -0.11 ± 0.14 D in the At+DF group. Myopia progressed 1 year after cessation of treatment: -0.29 ± 0.28 D in the At+SV group, -0.13 ± 0.28 D in the At+PDCL group, and -0.09 ± 0.18 D in the At+DF group. After 3 years, there was no statistically significant difference in myopia progression between the At+SV and At+PDCL or At+DF groups (P < .05).

CONCLUSIONS

Low-dose atropine has been substantiated in this cohort as an effective treatment to decelerate myopia progression over 3 years, more effective in the second and third years of treatment. The combination treatment did not exhibit a statistically significant advantage over monotherapy in this cohort. The At+DF group exhibited a statistically lower rebound effect than the At+SV group. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XXX-XXX.].

Iris color as a predictive factor for intraoperative floppy iris syndrome

PURPOSE

To assess the influence of iris color on the predisposition for intraoperative floppy iris syndrome (IFIS) during cataract surgery.

METHODS

Medical records of patients who underwent cataract surgery in two medical centers between July 2019 and February 2020 were reviewed. Patients younger than 50 years, with preexisting ocular conditions affecting pupillary size or anterior chamber depth (ACD), and combined procedures were excluded. The remaining patients were questioned via telephone regarding their iris color. The association of IFIS occurrence and severity with iris color was tested using univariant and multivariant analyses.

RESULTS

Overall, 155 eyes of 155 patients were included, 74 with documented IFIS and 81 without. The mean age was 74.03 ± 7.09 years, and 35.5% were female. The most common iris color among study eyes was brown (110/155, 70.97%), followed by blue (25/155, 16.13%) and green (20/155, 12.90%). Compared to brown-colored eyes, blue irises exhibited a 4.50-fold risk for IFIS (OR = 4.50, 95% CI: 1.73-11.70, p = 0.002), and green irises 7.00-fold risk (OR = 7.00, 95% CI: 2.19-22.39, p = 0.001). After adjusting for possible confounders, the results remained statistically significant (p < 0.01). Light-colored irises tended to exhibit a more severe IFIS compared to the brown iris group (p < 0.001). IFIS bilaterality was also affected by iris color (p < 0.001), with a 10.43-fold risk for fellow eye IFIS in the green iris group compared to eyes with brown irises (OR = 10.43, 95% CI: 3.35-32.54, p < 0.001).

CONCLUSIONS

Light iris color was associated with a significantly increased risk of IFIS occurrence, severity, and bilaterality on univariate and multivariate analysis in this study.

Psychiatric Comorbidities Associated With Keratoconus

Importance

Evaluating risk factors for keratoconus, often associated with recurrent eye rubbing, could generate hypotheses to be tested in future interventional trials.

Objective

To assess the risk for keratoconus associated with psychiatric comorbidities in adolescents and adults.

Design, Setting, and Participants

This population-based cross-sectional study included medical records of Israeli adolescents and adults in military service from January 2011 through December 2021.

Main Outcomes and Measures

The prevalence of anxiety, obsessive compulsive disorder (OCD), autism, and attention-deficit/hyperactivity disorder (ADHD) was evaluated in individuals with and without keratoconus. The association between keratoconus and psychiatric comorbidities was tested using univariate and multivariant analyses.

Results

Overall, 940 763 adolescents and adults were included. Mean (SD) age was 17.56 (1.47) years, and 59.3% were male. Keratoconus was documented in 1533 individuals, with a prevalence of 0.16%. Patients with keratoconus were more likely to be diagnosed with ADHD compared with the general population (odds ratio [OR], 1.58; 95% CI, 1.38-1.81; P < .001). After adjusting for age, sex, intellectual status, height, and weight, the results remained unchanged (hazard ratio, 1.46; 95% CI, 1.27-1.67; P < .001). Stratification according to age showed an association between keratoconus and ADHD for males (OR, 1.62; 95% CI, 1.39-1.90; P < .001) but not for females (OR, 1.29; 95% CI, 0.96-1.74; P = .09).

Conclusions and Relevance

In a large cohort of adolescents and adults, ADHD was associated with a diagnosis of keratoconus in male patients, even after adjusting for possible confounders. Although a causative effect could not be ascribed, these findings support further investigation into the potential value of education regarding eye rubbing in this population.

Variants in the WDR45 Gene Within the OPA-2 Locus Associate With Isolated X-Linked Optic Atrophy

Purpose

To describe clinical and molecular findings of two families with X-linked optic atrophy and present two new pathogenic variants in the WDR45 gene.

Methods

Case series and molecular analysis of two families of Jewish Ashkenazi descent with early onset bilateral optic atrophy. Whole-exome sequencing (WES) and bioinformatic analysis were performed, followed by Sanger sequencing and segregation analysis.

Results

In both families, male siblings (three in family 1, two in family 2) had early-onset isolated bilateral optic atrophy. The sibling's healthy mother (and in the second family also one healthy sister) had a mild presentation, suggesting a carrier state and an X-linked inheritance pattern. All participants were otherwise healthy, apart from mild learning disabilities and autism spectrum disorder in two siblings of the second family. Variants in known optic atrophy genes were excluded. Analysis revealed a point variant in the WDR45 gene-a missense variant in the first family, NM_001029896.2:c.107C>A; NP_001025067.1:p.Pro36His (variant ID: 1704205), and a splice site variant in the second family, NM_001029896.2:c.236-1G>T; NP_009006.2:p.Val80Leu (variant ID: 1704204), located on Xp11.23 (OPA2 locus). Both variants are novel and predicted as pathogenic. In both families, the variant was seen with full segregation with the disease, occurring in all affected male participants and in one allele of the carrier females, as well as none of the healthy participants.

Conclusions

Among two families with isolated X-linked optic atrophy, molecular analysis revealed novel variants in the WDR45 gene in full segregation with the disease. This gene resides within the OPA2 locus, previously described to associate with X-linked optic atrophy. Taken together, these findings suggest that certain pathogenic variants in the WDR45 gene are associated with isolated X-linked optic atrophy.

The association between keratoconus and systemic manifestations of connective tissue hyperlaxity

PURPOSE

To evaluate the correlation between keratoconus and systemic manifestations of tissue hyperlaxity in the general population.

METHODS

In this population based cross-sectional study 940,763 medical records of Israeli adolescents and young adults in military service were reviewed. Demographic and medical data were extracted. The prevalence of ligament injuries, habitual orthopedic deformities and umbilical/inguinal hernia was evaluated in cases with and without keratoconus. The association was tested using uni- and multivariant analyses.

RESULTS

Overall 938,411 adolescents and adults were included. Mean age was 17.55 ± 1.50 years, and 40.70% were female. Keratoconus was documented in 1,529 cases, with a prevalence of 0.16%. Compared to the general population, patients with keratoconus were significantly more likely to be diagnosed with genu varum/valgus (OR = 2.75, CI 1.48-5.13, p = 0.0015), pes planus (OR = 1.97, 95% CI: 1.62-2.38, p < 0.0001), scoliosis (OR = 1.88, 95% CI: 1.45-2.43, p < 0.0001) and umbilical/inguinal hernias (OR = 2.18, 95% CI: 1.47-3.24, p = 0.0001). On multivariate analysis the results remained significant (p < 0.05 for all). Joint injuries (ankle sprains, shoulder dislocation and injury to knee ligaments and menisci) were not significantly related to keratoconus (p > 0.05 for all).

