Improving medication dispensing and counselling for patients with vision impairment: a qualitative study of pharmacist-reported barriers and facilitators

BACKGROUND

People with vision impairment encounter many difficulties when it comes to medicines use. However, evidence indicates that there are major gaps in pharmaceutical care service provision worldwide and limited research on interventions to optimise medication use for this patient population. The Theoretical Domains Framework (TDF) provides a method for theoretically understanding individuals' behaviour and informing development of interventions. The aim of this research was to (a) identify the barriers and facilitators to the provision of medication dispensing and counselling services by pharmacists to patients with vision impairment, and (b) identify key TDF domains to be targeted in a future intervention.

METHODS

Semi-structured interviews were conducted with pharmacists from different pharmacy practice settings/areas in Saudi Arabia. The 14-domain TDF was utilised as the theoretical lens through which pharmacists' behaviours were examined. Interviews were conducted in Arabic or English, either face-to-face or over the telephone based on the participant's preference. Following transcription, interviews conducted in Arabic were translated into English before analysis. Data analysis involved using the framework method and content analysis to identify important barriers and facilitators to the provision of dispensing and counselling services to those with vision impairment. Key TDF domains that could be targeted in a future intervention were then identified using a consensus-based approach.

RESULTS

Twenty-six pharmacists were interviewed. Pharmacists' experience in pharmacy practice ranged from two to 28 years. A range of barriers and facilitators were highlighted as important in providing services to those with vision impairment. Eight domains were identified as 'key domains' including: 'Knowledge', 'Skills', 'Beliefs about capabilities', 'Goals', 'Memory, attention, and decision processes', 'Environmental context and resources', 'Social influences', and 'Behavioural regulation'.

CONCLUSIONS

Barriers and facilitators identified by pharmacists will inform the development of an intervention to ensure its applicability to everyday practice. Future research will focus on the process of developing the proposed intervention through targeting key TDF domains to improve medication dispensing and counselling by pharmacists to patients with vision impairment.

Reconsideration of Surgical Indication for Prolactin-producing Pituitary Tumor Focusing on Visual Impairment

Prolactin-producing pituitary tumor (PRLoma) is the most prevalent functional pituitary tumor. If the tumor becomes large, vision can be impaired. In contrast to other pituitary tumors, cabergoline (CAB) is extremely effective for PRLoma and has become the first-line treatment. In this study, we examined our experience with the pharmacological and surgical management of PRLomas with visual impairment (VI) to determine whether VI could be a surgical indication. Further, we discussed the function of surgery in situations where the gold standard of PRLoma treatment was CAB administration. Of the 159 patients with PRLomas (age, 13-77 [mean = 36.3] years; men, 29; women, 130) at Tokyo Women's Medical University Hospital from 2009 to 2021, 18 (age, 15-67 [mean = 35.8] years; men, 12; woman, 6) had VI (subjectively, 12; objectively, 6). They started CAB treatment immediately (maximum dose: 0.5 to 6 mg/week; average: 2.17 mg/week). VI improved in 16 patients (88.9%) but did not improve in 2 (11.1%) requiring surgeries. One of the two patients had a parenchymal tumor resistant to CAB, and the other had a cystic tumor due to intratumoral bleeding. Consequently, CAB is the first-line treatment for PRLomas with VI because of its significantly high rate of improvement. However, close and rigorous surveillance is necessary for cases resistant to CAB, and the correct decision is required regarding surgical interventions at proper timing and appropriate surgical approaches considering the purpose of surgery.

Central Toxic Keratopathy After Collagen Cross-Linking: A Case Series

PURPOSE

The aim of this study was to report a case series of central toxic keratopathy (CTK) after collagen cross-linking (CXL) in keratoconus.

METHODS

This is a retrospective case series between January 2020 and September 2021. In this period, CXL was performed for progressive keratoconus in 964 eyes. CXL was performed using the epithelium-off accelerated protocol in all patients with a riboflavin soak time of 20 minutes and a UVA light exposure of 9 mW for 10 minutes using the Avedro KXL (Glaukos Inc, Aliso Viejo, CA) cross-linking system.

RESULTS

Twelve of 964 eyes (1.2%) developed CTK within 1 week of CXL. All patients presented with well-circumscribed, central disciform haze that was broader in the anterior stroma and narrower in the posterior stroma. We noted initial flattening in keratometry up to 3 months post-CXL in these patients, which gradually steepened over 12 months, but did not reach preoperative levels. We also noted exuberant flattening in pachymetry in the first 3 months, which improved over 12 months. There was a statistically significant decrease in pachymetry in patients who developed CTK at 3 and 12 months postoperatively when compared to patients who underwent CXL but did not develop CTK.

CONCLUSIONS

Several reports of CTK postrefractive surgery have been described previously. However, the association of CXL in the development of CTK has not been described previously. Here, we elucidated the clinical features of CTK after CXL and how it differs from corneal scarring or haze that occurs post-CXL.

Bilateral herpes zoster ophthalmicus in an immunocompetent patient

INTRODUCTION

Bilateral herpes zoster ophthalmicus (HZO) is rare. We report a case of an immunocompetent patient with nonsimultaneous attacks of HZO in both eyes.

CASE DESCRIPTION

A 71-year-old female patient complained of blurred vision in the left eye for 1 week, which was treated with topical antiglaucomatous drugs due to elevated intraocular pressure. She denied any systemic diseases, but HZO had manifested as a rash with a crust over the right forehead skin 3 months earlier. Slit-lamp examination revealed localized corneal edema with keratin precipitates and mild anterior chamber reaction. Suspecting corneal endotheliitis, we performed aqueous tapping for detecting viral DNA, including cytomegalovirus, herpes simplex virus, and varicella zoster virus (VZV) DNA, through polymerase chain reaction (PCR) testing, but the PCR results were negative for all viruses. The endotheliitis resolved well after treatment with topical prednisolone acetate. However, the patient's blurred vision recurred in the left eye 2 months later. A dendritiform lesion on the left cornea was detected, and corneal scraping for PCR testing revealed VZV DNA. The lesion disappeared with antiviral treatment.

CONCLUSIONS

Bilateral HZO is uncommon, particularly in immunocompetent patients. When in doubt, physicians should perform tests such as PCR testing to help establish a definite diagnosis.

Researching Eyesight Trends IN ADHD (RETINA)

BACKGROUND

There has been limited exploration of the relationship between ADHD and vision impairment, especially in relation to ADHD medication regimens and age. This study aims to examine trends in visual disorders in young patients with ADHD.

METHODS

We analyzed deidentified patient records from TriNetX database. Patients under 22 years old were divided into cohorts based on ADHD status and medication regimen. We compared prevalence of vision disorders between cohorts.

RESULTS

We studied over 1 million patients. The ADHD cohort had higher rates of all visual disorders than their non-ADHD peers. Medication usage was found to have a slight impact, with non-stimulants associating with higher rates for all outcomes.

DISCUSSION

Our findings suggest that the higher occurrence of visual disorders in ADHD is not primarily due to misdiagnosis or medication effects. There is a need for regular eye care in ADHD patients and further investigation into the role of ADHD medications in eye health.

Characteristics of Ocular Inflammatory Side Effects Associated with Immune Checkpoint Inhibitors in a Northern California Population

PURPOSE

To characterize the ocular inflammatory side effects associated with immune checkpoint inhibitor (CPI) treatment in a Northern California population.

DESIGN

Retrospective case series.

PARTICIPANTS

Patients receiving CPI within an integrated healthcare delivery system.

METHODS

All patients within Kaiser Permanente Northern California receiving CPI between January 1, 2012 and November 1, 2018 were identified. Medical records of those seen in the ophthalmology clinic at least once were retrospectively reviewed.

