Importance of Baseline Fluorescein Angiography for Patients Presenting to Tertiary Uveitis Clinic

PURPOSE

To ascertain whether the use of ultra-wide-field fluorescein angiography (UWFFA) at baseline visit alters the assessment of disease activity and localization, as well as the management of patients presenting to a tertiary uveitis clinic.

DESIGN

Retrospective comparison of diagnostic approaches.

METHODS

Baseline visits of 158 patients who presented to the Uveitis Clinic at the Byers Eye Institute at Stanford between 2017 and 2022 were evaluated by three uveitis-trained ophthalmologists (I.K., A.B., and H.G.). Each eye had undergone clinical examination along with ultra-wide-field fundus photography (UWFFP) (Optos Plc, Dunfermline, Scotland, UK), spectral-domain optical coherence tomography (SD-OCT, Spectralis Heidelberg, Heidelberg Engineering, Heidelberg, Germany) and UWFFA (Optos Plc, Dunfermline, Scotland, UK) at the baseline visit. Investigators were asked to successively determine disease activity, localization of disease (anterior, posterior or both), and management decisions based on clinical examination and UWFFP and SD-OCT (Set 1) and Set 1 plus UWFFA (Set 2). The primary outcome was the percentage of eyes whose management changed based on the availability of UWFFA, compared with Set 1.

RESULTS

The mean age of the patients was 46.9±22.4 (range, 7-96) and 91 (57.6%) were female. With Set 1 alone, 138 (55.2%) eyes were found to have active disease; localization was anterior in 58 (42.0%) eyes, posterior in 53 (38.4%) eyes and anterior + posterior in 27 (19.6%) eyes. With Set 2, 169 eyes of 107 patients had active anterior, posterior or pan-uveitis. In comparison with Set 1, assessment with Set 2 identified additional 31 (18.3%) eyes with active disease (p=0.006), and additional 31 (18.3%) eyes having disease in both anterior + posterior segments (p<0.001). Regarding the primary outcome, management was changed in 68 (27.4%) eyes in Set 2, compared to Set 1.

CONCLUSION

Baseline UWFFA may alter assessment of disease activity, localization, and management decisions compared to clinical examination with only UWFFP and SD-OCT for eyes with uveitis. Thus, UWFFA may be considered as an essential tool in the evaluation of uveitis patients at the baseline visit.

TIMP3/Wnt axis regulates gliosis of Müller glia

BACKGROUND

Previous studies have confirmed the expression of tissue inhibitor of metalloproteinase-3 (TIMP3) in Müller glia (MG). However, the role of TIMP3 in MG remains unknown.

METHODS

A mouse model of laser-induced retinal damage and gliosis was generated using wild-type C57BL/6 mice. TIMP3 and associated proteins were detected using Western blotting and immunofluorescence microscopy. RNA sequencing (GSE132140) of mouse laser-induced gliosis was utilized for pathway analysis. TIMP3 overexpression was induced in human MG. Human vitreous samples were obtained from patients with proliferative diabetic retinopathy (PDR) and healthy controls for protein analysis.

RESULTS

TIMP3 levels increased in mouse eyes after laser damage. Morphology and spatial location of TIMP3 indicated its presence in MG. TIMP3-overexpressing MG showed increased cellular proliferation, migration, and cell nuclei size, suggesting TIMP3-induced gliosis for retinal repair. Glial fibrillary acidic protein (GFAP) and vimentin levels were elevated in TIMP3-overexpressing MG and laser-damaged mouse retinas. RNA sequencing and Western blotting suggested a role for β-catenin in mediating TIMP3 effects on the retina. Human vitreous samples from patients with PDR showed a positive correlation between TIMP3 and GFAP levels, both of which were elevated in patients with PDR.

CONCLUSIONS

TIMP3 is associated with MG gliosis to enhance the repair ability of damaged retinas and is mediated by the canonical Wnt/β-catenin. Changes in TIMP3 could potentially be used to control gliosis in a range of retinal diseases However, given the multifaceted nature of TIMP3, care must be taken when developing treatments that aim solely to boost the function of TIMP3.

FUNDING

National Cheng Kung University Hospital, Taiwan (NCKUH-10604009 and NCKUH-11202007); the Ministry of Science and Technology (MOST 110-2314-B-006-086-MY3).

Induction of Petite Colonies in Candida glabrate via Rose Bengal-Mediated Photodynamic Therapy

Facing a 40% mortality rate in candidemia patients, drug-resistant Candida and their petite mutants remain a major treatment challenge. Antimicrobial photodynamic therapy (aPDT) targets multiple fungal structures, unlike antibiotics/antifungals, potentially thwarting resistance. Traditional methods for inducing petite colonies rely on ethidium bromide or fluconazole, which can influence drug susceptibility and stress responses. This study investigated the application of green light (peak 520 nm) and rose bengal (RB) photosensitizer to combat a drug-resistant Candida glabrata isolate. The findings revealed that aPDT treatment significantly inhibited cell growth (≥99.9% reduction) and effectively induced petite colony formation, as evidenced by reduced size and loss of mitochondrial redox indicator staining. This study provides initial evidence that aPDT can induce petite colonies in a multidrug-resistant C. glabrata strain in vitro, offering a potentially transformative approach for combating resistant fungal infections.