CONCLUSIONS

In this large cohort of adolescents and young adults, an association was found between keratoconus and connective tissue hyperlaxity manifestations involving the knees, feet, spine and abdomen. These findings suggest that keratoconus might be a manifestation of a generalized connective tissue disorder, rather than just a local ocular phenomenon.

Genetic causes of inherited retinal diseases among Israeli Jews of Ethiopian ancestry

Purpose

This study sought to describe the phenotype frequency and genetic basis of inherited retinal diseases (IRDs) among a nationwide cohort of Israeli Jewish patients of Ethiopian ancestry.

Methods

Patients' data-including demographic, clinical, and genetic information-were obtained through members of the Israeli Inherited Retinal Disease Consortium (IIRDC). Genetic analysis was performed by either Sanger sequencing for founder mutations or next-generation sequencing (targeted next-generation sequencing or whole-exome sequencing).

Results

Forty-two patients (58% female) from 36 families were included, and their ages ranged from one year to 82 years. Their most common phenotypes were Stargardt disease (36%) and nonsyndromic retinitis pigmentosa (33%), while their most common mode of inheritance was autosomal recessive inheritance. Genetic diagnoses were ascertained for 72% of genetically analyzed patients. The most frequent gene involved was ABCA4. Overall, 16 distinct IRD mutations were identified, nine of which are novel. One of them, ABCA4-c.6077delT, is likely a founder mutation among the studied population.

Conclusions

This study is the first to describe IRDs' phenotypic and molecular characteristics in the Ethiopian Jewish community. Most of the identified variants are rare. Our findings can help caregivers with clinical and molecular diagnosis and, we hope, enable adequate therapy in the near future.

Micro chromosomal deletions at the NYS7 locus and autosomal dominant nystagmus

Nystagmus is an ocular condition characterized by bilateral involuntary ocular oscillation which can severely affect vision. When not associated with other ocular or systemic diseases, it is referred to as idiopathic or congenital motor nystagmus (CMN). Genome-wide linkage studies have previously identified several loci associated with CMN, however the genes responsible for some of these loci have yet to be identified. We have examined a large, five-generation family with autosomal dominant CMN. Our purpose was to characterize the clinical manifestations and reveal the molecular basis of the disease in this family. In addition to full ophthalmic examination and imaging, molecular analysis included copy number variation analysis, linkage studies, and Sanger sequencing. Expression analyses of candidate genes was done by real-time PCR. Of the 68 family members, 27 subjects in five-generations had CMN, in line with an autosomal dominant inheritance pattern. Molecular analysis was performed on 27 members, 15 of them affected by CMN. Copy number variation analysis using array comparative genomic hybridization (aCGH) revealed a novel deletion located on 1q32 (NYS7) among affected individuals. Linkage analysis using polymorphic markers demonstrated full segregation with a heterozygous haplotype in all affected patients, with a LOD score of >5. Sanger sequencing of affected subjects revealed a novel deletion of 732,526 bp in the linkage interval. No protein-coding genes exist within the deleted region; however, the deletion disrupts topologically associated domains encompassing the gene NR5A2 and the non-protein coding MIR181A. Both are strongly associated with other genes expressed in the retina such as PROX1, which in turn is also associated with genes related to nystagmus such as PAX6. We therefore hypothesized that the deletion might affect NR5A2 and MIR181A expression, causing CMN. Expression analysis by real-time PCR showed significantly lower expression of NR5A2, and significantly higher expression of PROX1 among patients compared with controls. To conclude, among a large five-generation family with autosomal dominant CMN, a large deletion in the interval of NYS7 was linked with the disease. No protein-coding genes exist inside the deleted region, and so the exact mechanism in which CMN is caused is uncertain. Based on topological association and expression analyses we suggest a possible mechanism for the pathogenesis.

Routine use of non-absorbable sutures in bi-medial rectus recession as a measure to reduce the incidence of consecutive exotropia

OBJECTIVE

To evaluate the incidence of consecutive exotropia following bilateral medial rectus muscle recession surgery (BMR) for esotropia using non-absorbable compared with absorbable sutures in children undergoing strabismus surgery.

METHODS

A retrospective cohort study of all children with esotropia who underwent BMR by a single surgeon in a tertiary public hospital. As of February 2018, only non-absorbable sutures were used. The primary outcome was the incidence of consecutive exotropia.

RESULTS

A total of 121 children were included in the analysis, 3.66 ± 2.62 years, 53% were male. In 80 children (66%) non-absorbable sutures were used (non-absorbable group) and in 41 children (34%) absorbable sutures were used (absorbable group). Consecutive exotropia (≥ 8 prism dioptres) occurred in ten children (24%) in the absorbable group and in three children (4%) in the non-absorbable group (OR = 8.28, 95% CI = 2.13-32.13; P = 0.002). This difference between groups remained significant after adjustment for potential confounders and follow-up time (HR = 4.98, 95% CI = 1.30-19.05, P = 0.019). Mean follow-up time was 22 and 12 months in the absorbable and non-absorbable groups, respectively (P < 0.001). Two children in the non-absorbable group had pyogenic granuloma that resolved after 3 months of topical steroidal therapy.

CONCLUSION

Routine use of non-absorbable sutures in BMR surgery for esotropia may be a preferable alternative to absorbable sutures for the prevention of consecutive exotropia.

THE TARGET SIGN: A Near Infrared Feature and Multimodal Imaging in a Pluri-Ethnic Cohort with RDH5-Related Fundus Albipunctatus

PURPOSE

Retinol dehydrogenase 5 (RDH5)-related fundus albipunctatus can present with phenotypic variability. Our purpose was to investigate new clinical characteristics and multimodal imaging findings in patients from different ethnic origins, carrying different mutations.

METHODS

Multicenter international retrospective case series of 18 patients with genetically confirmed RDH5-related fundus albipunctatus. Patients' files were reviewed for fundus images, visual acuity, macular optical coherence tomography scans, near-infrared images, fundus autofluorescence, electroretinogram, and genetic mutations. Imaging and electroretinogram findings.

RESULTS

All eyes (n = 36, 100%) showed small circular findings seen on near-infrared images, termed as the "target sign," correlating to the yellowish dots seen clinically and to the distinct hyperreflective linear lesions on optical coherence tomography at the level between external limiting membrane and retinal pigment epithelium. Perifoveal atrophy with foveal sparing was seen in 4 eyes of 2 patients (both RDH5-c.160C>T, p.R54X mutation). Fundus autofluorescence revealed small hyperautofluorescent dots (n = 16, 44.4%). Scotopic electroretinograms were significantly reduced in all cases with an electronegative pattern, 66.7% displayed cone dysfunction.