MAIN OUTCOME MEASURES

Type and duration of ocular inflammation, indication for and exposure to CPI, time from exposure to diagnosis of ocular inflammation.

RESULTS

31 cases of ocular inflammation were identified in 5061 patients (0.61%) receiving CPI. Mean ± SD age was 67 ± 11.9 (range 38-89). Mean time from exposure to diagnosis was 6.8 ± 5.5 months (range 0.5-17). 87% of cases were bilateral, and 43% of cases were chronic. Average ophthalmology follow-up was 16 ± 18 months (range 0-71). 16/31 (52%) had anterior uveitis, 7/31 (23%) had serous retinal detachment or panuveitis resembling Vogt-Koyanagi-Harada syndrome, 4/31 (13%) had papillitis, and 6/31 (19%) had diplopia or ocular motility defect. There was one case each (3.2%) of melanoma associated retinopathy, corneal edema, granulomatous lacrimal gland enlargement, and choroidal neovascularization.

CONCLUSIONS

Ocular inflammation is a rare immune associated side effect of CPI treatment, the most common manifestation of which is anterior uveitis.

Unusual Presentation of Acute Hydroxychloroquine Retinopathy

PURPOSE

To report a rare case of cystoid macular edema (CME) as a presentation of acute hydroxychloroquine-related retinal toxicity.

OBSERVATIONS

A 37-year-old female patient visited our ophthalmology department in October 2019 complaining of bilateral blurred vision and metamorphopsia for 3 days. Best-corrected visual acuity (BCVA) was 6/6 in the right eye and 6/7.5 in the left eye under the Snellen E chart. Before presentation, she had taken hydroxychloroquine as a "reproduction-facilitating medication" prior to the in vitro fertilization (IVF) procedures with the daily dose of 200 mg for 1 week in March 2019 and 400 mg for 1 month in September 2019. She also took a combination of several herbal medicine including "Angelica sinensis" for 6 months in this period. On examination, typical signs of hydroxychloroquine maculopathy such as bilateral paracentral retinal pigment epithelium (RPE) change in blue autofluorescence and loss of the paracentral ellipsoid zone in optical coherence tomography ("flying saucer sign") were noted. CME was also found in fluorescein angiography. Her symptoms improved gradually after cessation of hydroxychloroquine and herb medicine without any further treatment. Resolution of bilateral CME was revealed at 16 weeks with final bilateral BCVA 6/6.

CONCLUSIONS AND IMPORTANCE

Although rare, acute hydroxychloroquine maculopathy could occur in patients with concomitant usage of medications that could interfere with P450 enzymes system. Careful acquisition of drug history and serial ophthalmological examinations are advised in using hydroxychloroquine for disease management even for a short period of time.

SEVERE VISUAL LOSS DURING ANTI-VEGF INTRAVITREAL INJECTIONS IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: TIMING, PROGNOSIS, AND OPTICAL COHERENCE TOMOGRAPHY FINDINGS

PURPOSE

Intravitreal injection (IVI) of anti-vascular endothelial growth factor (VEGF) is the standard of care for neovascular age-related macular degeneration (nAMD). However, a small subgroup of patients still experience severe visual impairment, which may be related to the number of IVI administered.

METHODS

This retrospective observational study analyzed data from patients with sudden severe visual decline (≥15 Early Treatment Diabetic Retinopathy Study [ETDRS] letters loss between two consecutive IVIs) during anti-VEGF treatment for nAMD. Best-corrected visual acuity examination, optical coherence tomography (OCT), and OCT angiography (OCTA) were performed before every IVI and central macular thickness (CMT) and drug injected were collected.

RESULTS

1,019 eyes received anti-VEGF IVI for nAMD from December 2017 to March 2021. Severe VA loss occurred in 15.1% after a median of 6 (range 1-38) IVI. Ranibizumab was injected in 52.8% and aflibercept in 31.9% of cases. Functional recovery after 3 months was significant, without further improvement at 6 months. Visual prognosis relative to the percentage of CMT change showed better visual outcome in eyes with no substantial change in CMT compared with an increase of >20% or a decrease of >5%.

CONCLUSION

In this first real-life study exploring severe VA loss during anti-VEGF treatment in patients with nAMD, it was found that it was not unusual for a ≥15 ETDRS letters loss to occur between two consecutive IVIs, often within 9 months of diagnosis and 2 months after the last IVI. Close follow-up and a proactive regimen should be preferred, at least in the first year.

Real-World Outcomes of Ranibizumab Treatment in French Patients with Visual Impairment due to Macular Edema Secondary to Retinal Vein Occlusion: 24-Month Results from the BOREAL-RVO Study

INTRODUCTION

Information about real-world ranibizumab use is needed to optimize treatment of macular edema secondary to retinal vein occlusion (RVO). The BOREAL-RVO study assessed treatment use, effectiveness, and safety of 24-month treatment with ranibizumab 0.5 mg in patients with visual impairment due to macular edema secondary to RVO in a real-world setting.

METHODS

This was a multicenter, post-authorization, observational study in France, including patients starting ranibizumab for RVO. Primary endpoint was mean change from baseline in best-corrected visual acuity (BCVA) at month 6. Secondary endpoints were mean changes from baseline in BCVA at month 24 and central retinal thickness (CRT) at months 6 and 24, and treatment use in real-world setting.

RESULTS

226 branch RVO (BRVO) and 196 central RVO (CRVO) patients were enrolled; 71.7% and 70.9% completed the 24-month follow-up, respectively. In BRVO, mean (SD) baseline BCVA was 55.2 (18.7) letters, with gains of 14.3 (13.7), 14.1 (16.5), 13.0 (17.5), and 11.4 (20.1) letters at months 3, 6, 12, and 24, respectively. In CRVO, mean (SD) baseline BCVA was 40.4 (25.6) letters, with gains of 16.0 (21.2), 9.5 (25.4), 9.2 (27.7), and 8.3 (23.8) letters at months 3, 6, 12, and 24, respectively. At month 24, 52% of BRVO and 41% of CRVO patients had gains of 15 or more letters. In BRVO, mean (SD) CRT values at baseline and months 3, 6, 12, and 24 were 550 (175), 315 (104), 343 (122), 335 (137), and 340 (105) μm. In CRVO, mean (SD) CRT values at baseline and months 3, 6, 12, and 24 were 643 (217), 327 (152), 400 (203), 379 (175), and 348 (161) μm. On average, BRVO patients had 3.8 injections for 6.9 visits by month 6, and 7.2 injections for 19.7 visits by month 24. CRVO patients had 2.7 injections for 4.2 visits by month 6 and 7.1 injections for 21.1 visits by month 24. Factors predictive of better BCVA gain at month 6 were age under 60 at baseline, lower baseline BCVA and BCVA gain at month 3. There were no new safety findings.

CONCLUSION

Major improvements in BCVA and CRT were observed at month 3 after the induction phase and then were sustained up to month 24, with a slight decrease, probably due to under-treatment. This study demonstrated ranibizumab to be a safe and effective treatment for BRVO and CRVO in the real-world setting, although more regular or proactive treatment could further improve outcomes.

Four-Year Visual Outcomes in the Protocol W Randomized Trial of Intravitreous Aflibercept for Prevention of Vision-Threatening Complications of Diabetic Retinopathy

Importance

Anti-vascular endothelial growth factor (VEGF) injections in eyes with nonproliferative diabetic retinopathy (NPDR) without center-involved diabetic macular edema (CI-DME) reduce development of vision-threatening complications from diabetes over at least 2 years, but whether this treatment has a longer-term benefit on visual acuity is unknown.

Objective

To compare the primary 4-year outcomes of visual acuity and rates of vision-threatening complications in eyes with moderate to severe NPDR treated with intravitreal aflibercept compared with sham. The primary 2-year analysis of this study has been reported.