Diagnosis, Treatment, and Prevention of Noninfectious Acute Anterior Uveitis with or without Human Leukocyte Antigen B27 in Adults - Expert Consensus in Taiwan

BACKGROUND

Anterior uveitis is the most common anatomical type of uveitis. Patients with noninfectious anterior uveitis may develop various ocular complications and eventually visual impairment. Appropriately differentiating the etiologies can help clinicians to predict the outcome, arrange clinical follow-up, and decide the treatment or prevention strategy. Adequate treatment and effective prevention strategies can reduce the frequency of recurrence and the risk of developing complications. Human leukocyte antigen (HLA)-B27 is the most common positive finding in patients with noninfectious AAU in many countries including Taiwan.

PURPOSE

To report a consensus from experienced uveitis specialists and rheumatologists was made in Taiwan.

METHODS

A panel of nine ophthalmologists from nine different referral centers with expertise in the management of uveitis and an experienced rheumatologist was held on January 16, 2022. A comprehensive literature review was performed. Differential diagnoses for etiologies, general treatments, and prevention strategies were discussed. Each statement in the consensus was made only if more than 70% of the experts agreed.

RESULTS

A flow chart and seven statements regarding the differential diagnoses for etiologies, treatments and preventions, and co-management with rheumatologists were included in the consensus.

CONCLUSIONS

This article discusses the general diagnosis, treatment, and prevention of noninfectious acute anterior uveitis, with or without HLA-B27, in adults for general ophthalmologists to improve overall outcomes of these patients.

Double-Needle Haptic Repositioning: A Troubleshooting Technique for Flanged Intraocular Lens Fixation

PURPOSE

Haptic repositioning during flanged intraocular lens (IOL) fixation can be difficult, and the haptic requiring repositioning may be at increased risk of excessive bending or breakage. This study aimed to report double-needle haptic repositioning technique outcomes for the aforementioned difficulty during flanged IOL fixation.

METHODS

This retrospective case series included seven eyes requiring haptic repositioning during flanged IOL fixation. The method features reinsertion of an already externalized haptic into the needle lumen followed by a needle-haptic complex internalized through the original tract into the eyeball. Thus, an adequate configuration for contralateral haptic can be achieved for insertion into the needle lumen to create a double-needle condition before both haptics are successfully externalized.

RESULTS

The median follow-up duration was 24 months (range, 4-24 months). Postoperatively, the IOL was well-centered, and corrected distance visual acuity improved from 20/320 (20/4,000-20/70) to 20/50 (20/250-20/20). No intraoperative or postoperative complications were noted.

CONCLUSION

The technique produced encouraging results in patients undergoing haptic repositioning during flanged IOL fixation. This technique could potentially reduce haptic overbending risk and facilitate haptic adjustment. Further studies are needed to confirm the feasibility of the technique.

Acute Kidney Injury from Intravitreal Anti-vascular Endothelial Growth Factor Drugs: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Several observational studies have reported acute kidney injury from intravitreal anti-vascular endothelial growth factor (anti-VEGF) drugs for retinal diseases. However, systematic reviews and meta-analyses of randomized controlled trials on this critical topic are scant.

OBJECTIVE

To evaluate acute kidney injury risk associated with intravitreal anti-VEGF drugs in patients with retinal diseases.

METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials on 12 July, 2023, and included randomized controlled trials reporting acute kidney injury between anti-VEGF drugs (e.g., aflibercept, bevacizumab, brolucizumab, and ranibizumab) and controls for retinal diseases (e.g., age-related macular degeneration, polypoidal choroidal vasculopathy, diabetic retinopathy/diabetic macular edema, retinal vein occlusion, and myopic choroidal neovascularization). Data were synthesized by a fixed-effects model for pooling odds ratios (ORs) using the Peto method.

RESULTS

We included 13 randomized controlled trials (four and nine trials for aflibercept and ranibizumab, respectively) with a total of 4282 participants. The meta-analysis indicated intravitreal anti-VEGF drugs did not increase the acute kidney injury risk, compared with controls (odds ratio [OR]: 1.00, 95% confidence interval [CI] 0.49-2.04, I2: 0%), and no differences in the acute kidney injury risk were observed between different anti-VEGF drugs (OR: 1.10, 95% CI 0.27-4.43, I2: 0% for aflibercept; OR: 0.97, 95% CI 0.42-2.22, I2: 0% for ranibizumab) and between different retinal diseases (OR: 4.61, 95% CI 0.07-284.13, I2: not applicable for age-related macular degeneration; OR: 0.90, 95% CI 0.42-1.93, I2: 0% for diabetic retinopathy/diabetic macular edema; OR: 1.57, 95% CI 0.16-15.88, I2: 0% for retinal vein occlusion).