CONCLUSION

Our results show distinct imaging findings present in all patients with fundus albipunctatus independent of ethnicity or genetic mutation. Our results can facilitate the current algorithm to diagnose RDH5-related fundus albipunctatus and allow for targeted genetic testing.

Hyperbaric oxygen treatment for non-arteritic central retinal artery occlusion retrospective comparative analysis from two tertiary medical centres

OBJECTIVES

To compare the visual outcome of patients treated for non-arthritic central retinal artery occlusion (CRAO) in a medical centre that uses hyperbaric oxygen therapy (HBOT) as part of the standard of care (SOC) to medical centres that does not.

METHODS

The study included data from two tertiary medical centres. The medical records of all patients diagnosed with non-arthritic CRAO without a patent cilioretinal artery between January 2010 and December 2018 in two tertiary medical centres were reviewed.

RESULTS

One hundred and twenty-one patients were treated by HBOT and 23 patients received only SOC. In the HBOT group, best-corrected visual acuity (BCVA) improved from 2.89 ± 0.98 logMAR at presentation to 2.15 ± 1.07 logMAR upon the end of HBOT (P < 0.001), while the SOC group had no significant improvement, from 3.04 ± 0.82 logMAR at presentation to 2.80 ± 1.50 logMAR (P = 0.24). With adjustment for age, gender, and the duration of symptoms, final BCVA in the HBOT group was significantly better compared to the control group (P = 0.023). Rates of patients achieving vision of 20/200 or better were similar between groups (17.4% vs. 19.8%, P = 0.523).

CONCLUSION

Utilizing HBOT as part of the SOC for CRAO improves the final visual outcome. HBOT is safe and can be implemented, if available, as part of SOC in all tertiary medical centres.

Myopia and Early-Onset Type 2 Diabetes: A Nationwide Cohort Study

CONTEXT

A correlation between myopia and insulin resistance has been suggested.

OBJECTIVE

We investigated the association between myopia in adolescence and type 2 diabetes (T2D) incidence in young adulthood.

METHODS

This population-based, retrospective, cohort study comprised 1 329 705 adolescents (579 543 women, 43.6%) aged 16 to 19 years, who were medically examined before mandatory military service during 1993 to 2012, and whose data were linked to the Israel National Diabetes Registry. Myopia was defined based on right-eye refractive data. Cox proportional models were applied, separately for women and men, to estimate hazard ratios (HRs) for T2D incidence per person-years of follow-up.

RESULTS

There was an interaction between myopia and sex with T2D (P < .001). For women, T2D incidence rates (per 100 000 person-years) were 16.6, 19.2, and 25.1 for those without myopia, and with mild-to-moderate and high myopia, respectively. These corresponded to HRs of 1.29 (95% CI, 1.14-1.45) and 1.63 (1.21-2.18) for women with mild-to-moderate and high myopia, respectively, compared to those without myopia, after adjustment for age at study entry, birth year, adolescent body mass index, cognitive performance, socioeconomic status, and immigration status. Results persisted in extensive sensitivity and subgroup analyses. When managed as a continuous variable, every 1-diopter lower spherical equivalent yielded a 6.5% higher adjusted HR for T2D incidence (P = .003). There was no significant association among men.

CONCLUSION

For women, myopia in adolescence was associated with a significantly increased risk for incident T2D in young adulthood, in a severity-dependent manner. This finding may support the role of insulin resistance in myopia pathogenesis.

Original article: Myopia control utilizing low-dose atropine as an isolated therapy or in combination with other optical measures: A retrospective cohort study

PURPOSE

To assess the additive potency of low-dose atropine combined with optical measures designed to decrease myopia progression.

MATERIALS AND METHODS

This retrospective study included 104 myopic children aged 5-12 over 4 years, divided into five groups: daily instillation of 0.01% atropine and distance single-vision spectacles (A), 0.01% atropine and progressive addition lenses (A + PAL), 0.01% atropine and soft contact lens with peripheral blur (A + CL). Two control groups were included, prescribed bifocal spectacles or single vision (SV) spectacles. Cycloplegic spherical equivalence refraction was measured biannually, including 1 year after cessation of treatment.

RESULTS

A significant decrease in myopia progression was noted during the 2^nd and 3^rd years of atropine treatment: A -0.55 ± 0.55D, -0.15 ± 0.15, -0.12 ± 0.12D were 1^st, 2^nd, 3^rd years, respectively, A + PAL -0.47 ± 0.37D, -0.10 ± 0.25D, and -0.11 ± 0.25D were 1^st, 2^nd, 3^rd years, respectively, A + CL -0.36 ± 0.43D, -0.13 ± 0.29D, and -0.10 ± 0.27D were 1^st, 2^nd, 3^rd years, respectively. Myopia progression over 3 years, respectively, was -0.82 ± 0.50D, -0.70 ± 0.69D, -0.59 ± 0.66D in the bifocal group and -1.20 ± 1.28D, -0.72 ± 0.62D, -0.65 ± 0.47D in the SV group. One year after cessation of atropine treatment, myopia progression was - 0.32 ± 0.31D in A, -0.23 ± 0.28D in A + PAL, and -0.18 ± 0.35D in A + CL.

CONCLUSION

Atropine 0.01% presented as effective at decelerating myopia progression, more prominent in the 2^nd and 3^rd years of treatment. Combining atropine 0.01% with optical modalities exhibited a trend for added efficacy over monotherapy. A + CL exhibited the least rebound effect 1 year after cessation of treatment.

Treatment of Rapid Progression of Myopia: Case Series and Literature Review

This retrospective case series demonstrates the combination of 0.05% atropine with MiSight^® 1 day (Cooper vision, Sar Ramon, CA, USA) in rapid progression of myopia of 4 children. MiSight^® 1 day is a peripheral defocus, center-distance soft contact lens and is effective at controlling moderate progression of myopia during the course of 1 year. The current case series included 2 females and 2 males with an average age of 9.68 ± 0.26 years and an average axial length of 24.81 ± 0.92 mm. Their myopic progression during the previous year was −1.45 ± 0.27 D. The children had not attempted any myopia control thus far. This relatively high increase prompted a combination treatment of daily instillation of 0.05% atropine and MiSight, a daily replacement soft contact lens. Cycloplegic refraction and a slit-lamp evaluation were performed every 6 months to confirm no adverse reactions or staining was present. The 8-item contact lens dry eye questionnaire (CLDEQ-8) score of these children was 10.66 ± 1.52. The average myopia progression at the end of 1 year decreased to −0.41 ± 0.11 D, and the average axial length increase was 0.28 ± 0.08 mm. To the best of the authors' knowledge, this is the first published study showing a combination of 0.05% atropine and peripheral defocus soft contact lenses indicating efficacy at controlling moderate myopia progression.

Association of Variants in TMEM45A With Keratoglobus

Importance

Keratoglobus is a rare corneal disorder characterized by generalized thinning and globular protrusion of the cornea. Affected individuals typically have significantly decreased vision and are at risk of corneal perforation. The genetic basis and inheritance pattern of isolated congenital keratoglobus are currently unknown.