Design, Setting, and Participants

Randomized clinical trial conducted at 64 clinical sites in the US and Canada from January 2016 to March 2018, enrolling 328 adults (399 eyes) with moderate to severe NPDR (Early Treatment Diabetic Retinopathy Study [ETDRS] severity level 43-53; range, 0 [worst] to 100 [best]) without CI-DME.

Interventions

Eyes were randomly assigned to 2.0 mg aflibercept (n = 200) or sham (n = 199). Eight injections were administered at defined intervals through 2 years, continuing quarterly through 4 years unless the eye improved to mild NPDR or better. Aflibercept was given in both groups to treat development of high-risk proliferative diabetic retinopathy (PDR) or CI-DME with vision loss.

Main Outcomes and Measures

Development of PDR or CI-DME with vision loss (≥10 letters at 1 visit or ≥5 letters at 2 consecutive visits) and change in visual acuity (best corrected ETDRS letter score) from baseline to 4 years.

Results

Among participants (mean age 56 years; 42.4% female; 5% Asian, 15% Black, 32% Hispanic, 45% White), the 4-year cumulative probability of developing PDR or CI-DME with vision loss was 33.9% with aflibercept vs 56.9% with sham (adjusted hazard ratio, 0.40 [97.5% CI, 0.28 to 0.57]; P < .001). The mean (SD) change in visual acuity from baseline to 4 years was -2.7 (6.5) letters with aflibercept and -2.4 (5.8) letters with sham (adjusted mean difference, -0.5 letters [97.5% CI, -2.3 to 1.3]; P = .52). Antiplatelet Trialists' Collaboration cardiovascular/cerebrovascular event rates were 9.9% (7 of 71) in bilateral participants, 10.9% (14 of 129) in unilateral aflibercept participants, and 7.8% (10 of 128) in unilateral sham participants.

Conclusions and Relevance

Among patients with NPDR but without CI-DME at 4 years treatment with aflibercept vs sham, initiating aflibercept treatment only if vision-threatening complications developed, resulted in statistically significant anatomic improvement but no improvement in visual acuity. Aflibercept as a preventive strategy, as used in this trial, may not be generally warranted for patients with NPDR without CI-DME.

Trial Registration

ClinicalTrials.gov Identifier: NCT02634333.

Long-Term Outcomes of High-Dose Conbercept Treatment for Myopic Choroidal Neovascularization and Idiopathic Choroidal Neovascularization

INTRODUCTION

The aim of the study was to report 2-year outcomes of intravitreal injection of high-dose conbercept (1 mg 2 + PRN scheme) for subjects with myopic choroidal neovascularization (mCNV) and idiopathic choroidal neovascularization (iCNV) by optical coherence tomography angiography follow-up.

METHODS

A total of 38 subjects (38 eyes) were enrolled in this retrospective study, which were divided into group A (mCNV, 20 subjects, 20 eyes) and group B (iCNV, 18 subjects, 18 eyes). All subjects received 1.0 mg of conbercept intravitreally at diagnosis and again 35 days later. Additional conbercept injection was administered upon findings of decreased best-corrected visual acuity (BCVA); metamorphosis aggravation, macular hemorrhage, or edema; increased central retinal thickness (CRT); or leakage observed by fluorescein angiography. The BCVA, CRT, and CNV areas of the two groups were evaluated at baseline and at 1, 2, 4, 6, 12, and 24 months after surgery.

RESULTS

The BCVA of group A improved from 0.31 ± 0.16 logMAR at baseline to 0.12 ± 0.03 logMAR at the final follow-up (p < 0.001), while in group B the corresponding improvement was from 0.33 ± 0.16 logMAR at baseline to 0.12 ± 0.03 logMAR at the final follow-up (p < 0.001). Visual acuity improved in 17 subjects in group A and 15 in group B, while it remained stable in 3 subjects in each of groups A and B. CRT decreased from 311.83 ± 30.95 μm in group A and 351.17 ± 37.09 μm in group B preoperation to 229.56 ± 5.75 μm and 227.67 ± 4.98 μm at 24-month follow-up, respectively (p < 0.001 in groups A and B). Metamorphopsia was improved in subjects in groups A and B. CNV had disappeared in the two groups at the last postoperative visit. The BCVA, CRT, and CNV areas showed no statistical differences between the two groups at 6-, 12-, and 24-month follow-up (p > 0.05).

CONCLUSION

Intravitreal injection of conbercept (1 mg 2 + PRN scheme) is effective for treating patients with mCNV or iCNV, which can improve and stabilize vision as well as dramatically alleviate metamorphopsia.

Optimizing treatment for diabetic macular edema during cataract surgery

Diabetic macular edema (DME) causes visual impairment in diabetic retinopathy (DR). Diabetes mellitus is a global epidemic and diabetic individuals are at risk of developing DR. Approximately 1 in 10 diabetic patients suffers from DME, which is the commonest cause of vision-threatening DR at primary-care screening. Furthermore, diabetes predisposes to a higher frequency and a younger onset of cataract, which further threatens vision in DME patients. Although cataract extraction is an effective cure, vision may still deteriorate following cataract surgery due to DME progression or recurrence, of which the risks are significantly higher than for patients without concurrent or previous history of DME at the time of operation. The management of pre-existing DME with visually significant cataract is a clinical conundrum. Deferring cataract surgery until DME is adequately treated is not ideal because of prolonged visual impairment and maturation of cataract jeopardizing surgical safety and monitoring of DR. On the other hand, the progression or recurrence of DME following prompt cataract surgery is a profound disappointment for patients and ophthalmic surgeons who had high expectations for postoperative visual improvement. Prescription of perioperative anti-inflammatory eye drops is effective in lowering the risk of new-onset DME after cataract surgery. However, management of concurrent DME at the time of cataract surgery is much more challenging because DME is unlikely to resolve spontaneously even with the aid of anti-inflammatory non-steroidal or steroid eye drops. A number of clinical trials using intravitreal injection of corticosteroids and anti-vascular endothelial growth factor (anti-VEGF) as first-line therapy have demonstrated safety and efficacy to treat DME. These drugs have also been administered perioperatively for the prevention of DME worsening in patients undergoing cataract surgery. This article reviews the scientific evidence to guide ophthalmologists on the efficacy and safety of various therapies for managing patients with DME who are particularly vulnerable to cataract surgery-induced inflammation, which disintegrates the blood-retinal barrier and egression of fluid in macular edema.

A CONSENSUS ON RISK MITIGATION FOR BROLUCIZUMAB IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: Patient Selection, Evaluation, and Treatment

PURPOSE

Brolucizumab has high efficacy in retinal fluid resolution and provides the possibility for longer dosing intervals in the treatment of neovascular age-related macular degeneration. However, brolucizumab has been associated with events of retinal vasculitis and retinal vascular occlusion typically in the presence of other signs of intraocular inflammation (IOI). The purpose of this report is to provide guidance on the use of brolucizumab for neovascular age-related macular degeneration to a global audience.

METHODS

A literature review was conducted on adverse events related to IOI after administration of brolucizumab in eyes with neovascular age-related macular degeneration.

RESULTS

Possible risk factors for IOI and retinal vascular occlusion after brolucizumab should be considered before administering brolucizumab. Patients who receive brolucizumab should be educated on the symptoms, signs, and time course of IOI after brolucizumab. Before each injection of brolucizumab, physicians should assess the eye for any signs of inflammation and not treat with brolucizumab if inflammation is detected. Treatment of IOI should be prompt and provided with particular attention to the posterior segment.

CONCLUSION

Careful patient selection, patient education, assessment for inflammation, and intensive treatment of possible inflammation are important when using brolucizumab in patients with neovascular age-related macular degeneration.