CONCLUSIONS

Intravitreal anti-VEGF drugs were not associated with an acute kidney injury risk, regardless of which anti-VEGF drugs (aflibercept or ranibizumab) or retinal diseases (age-related macular degeneration, diabetic retinopathy/diabetic macular edema, or retinal vein occlusion) were involved.

SYSTEMATIC REVIEW PROTOCOL REGISTRATION

PROSPERO CRD42021267854.

Trends in diabetic eye disorders and associated comorbidities in Taiwan: a 10-year nationwide population-based cohort study

BACKGROUND/AIMS

In-depth analysis is needed to investigate trends in diabetic retinopathy (DR), diabetic macular oedema (DME) and associated comorbidities in patients with type 2 diabetes mellitus (T2DM) so that we can better understand their prevalence and incidence.

METHODS

A retrospective population-based study was conducted using data from Taiwan's National Health Insurance Research Database from 2005 to 2015, and T2DM, DR and associated comorbidities were identified based on diagnostic codes. We used a standardised incidence rate with age and sex adjustment to estimate the prevalence and incidence of DR, proliferative DR (PDR), advanced PDR (aPDR) and DME, while the difference in each study period was calculated as the annual percentage change. We used the absolute standardised difference to analyse changes in related comorbidities in different periods.

RESULTS

The population of patients with DM increased over 50% between 2005 and 2015, while the prevalence and incidence of DR decreased, as did the incidence of PDR and aPDR. However, the prevalence and incidence of DME increased over the course of 10 years, with an upward trend in all forms of DR. The percentage of patients with hyperlipidaemia in DME and all DR increased, and the percentage of patients with end-stage renal disease (ESRD) was also elevated in DME.

CONCLUSION

The prevalence and incidence of DR, PDR and aPDR decreased with time in patientsT2DM, while the ratio of DME increased gradually. The incidence of hyperlipidaemia also increased in all forms of diabetic eye disorders, while ESRD increased solely in DME.

Dilated choroidal vascular channels in pachychoroid neovasculopathy

BACKGROUND

To elucidate the pattern of the choroidal vasculature in exudative pachychoroid neovasculopathy (PNV) and its correlation with the clinical course and treatment outcomes.

METHODS

The retrospective study included consecutive patients in National Taiwan University Hospital between 2014 and 2020 who fulfilled the criteria for exudative PNV defined as active type 1 macular neovascularization (MNV) on optical coherence tomography angiography (OCTA) and with leakage on fluorescein angiography (FA) or indocyanine green angiography (ICGA) associated with pachychoroid features. The corrected distance visual acuity (CDVA), FA, ICGA, and OCT images obtained by Optovue (Optovue Inc, Freemont CA, USA) spectral domain OCT were evaluated at baseline and various time points during the 12-month treatment period. The correlations between the choroidal vascular patterns, specifically those with or without dilated choroidal vascular channels (DCVC) revealed by ICGA, and baseline characteristics and treatment outcomes were evaluated using multiple regression models.

RESULTS

The study enrolled 34 eyes of 31 patients. The average age was 59.0 ± 9.3 years, and 20 participants were men. ICGA revealed DCVCs in 21 eyes, while the remaining 13 eyes did not have DCVCs. At baseline, DCVC group was older (p = 0.03) and had a longer duration of visual symptoms (p = 0.02), with a higher vessel density (defined as the percentage of the measured area occupied by flow area) of MNV (p = 0.04), higher proportion of ellipsoid zone disruption (p = 0.01), and poorer CDVA (p = 0.03). After the 12-month treatment period, the frequency of requirement of anti-VEGF injections (p < 0.01) was higher, and the risk for CDVA <20/40 was higher (adjusted OR: 5.29, 95% CI: 1.24-22.48, p = 0.02) in eyes with DCVCs.

CONCLUSIONS

For PNV, eyes with DCVCs were associated with higher vessel density of macular neovascularization and poorer CDVA at baseline, and had poorer visual and anatomical outcomes although more anti-VEGF injections were given.