Objective

To identify the genetic basis of isolated congenital keratoglobus.

Design, Setting, and Participants

This case series and molecular analysis studied 3 unrelated nonconsanguineous families with keratoglobus at a medical center in Israel. Data were collected from June 2019 to March 2021 and analyzed during the same period.

Exposures

Whole-exome sequencing and direct Sanger sequencing, expression analysis by real-time polymerase chain reaction, splice-site variant analysis, immunohistochemical staining, and histological evaluation of a knockout mouse model.

Main Outcomes and Measure

Molecular characteristics associated with keratoglobus.

Results

Four pediatric patients (3 male individuals) from 3 families had clinical findings consistent with keratoglobus. These included globular protrusion, corneal thinning more prominent at the periphery, and high astigmatism. Truncating and splice site variants were identified in the TMEM45A gene, which fully segregate with the disorder. All affected individuals were homozygous or compound heterozygous for variants in the TMEM45A gene, while unaffected family members were heterozygous carriers. Expression analysis in healthy controls showed that TMEM45A was expressed 23 times higher in the human cornea compared with peripheral blood. Immunohistochemical staining of the TMEM45A protein in normal corneas confirmed its expression in the corneal stroma and epithelium. A TMEM45A knockout mouse model showed structural features consistent with keratoglobus.

Conclusions and Relevance

Expression of TMEM45A has been previously shown to result in upregulation of extracellular matrix components and fibrosis. These results suggest that isolated congenital keratoglobus is an autosomal recessively inherited disorder associated with variants in the TMEM45A gene.

The ABCD Keratoconus Grading System-A Useful Tool to Estimate Keratoconus Progression in the Pediatric Population

PURPOSE

To evaluate the ABCD grading system in pediatric keratoconus.

METHODS

A retrospective cohort analysis of all children with keratoconus followed up at the Shamir medical center between 2010 and 2017. A recommendation by the treating physician to undergo corneal crosslinking (CXL) was used as an estimate for clinically significant disease progression. The ABCD grading was not available to the treating physician and was computed post hoc. The ABCD grading was compared between patients who required CXL with those who did not. A single eye of each patient was included.

RESULTS

Fifty eyes of 50 children were analyzed. The mean age at presentation was 15.56 ± 1.36 years. In 23 eyes, progression of keratoconus was recorded and CXL was performed (CXL-group). On presentation, the stable and CXL groups did not differ significantly in their clinical parameters. In the CXL-group, a statistically significant increase was seen in the ABCD staging (P < 0.001). In the stable group, the ABCD staging did not change significantly in parallel visits (P = 0.87). An increase of 1 point in the sum of the ABCD staging showed a 5-fold risk for undergoing CXL (odds ratio = 5.28; 95% CI, 1.82-15.34). There was no significant change in the Amsler-Krumeich classification in the CXL group.

CONCLUSIONS

Among a cohort of pediatric patients with keratoconus, worsening in the ABCD grading was associated with disease progression, whereas no significant change was demonstrated in the Amsler-Krumeich classification The ABCD grading system is a useful tool for initial assessment of disease progression in the pediatric population, in which early recognition is of paramount importance.

Modification of intraocular lens insertion using 4-flanged fixation with a standard cartridge and a 2.4 mm corneal incision in eyes with no capsular support

A modification of intraocular lens (IOL) implantation, using the 4-flanged IOL fixation technique, through a 2.4 mm corneal incision using a standard cartridge and injector, is presented. An IOL with 4 eyelets is used, through which a 6-0 polypropylene suture is threaded on one side and then loaded into a provided cartridge and inserted to the anterior chamber through a 2.4 mm corneal incision. Using the handshake technique, the suture ends are eventually threaded through the eyelets and secured outside the eye with the creation of 4 flanges. This technique was used in 6 eyes of 5 consecutive patients with the absence of capsular support. During all follow-up visits, the IOLs were well centered and stable, and the flanges were buried in the sclera and covered with the conjunctiva. No complications were recorded. This modification simplifies the technique and reduces the well-known complications of large corneal incisions.

Association of COVID-19 Vaccination and Facial Nerve Palsy: A Case-Control Study

Importance

Peripheral facial nerve (Bell) palsy has been reported and widely suggested as a possible adverse effect of the BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine. Israel is currently the leading country in vaccination rates per capita, exclusively using the BNT162b2 vaccine, and all residents of Israel are obligatory members of a national digital health registry system. These factors enable early analysis of adverse events.

Objective

To examine whether the BNT162b2 vaccine is associated with an increased risk of acute-onset peripheral facial nerve palsy.

Design, Setting, and Participants

This case-control study was performed from January 1 to February 28, 2021, at the emergency department of a tertiary referral center in central Israel. Patients admitted for facial nerve palsy were matched by age, sex, and date of admission with control patients admitted for other reasons.

Exposures

Recent vaccination with the BNT162b2 vaccine.

Main Outcomes and Measures

Adjusted odds ratio for recent exposure to the BNT162b2 vaccine among patients with acute-onset peripheral facial nerve palsy. The proportion of patients with Bell palsy exposed to the BNT162b2 vaccine was compared between groups, and raw and adjusted odds ratios for exposure to the vaccine were calculated. A secondary comparison with the overall number of patients with facial nerve palsy in preceding years was performed.

Results

Thirty-seven patients were admitted for facial nerve palsy during the study period, 22 (59.5%) of whom were male, and their mean (SD) age was 50.9 (20.2) years. Among recently vaccinated patients (21 [56.7%]), the mean (SD) time from vaccination to occurrence of palsy was 9.3 (4.2 [range, 3-14]) days from the first dose and 14.0 (12.6 [range, 1-23]) days from the second dose. Among 74 matched controls (2:1 ratio) with identical age, sex, and admittance date, a similar proportion were vaccinated recently (44 [59.5%]). The adjusted odds ratio for exposure was 0.84 (95% CI, 0.37-1.90; P = .67). Furthermore, analysis of the number of admissions for facial nerve palsy during the same period in preceding years (2015-2020) revealed a relatively stable trend (mean [SD], 26.8 [5.8]; median, 27.5 [range, 17-35]).

Conclusions and Relevance

In this case-control analysis, no association was found between recent vaccination with the BNT162b2 vaccine and risk of facial nerve palsy.

Intrascleral 4-flanged technique for in-the-bag intraocular lens subluxation

PURPOSE

To present a series of cases in which the 4-flanged technique was used in the management of in-the-bag intraocular lens (IOL) subluxation.

SETTING

Shamir Medical Center, Israel.

DESIGN

Retrospective cohort analysis.

METHODS

Included were consecutive cases with secondary IOL subluxation that underwent scleral fixation with the 4-flanged technique using 6-0 polypropylene and low temperature cautery. Surgeries were performed during September 2019 to April 2020. Postoperative IOL angle tilt was evaluated using high-resolution ocular coherence tomography.