MULTIMODAL IMAGING OF RECURRENT CYSTOID MACULAR EDEMA ASSOCIATED WITH POEMS SYNDROME RESPONSIVE TO INTRAVITREAL DEXAMETHASONE IMPLANT

PURPOSE

To describe the multimodal imaging findings of cystoid macular edema (CME) in POEMS syndrome and to demonstrate the effectiveness of the dexamethasone intravitreal implant in this condition.

METHODS

A case report of a patient with POEMS syndrome. Multimodal imaging, including optical coherence tomography and ultra-wide field fluorescein angiography, was used to evaluate the CME and its response to treatment.

RESULTS

A 66-year-old man with a history of POEMS syndrome in clinical remission after chemotherapy presented with blurry vision in the left eye. Vitreomacular traction and CME were noted on optical coherence tomography. After pars plana vitrectomy, the patient had persistent CME in the left eye and developed new CME in the right eye, which worsened over the next year. Visual acuities at this time were 20 of 60 in both eyes. The CME was unresponsive to topical ketorolac and prednisolone acetate and intravitreal bevacizumab but partially response to intravitreal and sub-Tenon's triamcinolone acetate injections. Intravitreal dexamethasone implant was given bilaterally with full resolution and visual acuities improvement to 20 of 40 in the right eye and 20 of 30 in the left eye. However, CME recurred after 3 months. Ultra-wide field fluorescein angiography demonstrated bilateral CME and diffuse peripheral vascular leakage. Serum vascular endothelial growth factor levels were normal.

CONCLUSION

Cystoid macular edema may develop in POEMS syndrome in the absence of systemic findings, elevated serum vascular endothelial growth factor, or optic nerve edema. Previously unreported peripheral vascular leakage was demonstrated on ultra-wide field fluorescein angiography. Dexamethasone implant was the most effective of used therapies to treat CME.

Dopamine agonist for the rapid improvement of visual field defects in giant and macro-prolactinomas

PURPOSE

To evaluate effect of first-line dopamine agonist (DA) therapy as an alternative to surgery for visual field defect (VFD) recovery in giant and macro-prolactinoma.

METHODS

In this retrospective study, 125 patients with giant and macro-prolactinoma, except those with a history of previous surgery or radiotherapy, were evaluated. Those who underwent visual field examinations using the Humphrey Visual Field analyser upon initial assessment and after treatment were included for analysis. Twelve patients with VFD were included. The effects of DA therapy on both VFD and tumor size were evaluated within the first three months.

RESULTS

There were twelve patients analysed: three females and nine males, five giant and seven macroprolactinomas; eight patients received cabergoline (CAB) and four patients received bromocriptine (BRC). The mean adenoma diameter was 35±13mm (range 15-60), and the mean PRL level was 3,523ng/dL (range 312-11,703). Eight patients (67%) complained of blurred vision, while four patients (33%) reported no visual symptoms. After a median duration of three weeks, the VFD completely resolved in ten patients (83%) but only partially improved in two (17%). The mean initial doses of CAB and BRC that provided VFD improvement were 0.5±0.2mg/week and 6.3±1.4mg/day, respectively. After a mean duration of 2.2±0.9months, the mean decrease in adenoma size was 43.6±24.5% (range 10-95%).

CONCLUSION

The use of DA as a first-line treatment for at least one month before deciding on surgery is recommended in giant and macro-prolactinomas with VFD. Surgery should be considered only in cases with DA resistance or persistent visual impairment despite medical therapy.

Rare cause of left eye floaters and blurred vision in an immunocompromised patient: acute retinal necrosis (ARN)

Acute retinal necrosis (ARN) is a clinical syndrome featuring severe vitritis and occlusive vasculitis characterised by full thickness necrotising retinitis. ARN is usually caused by an acute infection by either varicella zoster virus or herpes simplex virus, rarely cytomegalovirus (CMV). ARN often occurs in healthy adults; occasionally affecting immunocompromised patients with poor prognosis including significant visual loss and detachment of the atrophic retina regardless of antiviral treatment. We presented a man in his early 30s with a history of left eye floaters and blurred vision. He was diagnosed with T-cell acute lymphoblastic leukaemia 1 year ago and treated with chemotherapy and allogenic haematopoietic stem cell transplant 5 months ago. His clinical diagnosis was left eye ARN caused by acute viral infection with CMV being the most likely cause, which is rarely seen in immunocompromised patients. Our case highlighted a diagnostic and therapeutic challenge in the absence of guideline or evidence-based literature to follow.

Systemic corticosteroid use in UK Uveitis practice: results from the ocular inflammation steroid toxicity risk (OSTRICH) study

OBJECTIVES

To ascertain adherence to an international consensus target of ≤7.5 mg/day of prednisolone for maintenance systemic corticosteroid (CS) prescribing in uveitis and report the frequency of courses of high-dose systemic CS in the UK.

METHODS

We conducted a national, multicentre audit of systemic CS prescribing for uveitis at 11 UK sites between November 2018 and March 2019. High-dose CS was defined as (1) maintenance >7.5 mg prednisolone for >3 consecutive months, or (2) >1 course ≥40 mg oral CS or ≥500 mg intravenous (IV) methylprednisolone in the past 12 months. Case notes of patients exceeding threshold CS doses were reviewed by an independent uveitis specialist and judged as avoidable or not, based upon a scoring matrix.

RESULTS

Of 667 eligible patients, 285 (42.7%) were treated with oral or IV CS over the preceding 12 months; 96 (33.7%) of these exceeded the threshold for high-dose CS. Twenty-five percent of prescribing in patients on excess CS was judged avoidable; attributed to either prescribing long-term CS without evidence of consideration of alternative strategies, prescribing error or miscommunication. More patients received immunomodulatory therapy (IMT) in the group treated with CS above threshold than below threshold (p < 0.001) but there was no significant difference in doses of IMT.

CONCLUSION

33% of patients had been prescribed excessive corticosteroid when compared to the reference standard. An analysis of decision-making suggests there may be opportunity to reduce excess CS prescribing in 25% of these patients.

[Endogenous endophtalmitis in a patient withStaphylococcus aureusbacteraemia]

BACKGROUND

Staphylococcus aureas bacteraemia can spread to cause endocartitis, spondylodiscitis or infection of vascular or joint prostheses. Endogenous endophtalmitis is a serious complication which may result in permanent visual loss of the affected eye. Treatment consists of intra-ocular injection of antibiotics or a vitrectomy.

CASE DESCRIPTION

A 79-year-old man attended the emergency department because of septic arthritis. Blood cultures were positive for a S. aureus bacteraemia. On the second day of admission he developed a blurred vision and he was diagnosed with an endophtalmitis. The patient was referred to an academic hospital for treatment with intra-ocular antibiotics. After treatment his vision improved again.

CONCLUSION

Visual complaints should be taken seriously when a patient has a proven S. aureus bacteraemia. Infectious disease consultation may accelerate early recognition, referral and treatment. When endophtalmitis is suspected, it is essential to refer the patient to a treatment centre where intra-ocular antibiotics can be administered.

Randomized control trial of evaluation of Clemastine effects on visual evoked potential, nerve fiber layer and ganglion cell layer complex in patients with optic neuritis

OBJECTIVES

Optic neuritis (ON) is the most common cause of optic neuropathy; typically presenting with a unilateral visual loss in young adults, with incidence of 1-5 in 100,000 per year. We evaluated the effect of Clemastine, a first-generation and CNS (central nervous system)-penetrant H1 receptor antagonist on visual evoked potential (VEP), retinal nerve fibre layer (RNFL) and ganglion cell layer (GCL) complex in patients with optic neuritis.