Overweight and Obesity as Risk Factors for Recurrent Herpetic Stromal Keratitis during Long-Term Antiviral Prophylaxis

Although past research has shown an association between obesity and herpes simplex virus infection, the relationship between body mass index (BMI) and herpetic stromal keratitis (HSK) recurrence has never been investigated. In this study, we included HSK patients who received oral valacyclovir as prophylactic treatment between January 2016 and January 2021. Recurrence, possible risk factors, and the time to recurrence were recorded during follow-ups. Among the 56 patients included in this study, recurrence was reported in 21 (37.5%) patients. The age at disease onset and mean follow-up time were not significantly different in the recurrence and non-recurrence groups. However, in the Cox regression analysis, BMI ≥ 24 kg/m2 was noted as the variable having significant correlation with recurrence (p = 0.01 in univariate analysis and p = 0.001 in multivariate analysis). In conclusion, overweight and obesity were revealed as risk factors for HSK recurrence in patients receiving long-term antiviral prophylaxis. Further studies are needed to determine the appropriate acyclovir concentrations in the blood or aqueous humour in order to achieve desirable prophylactic effects, especially in the overweight and obese patients.

Eyelid and scleral thermal injury following phacoemulsification in silicone oil: a case report

Background

Phacoemulsification has been the mainstay method for extracapsular cataract extraction surgery in the anterior segment; for cases of posterior drop of lens fragments into the vitreous, a posterior segment phacoemulsification instrument (fragmatome; Alcon, Inc., Fort Worth, TX) can be employed to remove the dislocated lens materials. Studies have reported on thermal injury to the cornea during phacmoemulsification of the anterior segment. However, few studies have investigated thermal burn in the simultaneous sclera and eyelid induced by the fragmatome. Currently, there is no reports and lack of optimal strategy for the management of nucleus drop in a vitreous cavity filled with silicon oil.

Case Presentation

We present the case of a 53-year-old male patient with a thermal burn wound on the upper eyelid and sclera following phacoemulsification for a dropped lens in a silicone oil-filled vitreous. We further designed an experiment to verify our hypothesis that thermal injury could be induced by the high temperature of the metal tip during phacoemulsification in silicone oil. In our experiment, during 420 s of continuous ultrasonic wave, the temperature of the fragmatome tip in the balanced salt solution (BSS) increased from 22.0 to 24.0 ºC, while the temperature of the fragmatome tip in the silicone oil group increased from 22.0 to 43.0 ºC.

Conclusions

The temperature of the fragmatome tip increased significantly in silicone oil compared to BSS in the experiment. Thus, physicians should be aware of possible thermal complications when using fragmatome in eyes filled with silicone oil.

Vitreoretinal surgery in the management of infectious and non-infectious uveitis - a narrative review

PURPOSE

This study aims to conduct a narrative review about the current role of vitreoretinal surgery in the management of infectious and non-infectious uveitis.

METHODS

This review was performed based on a search of the PubMed database or on relevant published papers according to our current knowledge.

RESULTS

A total of 91 articles were identified in the literature review. With the advance of microincision vitrectomy surgery (MIVS), pars plana vitrectomy (PPV) has gained increasing popularity in the management of infectious and non-infectious uveitis. For diagnostic purposes, larger amounts of sample can be obtained by MIVS than traditional vitreous aspiration using needles. For treatment purposes, PPV removes vitreous opacities, decreases inflammatory cytokines and mediators of inflammation, and tackles related complications, including hypotony, epiretinal membrane, macular holes, and retinal detachment. Achieving optimum control of inflammation prior to surgery is important for surgical interventions for non-emergent therapeutic indications and complications of uveitis. Peri-operative inflammation management is essential for decreasing the risk of surgical intervention. An overall complication rate of 42-54% was reported with cataract to be the leading cause of complications.

CONCLUSION

Most reports affirm the role of PPV in the management of infectious and non-infectious uveitis, although the quality of data remains limited by a lack of applying standardized reporting outcomes, limitations in study design, and a paucity of prospective data.

Comparative anatomical outcomes of high-flow vs. low-flow phacoemulsification cataract surgery: A systematic review and meta-analysis

Background

Phacoemulsification is an effective and widely performed technique in cataract surgery, but the comparative anatomical outcomes, including endothelial cell loss (ECL), central corneal thickness (CCT), and central macular thickness (CMT), between high-flow and low-flow phacoemulsification cataract surgery remain unclear.

Methods

This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. Random-effects models were applied to measure pooled mean differences (MD) with 95% confidence intervals (CI) of anatomical outcomes between high-flow and low-flow phacoemulsification cataract surgery. We judged overall certainty of evidence (CoE) based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

Results

We included six randomized controlled trials (RCTs) totaling 477 participants. The meta-analysis showed similar changes associated with these two surgery types in both ECL at postoperative days 2–14 (MD: −1.63%; 95% CI: −3.73 to 0.47%; CoE: very low), days 15–42 (MD: −0.65%; 95% CI −2.96 to 1.65%; CoE: very low) and day 43 to month 18 (MD: −0.35%; 95% CI: −1.48 to 0.78%; CoE: very low), and CCT at postoperative day 1 (MD: −16.37 μm; 95% CI: −56.91 to 24.17 μm; CoE: very low), days 2–14 (MD: −10.92 μm; 95% CI: −30.00 to 8.16 μm; CoE: very low) and days 15–42 (MD: −2.76 μm; 95% CI: −5.75 to 0.24 μm; CoE: low). By contrast, low-flow phacoemulsification showed less increase in CMT at postoperative days 15–42 (MD, −4.58 μm; 95% CI: −6.3 to −2.86 μm; CoE: low).