RESULTS

Eleven eyes of 11 patients were included. The mean age was 82.7 ± 5.5 years, and 60% were men. Pseudoexfoliation was noted in 82% of patients, and only 1 case was related to trauma. The mean corrected distance visual acuity (CDVA) postoperatively was within 1 line of the original presubluxation CDVA (0.55 ± 0.41 vs 0.54 ± 0.6 logMAR, P = .965). The mean postoperative IOL tilt was 5.78 ± 3.85 degrees. Surgery duration decreased from 70 ± 14 minutes to 39 ± 15 minutes (first to last operations). No intraoperative complications were reported. Postoperatively, transient intraocular pressure elevation, which resolved at 1 week, was recorded in 45% of cases. Cystoid macular edema, which resolved within a few months under topical treatment, was seen in 2 patients.

CONCLUSIONS

Among a cohort of patients with secondary in-the-bag IOL subluxation, the 4-flanged technique was safe and resulted in satisfactory visual outcomes and a stable IOL position, with a short learning curve.

Decreased effectiveness of 0.01% atropine treatment for myopia control during prolonged COVID-19 lockdowns

The COVID-19 pandemic of 2020 and its' accompanied lockdowns impacted the entire globe in ways the world is only beginning to comprehend. In Israel, children age 9–15 had not been in a frontal classroom and been socially restricted from March 2020 till March 2021. Fourteen of these children that had been under myopia control treatment which had been effective prior to the pandemic were included in this retrospective study to learn if their myopia continued to stay under control, or if the unique environmental modifications affected their progression. The results showed that average increase in spherical equivalent refraction and axial length, measured with optical biometer OA-2000 (Tomey GmbH, Nagoya, Japan), during the year of lockdowns was −0.73 ± 0.46D/0.46 ± 0.31 mm respectively, while the average increase in the year prior was −0.33 ± 0.27D/0.24 ± 0.21 mm. Though several articles have indicated the pandemic environment has influenced myopia progression in children, this communication indicates a possible significant impact of the environment on myopia increase even in individuals under effective atropine treatment. These children's' progression suggests practitioners consider and address multiple aspects simultaneously when attempting myopia control.

Seven years follow-up of corneal cross-linking (CXL) in pediatric patients: Evaluation of treated and untreated eye

BACKGROUND

Retrospective cohort study evaluating long term keratoconus progression amongst cross-linking (CXL) treated pediatric patients in the treated and the fellow untreated eyes.

METHODS

Data on 60 eyes of 30 patients, 18 years old or younger, who underwent CXL in at least one eye was collected and analyzed. Follow-up measurements taken from the treated and untreated eye up to 7 years after CXL treatment, were compared to baseline measurements. Parameters included uncorrected distance visual acuity (UCDVA), best-corrected spectacle visual acuity (BCSVA), manifest refraction, pachymetry, corneal tomography, and topography.

RESULTS

Mean age of patients was 16 ± 2.1 years. For the treated eyes, during follow-up period mean UCDVA had improved (from 0.78 ± 0.22 at baseline to 0.58 ± 0.26 logMAR at 7 years; p = 0.13), as well as mean BCSVA (from 0.23 ± 0.107 at baseline to 0.172 ± 0.05 logMAR at 7 years; p = 0.37). The mean average keratometry showed a significant flattening (from 49.95 ± 4.04 to 47.94 ± 3.3 diopters (D); p < 0.001), However there was no change in the mean maximal keratometry. The mean minimal corneal thickness (MCT) showed a significant mild reduction of 26 µm (p = 0.006). Although statistically insignificant, the mean manifest cylinder was also reduced to 2D (p = 0.15). During the follow-up period, eight untreated eyes (26.6%) deteriorated and underwent CXL, while only one treated eye (3.33%) required an additional CXL.

CONCLUSION

CXL is a safe and efficient procedure in halting keratoconus progression in the pediatric population, the fellow eye needs to be carefully monitored but only a 25% of the patients will require CXL in that eye during a period of 7 years.

Superior oblique split tendon elongation for Brown's syndrome: Long-term outcomes

PURPOSE

To report the outcomes of superior oblique split tendon elongation in Brown's syndrome.

METHODS

Charts of 17 consecutive Brown's syndrome patients who underwent superior oblique split tendon elongation were reviewed and clinical data regarding preoperative, intraoperative, and postoperative data were collected.

RESULTS

About 17 eyes of 17 children with congenital Brown's syndrome underwent superior oblique split tendon elongation between January 2012 and March 2020 by a single surgeon. Mean age at surgery was 5.47 ± 2.82 (range 1.50-13.2). Eight (47.1%) were female. Preoperative deficit of elevation in adduction was -4 in all children. At the end of surgery, all eyes were freely elevated on adduction, on forced duction test. Mean follow-up time of 26.24 ± 11.22 (range 11-53) months. In 15 of 17 children (88.2%), motility improved, orthotropia in primary position was achieved, and head posture eliminated (p < 0.001). Superior oblique palsy occurred in two children, who after reoperation, achieved an acceptable outcome. No intraoperative complications were recorded.

CONCLUSION

The superior oblique split tendon elongation procedure is a useful surgical technique with stable and satisfying outcomes for the treatment of severe congenital Brown's syndrome.

Eye patching after cataract surgery is associated with an increased risk of short-term corneal oedema

PURPOSE

To evaluate the effect of postoperative eye patching after routine cataract surgery on corneal oedema and visual acuity on the first postoperative day.

SETTING

One public healthcare centre.

DESIGN AND METHODS

This randomized controlled trial included patients undergoing uneventful cataract surgery in one medical centre. Patients were randomized into two groups: the surgical eye was patched with a single dose of a local steroid and antibiotic for 24 hr in the first group, and a plastic shield was used in the second with local steroid and antibiotic drops. The eyes were examined preoperatively and on the first postoperative day. Examination included the following: best-corrected visual acuity (BCVA), full slit lamp examination, intraocular pressure (IOP), anterior chamber depth (ACD) and central corneal thickness (CCT) using the IOL Master 700 (Zeiss, Germany). Cumulative dissipated energy (CDE) and operation time were recorded for all cases.

RESULTS

One hundred eyes of 100 patients were included in the study. The postoperative increase in CCT 24 hr after surgery was 138 and 70 µm in the patched group as compared to the non-patched group, respectively (p = 0.001). Best-corrected visual acuity (BCVA) on the first postoperative day was 0.5 ± 0.45 LogMAR and 0.3 ± 0.3 LogMAR in the patched and non-patched group, respectively (p = 0.01). There was no difference in CDE (11.33 ± 9.2 and 10.22 ± 7.3; p = 0.94) between the two groups.

CONCLUSIONS

Eye patching after routine cataract surgery is associated with an increase in corneal oedema and slower visual recovery on the first postoperative day.

Ocular involvement in coronavirus disease 2019 (COVID-19): a clinical and molecular analysis

Purpose

Coronavirus disease 2019 (COVID-19) caused a global pandemic with millions infected worldwide. Little is known on the ocular involvement associated with the disease. The aim of this study was to assess the clinical and molecular ocular involvement among patients with confirmed COVID-19 admitted to a tertiary care facility.