PATIENTS AND METHODS

This is a prospective comparative interventional case series in 25 patients with acute optic neuritis. Patients were randomly assigned to group 1 (treated with Clemastine 1 mg orally twice a day for 90 days; 16 patients) or group 2 (received placebo for 90 days; 9 patients) and both groups received standard treatment of optic neuritis. We recorded VEP and peripapillary OCT (optical coherence tomography) of patients before and after three months of treatment.

RESULTS

In contrast to patients treated with Clemastine, RNFL thickness loss between base line phase and after three months follow up in control group were statistically significant in temporal, supra temporal, Infrotemporal and almost global sections of RNFL map. The reduction in GCL thickness between base line phase and after three months follow up in control group were significant, while it did not reach significance in treatment group except in inferior region.

CONCLUSION

In contrast to treatment group, RNFL and GCL thickness of most quadrants are decreased significantly after three months in patients with ON in control group. In contrast to control group, p100 wave's amplitude recovered in a significant manner in treatment group.

A Novel Eye Drop Candidate for Age-Related Macular Degeneration Treatment: Studies on its Pharmacokinetics and Distribution in Rats and Rabbits

Age-related macular degeneration (AMD) is wearing down of macula of retina, causing a blur or loss of vision in the center of the visual field. It can be categorized into dry or wet AMD. Until now, medical treatments for dry AMD have not been developed yet. The aim of this study was to evaluate pharmacokinetics (PKs) and tissue distribution of CK41016, a novel candidate for dry AMD, after intravenous (IV) or eye drop administration in rats and rabbits. In addition, a simple and sensitive bioanalytical method for CK41016 using ultra performance liquid chromatography-tandem mass spectrometer (UPLC-MS/MS) was developed. PK parameters were estimated by compartmental analysis using a WinNonlin^® software version 8.1 (a Certara™ company). A PK model of CK41016 was well-described by the two-compartment model. The tissue-to-plasma partition coefficient (Kp) of CK41016 was the highest in the vitreous humor of rats and the cornea of rabbits after eye drop administration. In addition, the Caco-2 cell transporter assay confirmed that CK41016 was not an active substrate for the efflux transporter. In summary, the PKs and tissue distribution of CK41016 were successfully evaluated and investigated whether this drug was a substrate of efflux transporters.

Clinical, Hormonal, and Neuroradiological Characteristics and Therapeutic Outcomes of Prolactinomas in Children and Adolescents at a Single Center

Background/Purpose: A prolactinoma is the most common pituitary adenoma, but it is relatively rare in childhood and adolescence. There is only limited research about the clinical spectrum, treatment, and outcomes of prolactinomas in childhood and adolescence. In this single-center cohort study, we assessed the clinical, hormonal, and neuroradiological characteristics and therapeutic outcomes of children and adolescents with prolactinomas. Methods: This retrospective cohort study included 25 patients with prolactinomas diagnosed before 19 years of age, who presented at Samsung Medical Center during a 15-year period (March 2005 to August 2019). Results: The median age at diagnosis was 16.9 (range 10.1-18.5) years, and 80% of the patients were female. The common clinical manifestations at diagnosis were galactorrhea (10/20, 50%) and amenorrhea (9/20, 45%) among females and visual field defects (3/5, 60%) and headaches (2/5, 40%) among males. In our cohort, macroadenomas accounted for 56% of cases, and the rate of overall responsiveness to dopamine agonists (DAs) was 56% (10/18). Male gender, the prolactin (PRL) level at diagnosis, and the presence of panhypopituitarism were positively correlated with maximum tumor diameter (r = 0.443, P = 0.026; r = 0.710, P < 0.001; and r = 0.623, P = 0.001, respectively). After the trans-sphenoidal approach (TSA), 53% (8/15) of patients showed normalization of the PRL level. Three patients, who underwent gamma knife surgery (GKS) owing to either resistance or intolerance to DAs or recurrence after the TSA, achieved a normal PRL level accompanied with marked tumor reduction and symptom remission. Conclusions: A macroprolactinoma is more prevalent than a microprolactinoma in children and adolescents than in adults. Male gender, increased PRL levels, and the presence of panhypopituitarism at diagnosis are closely related to macroprolactinomas in children and adolescents.

EXPERIENCE WITH OCRIPLASMIN IN PATIENTS WITH VITREOMACULAR TRACTION SYNDROME: A RETROSPECTIVE STUDY OF 10 PATIENTS

PURPOSE

To assess the efficacy of ocriplasmin in patients with vitreomacular traction (VMT) syndrome <1,500 μm with or without a full-thickness macular holes of <400 μm.

METHODS

In this study, a retrospective analysis of 10 eyes of 10 patients with VMT who were treated with ocriplasmin between December 2014 and January 2016 was performed. Ocriplasmin 0.125 mg was injected only once in all cases. Outcome measures included the detachment of VMT, best-corrected visual acuity, the evaluation of optical coherence tomography, including the closure of full-thickness macular holes, and the reduction of macular edema (if present) and the decrease of metamorphopsia if present.

RESULTS

Ten patients (7 women and 3 men) with an average age of 75.1 years (range, 63-84 years) were treated with ocriplasmin with a follow-up period of 8 weeks. All patients were treated for VMT syndrome, and 5 patients (50.0%) showed an additional macular hole. An absolute detachment of VMT was seen in 3 patients (30.0%) and partially in 4 patients (40.0%). In three of the five patients, a complete closure of the full-thickness macular holes was seen. The two other patients needed an additional pars plana vitrectomy as a result of the persistent macular hole. An improvement of visual acuity was seen in 6 out of 10 patients (60.0%), a reduction of macular edema in 8 out of 9 patients (88.9%), and a decrease of metamorphopsia in 6 out of 7 patients (85.7%).

CONCLUSION

In this retrospective analysis, the treatment with ocriplasmin showed a resolution of VMT in 7 of 10 patients (70.0%) after a follow-up period of 8 weeks.

Corneal melt secondary to eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare antineutrophil cytoplasmic antibody-associated vasculitis that can affect any organ system. It is most often characterised by chronic airway inflammation along with prominent peripheral blood eosinophilia, although the disease can affect the cardiovascular, gastrointestinal, renal or central nervous systems. Ocular manifestations are uncommon and when they do occur, are varied in their clinical presentations. To the best of our knowledge, this is the first case of corneal melt secondary to EGPA to have been reported.

CYSTOID MACULAR EDEMA SECONDARY TO RITUXIMAB

BACKGROUND/PURPOSE

To describe a case of bilateral macular edema appearing after treatment with rituximab.

METHODS

This is a case report describing macular edema after rituximab infusions. The information was collected retrospectively through chart review.

RESULTS

A 53-year-old patient known for IgG4-related disease of the face and sinuses presented with bilateral decreased visual acuity from cystoid macular edema shortly after undergoing two rituximab infusions. Laboratory workup did not reveal any underlying systemic etiology. Treatment with topical and oral corticosteroids as well as with anti-vascular endothelial growth factor injections led to mild improvement. Treatment with intraocular triamcinolone resulted in complete resolution of the edema, although accompanied by an increase in intraocular pressure.

CONCLUSION

Rituximab has been previously associated with macular edema. Macular edema causing visual loss shortly after receiving rituximab may respond to discontinuation of the rituximab and local steroid injection.

Impact of ranibizumab on visual impairment in patients with bilateral diabetic macular edema

AIMS

Diabetic macular edema (DME) frequently presents bilaterally. In case of bilateral retinal disease, the visual impairment (VI) and the visual acuity (VA) are strongly correlated to the better eye. The aim of this study was to assess the impact of ranibizumab intravitreal injections (IVR) on VI in patients with simultaneous VA loss due to DME.

METHODS

This was a retrospective two-center study including consecutive DME patients with visual loss treated with ranibizumab since November 2011 and with a minimum follow-up of 6 months. Patients with bilateral visual decrease from DME undergoing IVR within 6 months of each other were included.