Conclusions

We found similar anatomical outcomes, except in CMT, for both high-flow and low-flow phacoemulsification cataract surgery. Future head-to-head RCTs on visual outcomes should confirm our findings.

Systematic review registration

PROSPERO, identifier: CRD42022297036.

Comparison of Sodium-Glucose Cotransporter 2 Inhibitors vs Glucagonlike Peptide-1 Receptor Agonists and Incidence of Dry Eye Disease in Patients With Type 2 Diabetes in Taiwan

IMPORTANCE

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been found to improve low-grade systemic and tissue inflammation; however, the association between SGLT2 inhibitor use and the incidence of dry eye disease (DED) has not been explored.

OBJECTIVE

To investigate the association between SGLT2 inhibitor use and dry eye disease in patients with type 2 diabetes (T2D).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort analysis of the largest multi-institutional electronic medical records database in Taiwan was conducted to identify patients with T2D newly receiving SGLT2 inhibitors or glucagonlike peptide-1 receptor agonists (GLP-1 RAs) from 2016 to 2018. Data analysis was performed from March 1 to May 31, 2022. Propensity scores with inverse probability of treatment weighting were generated to enable homogeneous comparisons between the 2 groups.

EXPOSURES

Treatment with SGLT2 inhibitors or GLP-1 RAs.

MAIN OUTCOMES AND MEASURES

Incident dry eye disease, which was defined by clinical diagnoses, plus the related drug prescription. Cox proportional hazards regression models were used to estimate hazard ratios with 95% CIs for the risk of DED.

RESULTS

A total of 10 038 and 1077 T2D patients newly receiving SGLT2 inhibitors (mean [SD] age, 59.5 [12.1] years; 5689 [56.7%] men) or GLP-1 RAs (mean [SD] age, 58.5 [41.2] years; 587 [54.5%] men), respectively, were included in the analysis. The incidence of DED was lower in patients newly receiving SGLT2 inhibitors (9.0 events per 1000 person-years) compared with those receiving GLP-1 RAs (11.5 events per 1000 person-years), yielding a hazard ratio of 0.78 (95% CI, 0.68-0.89). Subgroup analyses indicated that the lowered DED risks associated with SGLT2 inhibitors in patients with T2D were similar across different age, sex, blood glucose level, and kidney function groups. Results from the sensitivity analyses (including the propensity score-matching approach, on-treatment analyses, and different follow-up periods of 1, 2, and 3 years) were similar to the main analyses.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that patients with T2D newly receiving SGLT2 inhibitors may have a lower risk for DED compared with those receiving GLP-1 RAs. Prospective studies are needed to analyze these results.

Step-wise diagnostic approach for patients with uveitis - Experts consensus in Taiwan

Uveitis is a sight-threatening disease that can be associated with many different etiologies. Successful treatment of uveitis relies on accurate diagnosis and prompt efficient therapy. History taking, physical and ocular examinations, systemic evaluations, and response to treatment provide crucial information to differentiate possible etiologies involved in the pathophysiology of intraocular inflammation. This article provides recommendations for a step-wise approach to patients with uveitis in Taiwan based on an expert meeting and consensus. Systemic evaluations for uveitis should be performed step-by-step and include investigation of patients' general systemic conditions, ruling out infectious etiologies, and obtaining evidential biomarkers to diagnose a specific disease entity.

A systematic approach to reduce intraocular pressure (IOP) for the treatment of glaucoma

Glaucoma is the leading cause of irreversible blindness due to increased intraocular pressure (IOP) in the eye. We have developed a novel treatment option for glaucoma based on a real-time IOP-dependent nitric oxide synthase (NOS) and packed in a therapeutic contact lens to reduce the IOP. First, 1.6 nmole nitric oxide was produced from the genetic chassis, which was optimized for isopropyl β-d-1-thiogalactopyranoside (IPTG) induction in a T7 expression system. For biosafety concerns to human being, the csgAD genes responsible for curli biofilm formation in E. coli were co-expressed with NOS in the designated NOSAD strain to strengthen the adherence of cells to the contact lens, thereby preventing the contamination into the eyes. Moreover, NOSAD is a diaminopimelic acid (DAP) auxotrophic strain, which cannot survive without supplementation of DAP and reached the critical consideration of biosafety to the environment. We also demonstrated that the nitric oxide diffusion was 3.6-times enhanced from penetration into the aqueous humor of porcine eyes. The deformation ratio of the contact lens was correlated to the change of IOP by using a digital image correlation (DIC) system in a porcine eye model. The novel systematic approach provides an alternative treatment for glaucoma patients in the future. This article is protected by copyright. All rights reserved.