Methods

Consecutive patients admitted to the COVID-19 Ward of the Shamir Medical Center in Israel during March and April, 2020 were included. The control group included patients negative for COVID-19 admitted during a similar period to a different ward. Patients were examined by trained Ophthalmologists. SARS-CoV-2 conjunctival swab samples were obtained.

Results

Included were 48 patients, 16 with confirmed COVID-19 and 32 controls. Median patient age was 68.5 (interquartile range: 31.5, mean: 63 ± 21) years and 48% were male. Active conjunctival injection was present in three patients (19%) with COVID-19, compared to none in the controls (p = 0.034). Patients with COVID-19 were more likely to complain of foreign body sensation (31.3% vs 3.1%, p = 0.005) and redness of the eye (25% vs 0%, p = 0.003). Conjunctival injection was associated with loss of smell and taste (75% vs 7.7%, p = 0.018). Viral conjunctival swab tests all showed negative results for all three viral genes tested (E, N, and RdRp).

Conclusions

Among patients admitted to a tertiary referral center with confirmed COVID-19, active conjunctival injection was noted in one out of five cases, and was associated with loss of smell and taste. Conjunctival swabs for viral RNA were negative in patients with and without ocular involvement.

Electronic supplementary material

The online version of this article (10.1007/s10792-020-01592-1) contains supplementary material, which is available to authorized users.

Clinical outcomes of Ankoris toric intraocular lens implantation using a computer-assisted marker system

PURPOSE

To report the clinical outcomes of patients who underwent cataract surgery with implantation of Ankoris monofocal toric intraocular lens (IOL) (PhysIOL SA, Liège, Belgium) using the Zeiss Callisto Eye (Carl Zeiss AG, Dublin, CA).

METHODS

We conducted a retrospective case series of patients who underwent routine cataract extraction and implantation of Ankoris toric IOL using the Zeiss Callisto eye between January 2018 and December 2018 by four senior surgeons. Patients' medical records were reviewed, and clinical outcomes including postoperative refraction, visual acuity outcomes, IOL position and deviation from planned axis were collected.

RESULTS

Fifty-six eyes of 56 patients were included, 48% were female, and the mean age was 70 ± 8 years. Patients with pseudoexfoliation syndrome, glaucoma or keratoconus were excluded from the study. Pre-operative mean corneal astigmatism was 2.38 ± 0.78 diopters (D), and mean implanted IOL cylindrical power was 3.06 ± 1.07 D. IOL rotation 30 days postoperatively was within 5° in 82% of eyes and between 6° and 10° in 10.8% of eyes. Mean postoperative refractive astigmatism 30 days postoperatively was 0.22 ± 0.36 D; in 84% of eyes the postoperative refractive astigmatism was ≤ 0.50 D. IOL rotation significantly increased between day 1 to day 7 postoperatively (1.91 ± 3.15° to 3.18 ± 3.3°, P = 0.001). However, no significant rotation had occurred between day 7 and day 30 postoperatively (P = 0.093).

CONCLUSION

Cataract surgery with implantation of Ankoris monofocal toric IOL using the Zeiss Callisto Eye marking system is predictable and effective in reducing refractive astigmatism.

The pathogenicity of SLC38A8 in five families with foveal hypoplasia and congenital nystagmus

PURPOSE

A recently described subtype of foveal hypoplasia with congenital nystagmus and optic-nerve-decussation defects was found to be associated with mutations in the SLC38A8 gene. The aim of this study is to advance the clinical and molecular knowledge of SLC38A8 gene mutations.

METHODS

Five Israeli families with congenital foveal hypoplasia were studied, two of Karait Jewish origins and three of Indian Jewish origins. Subjects underwent a comprehensive ophthalmic examination including retinal photography and ocular coherence tomography. Molecular analysis including whole exome sequencing and screening of the SLC38A8 gene for specific disease-causing variants was performed.

RESULTS

Eight affected individuals were identified, all had congenital nystagmus and all but one had hypoplastic foveal pits. Anterior segment dysgenesis was observed in only one patient, one had evidence of developmental delay and another displayed early age-related macular degeneration (AMD). Molecular analysis revealed a recently described homozygous mutation, c.95T > G; p.Ile32Ser, in two families of Jewish Indian descent, and the same mutation in two families of Karaite Jewish descent. In a patient with only one pathogenic mutation (c.95T > G; p.Ile32Ser), a possible partial clinical expression of the disorder was seen. One patient of Jewish Indian descent was found to be compound heterozygous for c.95T > G; p.Ile32Ser and a novel mutation c.490_491delCT; p.L164Vfs*41.

CONCLUSIONS

In five unrelated families with congenital nystagmus and foveal hypoplasia, mutations in the SLC38A8 gene were identified. Possible partial expression in a heterozygous patient was observed and novel potential disease-related phenotypes were identified including early-onset AMD and developmental delay. A novel mutation was also identified and a similar mutation in both Indian and Karaite Jewish ethnicities could be suggestive for common ancestry.

Effect of light and diurnal variation on macular thickness in X-linked retinoschisis: a case series

BACKGROUND

Diurnal variations in foveal thickness have been reported in several ocular pathologies including X-linked retinoschisis (XLRS), but its underlying mechanism is poorly understood. Rods are active under scotopic conditions with high metabolic demand, and its decrease may have positive effect on metabolic activity and macular thickness. The purpose of this study is to evaluate whether exposure to light and diurnal variation influence macular thickness in XLRS patients.

METHODS

Five patients with clinical suspicion of XLRS underwent RS1 gene sequencing and optical coherence tomography measurements at three consecutive times: morning following sleep in a dark room, morning following sleep in an illuminated room, and late afternoon following sleep in an illuminated room. Central macular thickness (CMT) was compared between measurements, and molecular analysis was performed.

RESULTS

Five RS1 mutations were identified: p.Gly140Arg, p.Arg141Cys, p.Gly109Glu, p.Pro193Leu, and p.Arg200His in patients 1-5, respectively. Two patients (4-5) had atrophied macula and were excluded from macular thickness variation analysis. A significant decrease in CMT between morning and afternoon measurements was observed in all patients (1-3: mean: 455.0 ± 32 μm to 342.17 ± 39 μm, 25%). Morning measurements following sleep in an illuminated room show a CMT reduction in all eyes of all patients with a mean reduction of 113 μm (mean: 547.17 ± 105 μm to 455.0 ± 32 μm, 17%).

CONCLUSIONS

Among XLRS patients, CMT decreased at the afternoon compared to the morning of the same day and may be reduced following sleep in an illuminated room. These results help shed light on the pathophysiologic process underlying intraretinal fluid accumulation involved with the disease.

Balloon catheter dilation as the primary treatment of congenital nasolacrimal duct obstruction

PURPOSE

The aim of this study is to report the outcome of balloon catheter dilation as the primary treatment of congenital nasolacrimal duct obstruction in children of all ages.