RESULTS

Twenty-nine DME patients who received bilateral IVR within a 6-month interval in the second eye were included. At baseline, 82.8% (n = 24) of patients had a VA < 20/40 in their better eye versus 44.8% (n = 13) of patients at the end of follow-up, i.e. a reduction by 45.9% of VI. In the better eye, the mean VA was 57.3, 65.0 and 65.5 ETDRS letters, respectively, at baseline, month 3 and month 6 (mean VA gain +8.2 letters). In the worse eye, the mean VA was 44.2, 53.5 and 53.8 ETDRS letters, respectively, at baseline, M3 and M6 (mean VA gain +9.6 letters).

CONCLUSIONS

In patients with bilateral DME, subsequent ranibizumab IVR reduced VI frequency.

Enduring remission of active and sight-threatening Graves' orbitopathy with rituximab: report of two cases

Intravenous (i.v.) glucocorticosteroids (GCs) constitute the first-line treatment for active and moderate-to-severe Graves' orbitopathy (GO). In cases of persistent disease, rituximab, a monoclonal anti-CD20 antibody, may be used, although studies have yielded conflicting results. In case 1, a 50-year-old female heavy smoker presented with severe bilateral disfiguring eyelid edema of four months, bilateral exophthalmos and a clinical activity score (CAS) of 5/7. Laboratory investigation showed thyrotoxicosis and high thyroid-stimulating immunoglobulin (TSI) levels [32 IU/L (normal <1.75]. After minor improvement by i.v. methylprednisolone and standard retrobulbar radiotherapy (20 Gy), her visual acuity progressively declined to "hand motion". Rituximab was administered (two pulses of 500 mg, two weeks apart), with significant response. At 3 1/2 years of follow-up, CAS is 0/7 and CD20+ lymphocytes remain at the lower normal range. In case 2, a 78-year-old non-smoker male was referred for management of severe active GO, one month after total thyroidectomy for Graves' thyrotoxicosis (TSI: 6.74 IU/L). Over the preceding two-three months, severe GO manifested with chemosis, constant diplopia, loss of color vision and acuity of 1/10 bilaterally (CAS: 7/7). Following partial response to i.v. methylprednisolone and concomitant radiotherapy, rituximab (two pulses of 500 mg each, two weeks apart), was administered. Vision partially recovered and GO remains in remission one year later, even after ¹³¹I (100 mCi) administration for papillary thyroid carcinoma (TSI: 0.9 IU/L and CD20+ count at the lower normal range). In conclusion, rituximab may be an effective second-line therapy in GO patients, providing long-lasting remission.

MD1003 (High-Dose Pharmaceutical-Grade Biotin) for the Treatment of Chronic Visual Loss Related to Optic Neuritis in Multiple Sclerosis: A Randomized, Double-Blind, Placebo-Controlled Study

BACKGROUND

Chronic visual loss is a disabling feature in patients with multiple sclerosis (MS). It was recently shown that MD1003 (high-dose pharmaceutical-grade biotin or hdPB) may improve disability in patients with progressive MS.

OBJECTIVE

The aim of this study was to evaluate whether MD1003 improves vision compared with placebo in MS patients with chronic visual loss.

METHODS

The MS-ON was a 6-month, randomized, double-blind, placebo-controlled study with a 6-month open-label extension phase. Adult patients with MS-related chronic visual loss of at least one eye [visual acuity (VA) below 0.5 decimal chart] were randomized 2:1 to oral MD1003 300 mg/day or placebo. The selected eye had to show worsening of VA within the past 3 years following either acute optic neuritis (AON) or slowly progressive optic neuropathy (PON). The primary endpoint was the mean change from baseline to month 6 in VA measured in logarithm of the minimum angle of resolution (logMAR) at 100% contrast of the selected eye. Visually evoked potentials, visual field, retinal nerve fiber layer (RNFL) thickness, and health outcomes were also assessed.

RESULTS

Ninety-three patients received MD1003 (n = 65) or placebo (n = 28). The study did not meet its primary endpoint, as the mean change in the primary endpoint was nonsignificantly larger (p = 0.66) with MD1003 (- 0.061 logMAR, + 3.1 letters) than with placebo (- 0.036 logMAR, + 1.8 letters). Pre-planned subgroup analyses showed that 100% contrast VA improved by a mean of + 2.8 letters (- 0.058 logMAR) with MD1003 and worsened by - 1.5 letters (+ 0.029 logMAR) with placebo (p = 0.45) in the subgroup of patients with PON. MD1003-treated patients also had nonsignificant improvement in logMAR at 5% contrast and in RNFL thickness and health outcome scores when compared with placebo-treated patients. There was no superiority of MD1003 vs placebo in patients with AON. The safety profile of MD1003 was similar to that of placebo.

CONCLUSIONS

MD1003 did not significantly improve VA compared with placebo in patients with MS experiencing chronic visual loss. An interesting trend favoring MD1003 was observed in the subgroup of patients with PON. Treatment was overall well tolerated.

TRIAL REGISTRATION

EudraCT identifier 2013-002112-27. ClinicalTrials.gov Identifier: NCT02220244 FUNDING: MedDay Pharmaceuticals.

Influence of Nifedipine on the Visual Fields of Patients with Optic-Nerve-Head Diseases

Calcium-channel blockers have long been employed in coronary disease, and recent investigations have indicated their efficacy in improving the visual field in low-tension glaucoma or presumed vasospasm, possibly by enhancing ocular circulation. We evaluated the short-term influence of a typical calcium-channel blocker, nifedipine, on 59 patients with visual-field defects, some with optic-nerve-head pathology (n = 38) and some with normal-appearing optic nerve heads (n = 21). On the average, a statistically significant improvement of 1.2 dB was observed. Different types of patients, however, behaved quite differently. The younger the patient, the greater the improvement. Patients with normal optic nerve heads improved by 1.54 dB, whereas patients with optic-nerve-head excavation improved by only 0.66 dB. No response was observed in patients with anterior ischemic neuropathy. Marked deterioration was noted in one glaucoma patient with low systemic blood pressure. The visual-field changes were observed in the scotomatous and non-scotomatous areas. Thus, the calcium-channel blocker nifedipine can be effective in some selected diseases whose pathogenesis probably involves vascular dysregulation though it may even be contraindicated in others

Macular Sensitivity Change in Multiple Sclerosis followed with Microperimetry

PURPOSE

To describe the efficacy of MP-1 in detecting early multiple sclerosis (MS) retinal lesions and in monitoring the effectiveness of treatment in terms of changes in macular sensitivity.

METHODS

A 21-year-old woman with MS was referred to us complaining of recurrent episodes of eyesight loss in both eyes. At ophthalmologic examination, best-corrected visual acuity was 20/25 bilaterally; ophthalmoscopy showed bilateral slight optic neuritis without swelling of the disc. Static perimetry of central visual field (30 degrees, by Octopus 101, Haag-Streit AG, Switzerland) and retinal sensitivity of the 12 central degrees (by MP-1 Micro Perimeter, Nidek Inc., Italy) were performed on the patient at that time. The micro perimeter (MP-1) showed a loss of sensitivity in the macular region with 0.28+/-0.9 dB sensitivity in the right eye and 19.42+/1.5 dB in the left. The mean fixation stability was 91% considering 2 degrees and 99% considering 4 degrees around the fixation points in the right eye, and 97% in 2 degrees and 100% in 4 degrees central degrees in the left. In the weeks that followed vision continued to get worse in both eyes, so she underwent a steroid therapy with methylprednisolone IV 1000 mg/day for 5 days and 500 mg/day for 3 days.