Long-Term Outcome of Treatment with 2% Topical Ganciclovir Solution in Cytomegalovirus Anterior Uveitis and Corneal Endotheliitis

Purpose

This study aimed to evaluate the therapeutic efficacy and long-term outcomes of treatment with topical 2% ganciclovir solution in immunocompetent patients with aqueous humor polymerase chain reaction (PCR)-proven cytomegalovirus (CMV) anterior uveitis and corneal endotheliitis.

Methods

We retrospectively reviewed the findings for immunocompetent patients diagnosed with CMV uveitis or endotheliitis based on clinical manifestations and polymerase chain reaction (PCR) examination results and treated with topical 2% ganciclovir solution at National Cheng Kung University Hospital. Clinical outcome measurements included evaluations of the response rate, relapses, resolution of anterior chamber inflammation, visual acuity, and intraocular pressure.

Results

The study included 38 eyes of 32 patients. Long-term administration of topical 2% ganciclovir significantly decreased keratic precipitates (p = 0.001), anterior chamber cells (p = 0.001), and reduced intraocular pressure (p < 0.001). Only one eye was unresponsive to topical ganciclovir treatment, and the recurrence decreased to 0.13 relapses per year. The presence of keratic precipitates and higher intraocular pressure at the initial presentation were significantly associated with recurrence (p = 0.036 and p = 0.001, respectively).

Conclusions

Long-term use of topical 2% ganciclovir solution is effective, safe, and applicable when commercialized ganciclovir gel is not available.

Risk of dialysis in patients receiving intravitreal anti-vascular endothelial growth factor treatment: a population-based cohort study

We utilized the Longitudinal Health Insurance Database which was stemmed from the Taiwan's National Health Insurance Research Database to conduct a retrospective cohort study investigating the risk of becoming dialysis dependent after receiving intravitreal anti-vascular endothelial growth factor (VEGF) agents for retinal diseases. Patients newly receiving intravitreal ranibizumab or aflibercept from 2000 to 2017 for age-related macular degeneration, polypoidal choroidal vasculopathy, diabetic macular edema, retinal vein occlusions, or myopic choroid neovascularization were included as the study group, and patients with same retinal diseases but did not receive intravitreal anti-VEGFs served as controls extracted by age- and sex-matched (1:4) and further propensity score matching (PSM). Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the risk of dialysis. A cohort of 2447 anti-VEGF users and 2447 controls by PSM were evaluated. Higher dialysis risks were observed among patients newly receiving anti-VEGF agents compared to controls (adjusted HR: 1.849; 95% CI: 1.378–2.482) in the PSM cohort. For subgroup analysis, patients newly receiving anti-VEGF treatment for diabetic macular edema had significant risk (adjusted HR: 1.834; 95% CI: 1.448–2.324) of becoming dialysis-dependent, while patients in other subgroups demonstrated similar risks as the controls. In conclusion, intravitreal anti-VEGF agents might increase the risk of becoming dialysis-dependent, especially in patients who are treated for diabetic macular edema.

Purification and biofabrication of 5-aminolevulinic acid for photodynamic therapy against pathogens and cancer cells

5-Aminolevulinic acid (5-ALA) is a non-proteinogenic amino acid which has involved in heme metabolism of organisms, and has been widely applied in agriculture, and medical fields nowadays. 5-ALA is used in the elimination of pathogens or cancer cells by photodynamic therapy (PDT) owing to the photosensitizer reaction which releases the reactive oxygen species (ROS). Currently, biofabrication of 5-ALA is regarded as the most efficient and eco-friendly approach, but the complicated ingredient of medium causes the nuisance process of purification, resulting in low recovery and high producing cost. In this study, hydrogen chloride, sodium acetate, and ammonia were examined to maximize the recovery of 5-ALA from ion-exchange chromatography (IEC), thus a 92% recovery in 1 M ammonia at pH 9.5 was obtained. Afterward, the activated carbon was used for decolorization to further remove the pigments from the eluent. Four organic solvents, i.e., diethyl ether, methanol, ethanol, and acetone were compared to extract and form 5-ALA precipitation. The purified 5-ALA was verified to eliminate 74% of A549 human lung cancer and 83% of A375 melanoma skin cancer cell. Moreover, Proteus hauseri, Aeromonas hydrophila, Bacillus cereus, and Staphylococcus aureus were killed via anti-microbial PDT with 1% 5-ALA and reached 100% killing rate at optimal condition. With the addition of 0.05% 5-ALA during the culture, the growth of microalgae Chlorella sorokiniana was improved to against a common aquatic pathogen, A. hydrophila. The broad application of 5-ALA was demonstrated in this study for the first time.