METHODS

A 10-year retrospective study of 148 children (270 eyes), aged 9 to 159 months (mean age: 29.6 ± 17.7 months), who previously had not undergone a nasolacrimal surgical procedure and who presented with clinical signs of nasolacrimal duct obstruction, was conducted. All children underwent balloon catheter dilation of the nasolacrimal duct.

RESULTS

Treatment success, defined as complete resolution of nasolacrimal duct obstruction symptoms present at follow-up visits at 1 week and up to 6 months after surgery, was 87% (234 of 270 eyes). Partial success was defined as occasional tearing which was acceptable to parents and present in 3% (nine eyes). Only 10% of the children underwent a second procedure due to complete failure. In a sub-analysis by age groups-under 18 months, between 18 and 36 months, and above 36 months-complete resolution rates were 85%, 93%, and 77%, and partial success rates were 3%, 3%, and 4%, respectively. There was a statistically significant difference between the age groups (p = .007).

CONCLUSION

In this large cohort of patients with nasolacrimal duct obstruction, balloon catheter dilation was successful as a primary treatment for congenital nasolacrimal duct obstruction, particularly under the age of 36 months.

Rare Genetic Variants in Jewish Patients Suffering from Age-Related Macular Degeneration

Purpose: To identify rare genetic variants in early age-related macular degeneration (AMD) utilizing whole-exome sequencing (WES). Methods: Eight non-related early-AMD families of different Jewish ethnicities were ascertained. Initial mutation screening (phase-1) included common complement factor-H (CFH) p.Y402H; and age related maculopathy susceptibility 2 (ARMS2) p.A69S; and rare variants complement factor-I (CFI) p.V412M; and hemicentin1 (HMCN1) c.4163delC identified previously in our population. Four families, whose initial screening for the aforementioned variants was negative, underwent WES (phase-2). Bioinformatics filtering was based on functionality (from a panel of 234 genes with proven or presumed association to AMD); predicted severity; and frequency (rare variants with minor allele frequency <1%). When applicable, further screening for specific rare variants was carried out on additional cases of similar ethnicities and phenotypes (phase-3). Results: Phase-1 identified three families carrying CFI p.V412M mutation. WES analysis detected probable disease-related variants in three out of the remaining families. These included: a family with a variant in PLEKHA1 gene p.S177N; a family with previously reported variant p.R1210C in CFH gene; and two families with the C3 p.R735W variant. Conclusions: Rare, high-penetrance variants have a profound contribution to early-AMD pathogenesis. Utilization of WES in genetic research of multifactorial diseases as AMD, allows a thorough comprehensive analysis with the identification of previously unreported rare variants.

A nationwide genetic analysis of inherited retinal diseases in Israel as assessed by the Israeli inherited retinal disease consortium (IIRDC)

Inherited retinal diseases (IRDs) cause visual loss due to dysfunction or progressive degeneration of photoreceptors. These diseases show marked phenotypic and genetic heterogeneity. The Israeli IRD consortium (IIRDC) was established in 2013 with the goal of performing clinical and genetic mapping of the majority of Israeli IRD patients. To date, we recruited 2,420 families including 3,413 individuals with IRDs. On the basis of our estimation, these patients represent approximately 40% of Israeli IRD patients. To the best of our knowledge, this is, by far, the largest reported IRD cohort, and one of the first studies addressing the genetic analysis of IRD patients on a nationwide scale. The most common inheritance pattern in our cohort is autosomal recessive (60% of families). The most common retinal phenotype is retinitis pigmentosa (43%), followed by Stargardt disease and cone/cone-rod dystrophy. We identified the cause of disease in 56% of the families. Overall, 605 distinct mutations were identified, of which 12% represent prevalent founder mutations. The most frequently mutated genes were ABCA4, USH2A, FAM161A, CNGA3, and EYS. The results of this study have important implications for molecular diagnosis, genetic screening, and counseling, as well as for the development of new therapeutic strategies for retinal diseases.

Chromatic pupilloperimetry for objective diagnosis of Best vitelliform macular dystrophy

Purpose

To determine the pupil response of Best vitelliform macular dystrophy (BVMD) patients for focal blue and red light stimuli presented at 76 test points in a 16.2° visual field (VF) using a chromatic pupilloperimeter.

Methods

An observational study was conducted in 16 participants: 7 BVMD patients with a heterozygous BEST1 mutation and 9 similar-aged controls. All participants were tested for best-corrected visual acuity, chromatic pupilloperimetry and Humphrey perimetry. Percentage of pupil contraction (PPC), maximal pupil contraction velocity (MCV) and latency of MCV (LMCV) were determined.

Results

The mean PPC and MCV recorded in BVMD patients in response to red stimuli were lower by >2 standard errors (SEs) from the mean of controls in 47% and 43% of VF test points, respectively. The mean PPC and MCV recorded in the patients in response to blue stimuli were lower by >2 SEs from the mean of controls in 36% and 24% of VF test points, respectively. The patients’ mean and median MCV recorded in response to red light correlated with their Humphrey mean deviation score (r=−0.714, P=0.071 and r=−0.821, P=0.023, respectively) and visual acuity (r=0.709, P=0.074 and r=0.655, P=0.111, respectively). A substantially shorter mean LMCV was recorded in BVMD patients compared to controls in 54% and 93% of VF test points in response to red and blue light, respectively. Receiver operating characteristic analysis for LMCV in response to red light identified a test point at the center of the VF with high diagnostic accuracy (area under the curve of 0.94).

Conclusion

Chromatic pupilloperimetry may potentially be used for objective noninvasive assessment of rod and cone cell function in different locations of the retina in BVMD patients.

[THE ISRAELI INHERITED RETINAL DISEASES CONSORTIUM (IIRDC)- CLINICAL-GENETIC MAPPING AND FUTURE PERSPECTIVES]

INTRODUCTION

The sense of vision is highly important for humans and its loss markedly affects function and quality of life. Many inherited retinal diseases (IRDs) cause visual loss due to dysfunction or progressive degeneration of photoreceptor cells. These diseases show clinical and genetic heterogeneity.

AIMS

The Israeli IRD consortium (IIRDC) was established with the goal of performing clinical and genetic mapping of IRDs in the Israeli population.

METHODS

Clinical evaluation is carried out at electroretinography (ERG) centers and ophthalmology departments, where the patients undergo a comprehensive eye exam, including testing of visual acuity, refractive error, imaging techniques and ERG tests. Genetic analysis is performed using Sanger sequencing, analysis of founder mutations, and whole exome sequencing.

RESULTS

We recruited over 2,000 families including more than 3,000 individuals with IRDs. The most common inheritance pattern is autosomal recessive (65% of families). The most common retinal phenotype is retinitis pigmentosa (RP- 45% of families), followed by cone/cone-rod dystrophy, Stargardt Disease and Usher syndrome. We identified the cause of disease in 51% of families, mainly due to mutations in ABCA4, USH2A, FAM161A, CNGA3, and EYS. IIRDC researchers were involved in the identification of 16 novel IRD genes. In parallel, IIRDC members are involved in the development of therapeutic modalities for these currently incurable diseases.