RESULTS

After 8 days of therapy the MP-1 showed a significant recovery in the right eye, with mean light sensitivity being 19.61+/-1.3 dB in the right eye and 20.0+/-0 dB in the left eye in both macular and peripapillary regions. The mean fixation stability was 100% considering 2 degrees and 100% considering 4 degrees around the fixation points in both eyes.

CONCLUSIONS

The MP-1 can be an interesting tool for neuro-ophthalmologists as it allows a more precise evaluation of the macular and peripapillary region, which is not easily studied with conventional automated perimetry. In MS, the presence of a subclinical form of optic nerve involvement can be demonstrated in a very early stage, and well followed by the introduction of micro perimeter testing in the standard examination protocol.

Nerve Growth Factor: Early Studies and Recent Clinical Trials

Since its discovery, nerve growth factor (NGF) has long occupied a critical role in developmental and adult neurobiology for its many important regulatory functions on the survival, growth and differentiation of nerve cells in the peripheral and central nervous system. NGF is the first discovered member of a family of neurotrophic factors, collectively indicated as neurotrophins, (which include brain-derived neurotrophic factor, neurotrophin-3 and neurotrophin 4/5). NGF was discovered for its action on the survival and differentiation of selected populations of peripheral neurons. Since then, an enormous number of basic and human studies were undertaken to explore the role of purified NGF to prevent the death of NGF-receptive cells. These studies revealed that NGF possesses important therapeutic properties, after topical administration, on human cutaneous pressure ulcer, corneal ulcers, glaucoma, retinal maculopathy, Retinitis Pigmentosa and in pediatric optic gliomas and brain traumas. The aim of this review is to present our previous, recent and ongoing clinical studies on the therapeutic properties of NGF.

Subacute loss of vision in one eye · rash on hands and feet · plaques with scaling on genitals · Dx?

A 67-year-old man presented to the hospital with subacute loss of vision in his left eye. The visual changes began 2 weeks earlier, with a central area of visual loss that had since progressed to near complete vision loss in the left eye. Physical examination revealed patchy alopecia, a scaling and hyperkeratotic rash of his hands and feet, and blanching, erythematous plaques with associated scaling on the scrotum and glans penis. Ophthalmologic examination revealed 1/200 vision in his left eye with a large plaque occupying a substantial portion of the superior quadrant, smaller perifoveal plaques in both of his eyes, and a small infiltrate above the left optic nerve head. The patient also described fatigue, loss of taste, and an unintentional weight loss of 7 to 10 kg over the previous 6 months. He had seen his primary care provider 3 months prior for a burning sensation and scaling rash on his feet and hands, and was prescribed a topical steroid.

Factors affecting eye drop instillation in glaucoma patients with visual field defect

Background

To investigate the success rate of eye drop instillation in glaucoma patients with visual field defect as well as non-glaucoma volunteers. Factors that may affect the success rate of eye drop instillation were also evaluated.

Design

A prospective, observational study.

Participants

Seventy-eight glaucoma patients and 85 non-glaucoma volunteers were recruited in this study.

Methods

Open angle glaucoma patients with visual field defect as well as non-glaucoma volunteers were asked to video record their procedures of eye drop instillation using a 5-mL plastic bottle of artificial tear solution. Success of eye drop instillation was judged on video based on the first one drop of solution successfully applied on the cornea, by two investigators.

Main outcome measures

Success rate of eye drop instillation in glaucoma patients and non-glaucoma volunteers. Factors related to success rate of eye drop instillation, such as visual field defect and clinical characteristics, were also analyzed using multivariable logistic regression.

Results

No significant deference in mean age was observed between two groups (glaucoma: 64.5 ± 14.4 years, non-glaucoma: 60.9 ± 14.1 years, P = 0.1156). Success rate of eye drop instillation was significantly lower (P = 0.0215) in glaucoma patients (30/78; 38.5%) than in non-glaucoma volunteers (48/85; 56.5%). The most frequent reason of instillation failure in glaucoma patients was touching the bulbar conjunctiva, cornea, eyelid or eyelashes with the tip of the bottle (29.5%). Multivariable logistic regression analysis identified lower corrected visual acuity (VA) (≤ 1.0; odds ratio [OR] = 0.20, 95% confidence interval [CI] 0.04–0.93, P = 0.0411), lower mean deviation (MD) (< -12 dB; OR = 0.20, 95% CI 0.05–0.86, P = 0.0307) and visual field defect (VFD) in the inferior hemifield (OR = 0.11, 95% CI 0.02–0.34, P < 0.001) to be significantly related to instillation failure in glaucoma patients.

Conclusions

Success rate of eye drop instillation was significantly lower in glaucoma patients than in non-glaucoma volunteers. Corrected VA ≤ 1.0, MD < -12 dB and/or VFD in the inferior hemifield may be related to failure of eye drop instillation.

Decompressive Cranioplasty in a Patient with Osteopetrosis

BACKGROUND

Osteopetrosis is a heterogeneous group of uncommon congenital disorders that causes bony sclerosis and remodeling. Patients who are symptomatic can show significant neurologic consequences with the involvement of cranial nerves and symptoms of increased intracranial pressure (ICP).

CASE DESCRIPTION

We report an unusual case of a 26-year-old woman with an autosomal-dominant type of osteopetrosis who presented with headache and severe visual deterioration, both attributed to increased ICP. A hemicranioplasty was preformed, resulting in the resolution of her symptoms of ICP and stabilization of her vision. Postoperative imaging showed expansion of the ventricles and the subarachnoid spaces with an improvement of the associated cerebellar herniation.

CONCLUSIONS

In conclusion, in patients with symptomatic osteopetrosis, cranioplasty can be considered as an option to treat high ICP-related symptoms.

Visual loss due to optic nerve infarction and central retinal artery occlusion after spine surgery in the prone position: A case report

RATIONALE

Visual loss after spine surgery in the prone position is a serious complication. Several cases of central retinal artery occlusion with ophthalmoplegia after spine surgery have been reported in patients with ophthalmic arteries fed by the internal carotid artery (ICA) in a normal manner.

PATIENT CONCERNS

A 74-year-old man developed visual loss after undergoing a spinal decompression and fusion operation in the prone position that lasted approximately 5 hours.

DIAGNOSES

We detected an extremely rare case of visual loss due to optic nerve infarction and central retinal artery occlusion through fundoscopic examination, fluorescein angiogram, brain magnetic resonance imaging, and magnetic resonance angiography. The patient's visual loss may have been caused by compromised retrograde collateral circulation of the ophthalmic artery from branches of the external carotid artery in the presence of proximal ICA occlusion after a spinal operation in the prone position.

INTERVENTIONS

To recover movement of the left extraocular muscles, the patient received intravenous injections of methylprednisolone for 3 days and then oral prednisolone for 6 days.

OUTCOMES

Twenty days after the treatment, the motion of the left extraocular muscles was significantly improved. However, recovery from the left visual loss did not occur until 4 months after the operation.

LESSONS

In high-risk patients with retrograde collateral circulation of the ophthalmic artery from the external carotid artery due to proximal ICA occlusion, various measures, including the use of a head fixator to provide a position completely free of direct compression of the head and face, should be considered to decrease the risk of postoperative visual loss.