Immediate Ocular Changes After Light-Emitting Diode Displays Exposure-A Preliminary Study

Purpose

Computer vision syndrome (CVS) is one of the most frequently encountered problems among video display terminals (VDT) users, but little is known regarding the short-term effect after exposure to light-emitting diodes (LED). The purpose of this study was to determine if short-term exposure to LED leads to changes in corrected distance visual acuity (CDVA), lipid layer thickness (LLT), blink rates, partial blink ratio, and computer vision syndrome questionnaire (CVS-Q) score.

Design

Prospective, cross-sectional study.

Methods

In this study, participants were recruited at the National Cheng-Kung University Hospital, a tertiary referral center in southern Taiwan, for examination. Participants were asked to complete the CVS-Q and undergo a series of ocular examinations, including CDVA, LLT, blink rates and partial blink ratio before and after watching an LED display for 15 min. Main Outcome Measures were changes in CDVA, LLT, blink rates, partial blink ratio, and CVS-Q measurements.

Results

In total, 120 eyes from 60 participants (mean age: 35.7 ± 9.4 years) were included; 31 participants were men (51.7%), and 29 were women (48.3%). The CDVA, LLT, blink rates, and partial blink ratio did not change after watching the LED display. The CVS-Q score significantly improved after short-term LED exposure (P < 0.001). A subgroup analysis of subjects with a baseline LLT of <60 nm or ≥60 nm determined that LLT significantly decreased in individuals with a baseline LLT of ≥60 nm (P = 0.016).

Conclusion

Short-term use of LED displays reduced LLT in individuals with a baseline LLT of ≥60 nm, despite the visual symptoms of CVS improved subjectively. Therefore, digital device users should be aware of the potential negative effects of LED exposure on the eyes.

Association between Sodium Glucose Co-transporter 2 Inhibitors and Incident Glaucoma in Patients with Type 2 Diabetes: A Multi-institutional Cohort Study in Taiwan

PURPOSE

Type 2 diabetes (T2D) is an important risk factor for glaucoma, and sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to protect the optic nerves. We therefore aimed to evaluate the association between SGLT2 inhibitors and incident glaucoma.

METHODS

This retrospective cohort study analyzed the largest multi-institutional electronic medical records database in Taiwan, containing data of over a million individuals. We included T2D patients newly prescribed SGLT2 inhibitors or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) from 2016 to 2018. Our primary outcome was incident glaucoma diagnosis between initiation of SGLT2 inhibitors or GLP-1 RAs, and 31st March 2021. After applying inverse probability of treatment weighting (IPTW) to increase homogeneity between the two treatment groups, we estimated hazard ratios (HR) with 95% confidence intervals (CI) for the risk of glaucoma, based on Cox proportional hazards regression models.

RESULTS

We included 9,927 and 1,065 T2D patients who had been newly prescribed SGLT2 inhibitors or GLP-1 RAs, respectively. Lower risk of incident glaucoma was observed in patients receiving SGLT2 inhibitors (7.9 events per 1,000 person-years), compared to those receiving GLP-1 RAs (10.0 events per 1,000 person-years), with an HR of 0.81 (95% CI: 0.69-0.95). Multiple sensitivity analyses and a negative control outcome analysis confirmed the robustness of our main findings.

CONCLUSION

This study suggests that T2D patients newly prescribed SGLT2 inhibitors have a reduced risk of incident glaucoma, compared to those prescribed GLP-1 RAs, in clinical practice. Future prospective studies are suggested to confirm this association.

Risk of diabetic macular oedema with sodium-glucose cotransporter-2 inhibitors in type 2 diabetes patients: A multi-institutional cohort study in Taiwan

AIMS

To investigate the risk of diabetic macular oedema (DMO) associated with the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors in patients with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

We conducted a retrospective cohort study by analysing a large multi-institutional electronic medical records database in Taiwan. We included adult patients with T2DM without DMO newly receiving either SGLT2 inhibitors or glucagon-like peptide-1 receptor agonists (GLP-1RAs) during the period 2016 to 2018. We used propensity scores with inverse probability of treatment weighting to generate comparable groups. The study outcome was incident DMO, determined by clinical diagnosis during outpatient visits or admissions. We followed patients from the index date to either DMO occurrence, last clinical visit, patient death, or December 31, 2020. We performed Cox proportional hazards regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk of DMO.