CONCLUSIONS

IIRDC works in close collaborative efforts aiming to continue and recruit for the genotype - phenotype study from the vast majority of Israeli IRD families, to identify all disease-causing mutations, and to tailor therapeutic interventions to each IRD patient.

Carrier frequency analysis of mutations causing autosomal-recessive-inherited retinal diseases in the Israeli population

Inherited retinal diseases (IRDs) are heterogeneous phenotypes caused by variants in a large number of genes. Disease prevalence and the frequency of carriers in the general population have been estimated in only a few studies, but are largely unknown. To this end, we developed two parallel methods to calculate carrier frequency for mutations causing autosomal-recessive (AR) IRDs in the Israeli population. We created an SQL database containing information on 178 genes from gnomAD (including genotyping of 5706 Ashkenazi Jewish (AJ) individuals) and our cohort of >2000 families with IRDs. Carrier frequency for IRD variants and genes was calculated based on allele frequency values and the Hardy-Weinberg (HW) equation. We identified 399 IRD-causing variants in 111 genes in Israeli patients and AJ controls. For the AJ subpopulation, gnomAD and HW-based regression analysis showed high correlation, therefore allowing one to use HW-based data as a reliable estimate of carrier frequency. Overall, carrier frequency per subpopulation ranges from 1/2.2 to 1/9.6 individuals, with the highest value obtained for the Arab-Muslim subpopulation in Jerusalem reaching an extremely high carrier rate of 44.7%. Carrier frequency per gene ranges from 1/31 to 1/11994 individuals. We estimate the total carrier frequency for AR-IRD mutations in the Israeli population as over 30%, a relatively high carrier frequency with marked variability among subpopulations. Therefore, these data are highly important for more reliable genetic counseling and genetic screening. Our method can be adapted to study other populations, either based on allele frequency data or cohort of patients.

Mutations in AIFM1 cause an X-linked childhood cerebellar ataxia partially responsive to riboflavin

BACKGROUND

AIFM1 encodes a mitochondrial flavoprotein with a dual role (NADH oxidoreductase and regulator of apoptosis), which uses riboflavin as a cofactor. Mutations in the X-linked AIFM1 were reported in relation to two main phenotypes: a severe infantile mitochondrial encephalomyopathy and an early-onset axonal sensorimotor neuropathy with hearing loss. In this paper we report two unrelated males harboring AIFM1 mutations (one of which is novel) who display distinct phenotypes including progressive ataxia which partially improved with riboflavin treatment.

METHODS

For both patients trio whole exome sequencing was performed. Validation and segregation were performed with Sanger sequencing. Following the diagnosis, patients were treated with up to 200 mg riboflavin/day for 12 months. Ataxia was assessed by the ICARS scale at baseline, and 6 and 12 months following treatment.

RESULTS

Patient 1 presented at the age of 5 years with auditory neuropathy, followed by progressive ataxia, vermian atrophy and axonal neuropathy. Patient 2 presented at the age of 4.5 years with severe limb and palatal myoclonus, followed by ataxia, cerebellar atrophy, ophthalmoplegia, sensorineural hearing loss, hyporeflexia and cardiomyopathy. Two deleterious missense mutations were found in the AIFM1 gene: p. Met340Thr mutation located in the FAD dependent oxidoreductase domain and the novel p. Thr141Ile mutation located in a highly conserved DNA binding motif. Ataxia score, decreased by 39% in patient 1 and 20% in patient 2 following 12 months of treatment.

CONCLUSION

AIFM1 mutations cause childhood cerebellar ataxia, which may be partially treatable in some patients with high dose riboflavin.

Nonsyndromic Retinitis Pigmentosa in the Ashkenazi Jewish Population: Genetic and Clinical Aspects

PURPOSE

To analyze the genetic and clinical findings in retinitis pigmentosa (RP) patients of Ashkenazi Jewish (AJ) descent, aiming to identify genotype-phenotype correlations.

DESIGN

Cohort study.

PARTICIPANTS

Retinitis pigmentosa patients from 230 families of AJ origin.

METHODS

Sanger sequencing was performed to detect specific founder mutations known to be prevalent in the AJ population. Ophthalmologic analysis included a comprehensive clinical examination, visual acuity (VA), visual fields, electroretinography, color vision testing, and retinal imaging by OCT, pseudocolor, and autofluorescence fundus photography.

MAIN OUTCOME MEASURES

Inheritance pattern and causative mutation; retinal function as assessed by VA, visual fields, and electroretinography results; and retinal structural changes observed on clinical funduscopy as well as by pseudocolor, autofluorescence, and OCT imaging.

RESULTS

The causative mutation was identified in 37% of families. The most prevalent RP-causing mutations are the Alu insertion (c.1297_8ins353, p.K433Rins31*) in the male germ cell-associated kinase (MAK) gene (39% of families with a known genetic cause for RP) and c.124A>G, p.K42E in dehydrodolichol diphosphate synthase (DHDDS) (33%). Additionally, disease-causing mutations were identified in 11 other genes. Analysis of clinical parameters of patients with mutations in the 2 most common RP-causing genes revealed that MAK patients had better VA and visual fields at relatively older ages in comparison with DHDDS patients. Funduscopic findings of DHDDS patients matched those of MAK patients who were 20 to 30 years older. Patients with DHDDS mutations were referred for electrophysiologic evaluation at earlier ages, and their cone responses became nondetectable at a much younger age than MAK patients.

CONCLUSIONS

Our AJ cohort of RP patients is the largest reported to date and showed a substantial difference in the genetic causes of RP compared with cohorts of other populations, mainly a high rate of autosomal recessive inheritance and a unique composition of causative genes. The most common RP-causing genes in our cohort, MAK and DHDDS, were not described as major causative genes in other populations. The clinical data show that in general, patients with biallelic MAK mutations had a later age of onset and a milder retinal phenotype compared with patients with biallelic DHDDS mutations.

NHS Gene Mutations in Ashkenazi Jewish Families with Nance-Horan Syndrome

PURPOSE

To describe ocular and extraocular abnormalities in two Ashkenazi Jewish families with infantile cataract and X-linked inheritance, and to identify their underlying mutations.

METHODS

Seven affected members were recruited. Medical history, clinical findings, and biometric measurements were recorded. Mutation analysis of the Nance-Horan syndrome (NHS) gene was performed by direct sequencing of polymerase chain reaction-amplified exons.

RESULTS

An unusual anterior Y-sutural cataract was documented in the affected male proband. Other clinical features among examined patients included microcorneas, long and narrow faces, and current or previous dental anomalies. A nonsense mutation was identified in each family, including a previously described 742 C>T, p.(Arg248*) mutation in Family A, and a novel mutation 2915 C>A, p.(Ser972*) in Family B.

CONCLUSIONS

Our study expands the repertoire of NHS mutations and the related phenotype, including newly described anterior Y-sutural cataract and dental findings.