A treatable cause of myelopathy and vision loss mimicking neuromyelitis optica spectrum disorder: late-onset biotinidase deficiency

Biotinidase deficiency is characterized by severe neurological manifestations as hypotonia, lethargy, ataxia, hearing loss, seizures and developmental retardation in its classical form. Late-onset biotinidase deficiency presents distinctly from the classical form such as limb weakness and vision problems. A 14-year-old boy presented with progressive vision loss and upper limb weakness. The patient was initiated steroid therapy with a preliminary diagnosis of neuromyelitis optica spectrum disorder due to the craniospinal imaging findings demonstrating optic nerve, brainstem and longitudinally extensive spinal cord involvement. Although the patient exhibited partial clinical improvement after pulse steroid therapy, craniocervical imaging performed one month after the initiation of steroid therapy did not show any regression. The CSF IgG index was <0.8 (normal: <0.8), oligoclonal band and aquaporin-4 antibodies were negative. Metabolic investigations revealed a low biotinidase enzyme activity 8% (0.58 nmoL/min/mL; normal range: 4.4 to 12). Genetic testing showed c.98-104delinsTCC and p.V457 M mutations in biotinidase (BTD) gene. At the third month of biotin replacement therapy, control craniospinal MRI demonstrated a complete regression of the lesions. The muscle strength of the case returned to normal. His visual acuity was 7/10 in the left eye and 9/10 in the right. The late-onset form of the biotinidase deficiency should be kept in mind in all patients with myelopathy with or without vision loss, particularly in those with inadequate response to steroid therapy. The family screening is important to identify asymptomatic individuals and timely treatment.

OCT angiography in the management of choroidal neovascular membrane secondary to Sorsby fundus dystrophy

We describe the management of a woman aged 52 years with molecularly confirmed Sorsby fundus dystrophy, who presented with acute visual deterioration in her right eye. Fundus examination identified a right macular lesion suggestive of a choroidal neovascular membrane (CNVM). Optical coherence tomography angiography (OCTA) confirmed the presence of a CNVM. She was treated with 2 monthly intravitreal injections of bevacizumab, associated with OCTA evidence of regression of the CNVM and improvement in her visual acuity. OCTA is a novel, non-invasive method of imaging the retinal vasculature. Images are acquired rapidly, with no associated side effects, offering advantages over the current gold standard technique-fundus fluorescein angiography.

Retinal Branch Artery Embolization Following Hyaluronic Acid Injection: A Case Report

Injection of hyaluronic acid (HA) filler is a common aesthetic procedure. Impairment of vision, although rare, is a devastating complication of this procedure, which may not be reversible. We report on a patient who experienced visual acuity impairment and ischemic oculomotor nerve palsy after injection of HA into the nasal dorsum. In this case, clinical signs improved within 14 days of treatment. We also provide a review of the mechanism, clinical features, risk factors, and prevention and treatment strategies relating to embolization of ocular circulation after injection of HA. Vision loss is a rare but devastating complication of injection of hyaluronic acid (HA) in the face. Visual acuity seldom recovers completely. We report on a 22-year-old Asian woman who experienced obstruction of a branch of the retinal artery after injection of HA to augment her nose. The patient's visual acuity declined shortly after the procedure, and ophthalmoplegia occurred. Combination treatment was administered to restore the perfusion and oxygen supply to the retina and optic nerve. Within 14 days of rigorous treatment, the patient experienced improvement in visual acuity, extraocular movement, and visual field defects. LEVEL OF EVIDENCE 5: Risk.

Combined etiology for bilateral and simultaneous optic neuropathy in a patient with ciancobalamin deficit and hepatitis C treated with peg-interferon and ribavirin

We report the case of a 53-year-old female patient who developed bilateral sudden visual acuity loss after 15 weeks from the initiation of Peg-Interferon and Ribavirin treatment for hepatitis C. Debut was simultaneous and asymmetric, reported in the morning, at awakening. No pain or other symptom was reported by the patient. Results. At presentation, visual acuity was 0.2 in RE and 3/ 50 in LE. Pupillary reflexes were sluggish and severe dyschromatopsia was documented in both eyes (Ishihara plates). Fundus examination revealed bilateral pale optic disc edema, more prominent in LE, with splinter hemorrhages in the RNFL around the optic disk. Visual field exam demonstrated severe defects in 3 quadrants of the RE, whereas in the LE, it was impossible to perform the investigation due to VA<0.1. Neurologic evaluation was normal; other possible causes of systemic vasculitis were excluded by negative lab tests. Acute inflammatory markers (fibrinogen and ESR) and mild pancytopenia were the only documented laboratory changes in this patient. Anamnesis cleared the traditional risk factors for conventional AION (hypertension, diabetes, ischemic heart disease, and hypercholesterolemia). Cranial and orbital CT scan and MRI findings were normal. Patient was withdrawn from the Interferon and Ribavirin treatment and was administered methyl prednisolone pulse therapy (1g/ day) for 3 days, continued with oral Prednisone (60 mg/ day) tapered slowly for over 12 weeks. VA increased to 0.8 during treatment in the RE, but visual recovery in the LE was not as spectacular (0.16) as in the fellow eye. Modified latencies and amplitudes in evoked visual potentials examination during 4 months time emphasized bilateral optic atrophy. Optic nerve sufferance was amplified by a low level of vitamin B12, detected by chance at the last eye visit. Due to the general condition, dietary supplementation was not possible. Conclusion. A case of a patient with bilateral and simultaneous NAION caused by IFN and Ribavirin treatment for hepatitis C, who was also vitamin B12 deficient, was analyzed. Therefore, a combined etiology for optic atrophy was explained.

Hypothalamic-pituitary sarcoidosis with vision loss and hypopituitarism: case series and literature review

PURPOSE

Hypothalamic-pituitary (HP) neurosarcoidosis (NS) accounts for 0.5 % cases of sarcoidosis and 1 % of HP masses. Correlative data on endocrine and neurological outcomes is lacking.

METHODS

Retrospective case series and literature review of presentation, treatment and outcome of HP NS.

RESULTS

Our series includes 4 men, ages 34-59, followed for a median of 7.3 years (range 1.5-17). All had optic neuropathy, multiple pituitary hormone abnormalities (PHAs) and other organ involvement by sarcoidosis (lung, sino-nasal, brain/spine and facial nerve). Two patients had central diabetes insipidus and one impaired thirst with polydipsia. After treatment with high-dose glucocorticoids, optic neuropathy improved in one case and stabilized in the others. After treatment, HP lesions improved radiologically, but PHAs persisted in all cases. Review of four published series on HP NS in addition to ours yielded 46 patients, age 37 ± 11.8 years, 65 % male. PHAs consisted of anterior hypopituitarism (LH/FSH 88.8 %, TSH 67.4 %, GH 50.0 %, ACTH 48.8 %), hyperprolactinemia (48.8 %) and diabetes insipidus (65.2 %). PHAs were the first sign of disease in 54.3 % patients. Vision problems occurred in 28.3 % patients, but optic neuropathy was not well documented in previous series. Most patients (93.5 %) received high-dose glucocorticoids followed by taper; 50 % also received other immunomodulators, including methotrexate, mycophenolate mofetil, cyclosporine, azathioprine, infliximab and hydrochloroquine. Only 13 % patients showed improvement in PHAs. All-cause mortality was 8.7 %.

CONCLUSION

HP NS is a serious disease requiring multidisciplinary treatment and lifelong follow-up. Prospective multicentric studies are needed to determine a more standardized approach to HP NS and outline predictors of disease outcome.

[Diagnostic challenges in presumably endogeneous fungal endophthalmitis]

Endogenous fungal endophthalmitis is a vision-threatening condition. Fungi are responsible for most cases of endogenous endophtalmitis, with intravenous catheters, bladder catheters, parenteral nutrition, abdominal surgery, long-term use of steroids and antibiotics, as well as immunosuppressive therapy known as its predisposing factors. Three cases of endogenous endophthalmitis in patients with predisposing factors.

Lacrimal duct cyst abscess

Cystic dilatation within the lacrimal gland is thought to be related to chronic inflammation and scarring of the lacrimal gland ductules. We review the literature and discuss a case and of lacrimal duct cyst suppuration presenting with visual loss, external ophthalmoplegia, proptosis and ptosis. To our knowledge, only one other report of a lacrimal ductal cyst abscess has been reported in the literature so far.