RESULTS

We included 9986 new users of SGLT2 inhibitors (mean [SD] age 59.6 (12.1) years, median [interquartile range {IQR}] glycated haemoglobin [HbA1c] 70 (61-81)mmol/mol, estimated glomerular filtration rate [eGFR] 89.1 [71.4-108.7] mL/min/1.73 m² and urine albumin-creatinine ratio [UACR] 26.1 [9.7-117.6] mg/g) and 1067 new users of GLP-1RAs (mean [SD] age 58.4 (41.5) years, median [IQR] HbA1c 73 [64-84] mmol/mol, eGFR 91.6 [68.6-114.0] mL/min/1.73 m² and UACR 37.6 [11.1-153.2] mg/g) with similar baseline characteristics. Lower DMO risks were observed among patients newly receiving SGLT2 inhibitors (7.9/1000 person-years), compared to those receiving GLP-1RAs (10.7/1000 person-years) with an HR of 0.75 (95% CI 0.64-0.88).

CONCLUSIONS

Our findings suggest use of SGLT2 inhibitors was associated with lower risk of DMO in T2DM patients in clinical practice, compared to use of GLP-1RAs. Future studies are necessary to confirm this observation.

A Novel Pathogenic HSPG2 Mutation in Schwartz-Jampel Syndrome

Schwartz–Jampel syndrome is a rare autosomal recessive disease caused by mutation in the heparan sulfate proteoglycan 2 (HSPG2) gene. Its cardinal symptoms are skeletal dysplasia and neuromuscular hyperactivity. Herein, we identified a new pathogenic mutation site (NM_005529.6:c.1125C>G; p.Cys375Trp) of HSPG2 leading to Schwartz–Jampel syndrome by whole-exome sequencing. This mutation carried by the asymptomatic parents was previously registered in a single-nucleotide polymorphism database of the National Institutes of Health as a coding sequence variant rs543805444. The pathogenic nature of this missense mutation was demonstrated by in silico pathogenicity assessment, clinical presentations, and cellular function of primary fibroblast derived from patients. Various in silico software applications predicted the mutation to be pathogenic [Sorting Intolerant From Tolerant (SIFT), 0; Polyphen-2, 1; CADD (Combined Annotation Dependent Depletion), 23.7; MutationTaster, 1; DANN (deleterious annotation of genetic variants using neural networks); 0.9]. Needle electromyography revealed extensive complex repetitive discharges and multiple polyphasic motor unit action potentials in axial and limb muscles at rest. Short exercise test for myotonia showed Fournier pattern I. At cellular levels, mutant primary fibroblasts had reduced levels of secreted perlecan and impaired migration ability but normal capability of proliferation. Patients with this mutation showed more neuromuscular instability and relatively mild skeletal abnormality comparing with previously reported cases.

Unilateral Vision Loss After Hyaluronic Acid Injection: A Case Report

ABSTRACT

Vascular occlusion causing vision loss is a rare yet one of the most devastating complications of facial esthetic fillers. In this article, we present a case of unilateral blindness and superficial skin necrosis in a 31-year-old woman after the injection of hyaluronic acid for esthetic purposes. The delicate ocular fundal findings of ophthalmic artery occlusion were demonstrated by ophthalmoscopy, optical coherence tomography, and fluorescein angiography. Magnetic resonance imaging also showed subsequent ischemic changes in the optic nerve and posterior scleral wall after ophthalmic artery occlusion. Despite management including intraocular pressure-lowering agents, globe massage, and anticoagulation with acetylsalicylic acid and hyperbaric oxygen therapy, her final vision was not restored. Given the lack of effective treatments, this report depicts the comprehensive ocular fundal findings of an ophthalmic artery occlusion after esthetic hyaluronic acid filler injection, and highlights the importance of a preventive approach to avoid such catastrophic complications.

Trend of Neovascular Glaucoma in Taiwan: A 15-year Nationwide Population-based Cohort Study

PURPOSE

To determine the trends in epidemiological data in patients with neovascular glaucoma (NVG) in Taiwan.

METHODS

The data were obtained from the 2016 version of the Longitudinal Health Insurance Database, which contains data on two million randomly sampled patients. Patients with NVG diagnostic codes were enrolled in this study, after which we separated the study population according to different time periods. The demographic data, systemic and ocular comorbidities and treatments that were applied to manage NVG were collected from the database.

RESULTS

The overall age-standardized prevalence was 52.48 per 100,000 individuals, and the age-standardized incidence was 4.33 per 100,000 person-years in patients with NVG. In general, men had a higher prevalence and incidence, and the incidence was observed to fluctuate. The patients with the highest educational levels accounted for less than 5% of the NVG patients, and the patients with the highest income levels accounted for less than 15% of the NVG patients. Systemic comorbidities in NVG patients, especially metabolic syndrome, were observed to increase. The percentage of the patients receiving anti-vascular endothelial growth factor treatments increased by more than two-fold after 2008, whereas reductions in trabeculectomy and cyclodestruction procedures were observed.

CONCLUSION

The prevalence of NVG was observed to increase in men, and the incidence fluctuated during the study period. Furthermore, the systemic comorbidities, and the use of anti-vascular endothelial growth factor treatment increased; the latter may be associated with a decrease in the use of incisional glaucoma surgery for NVG in recent years.

Microsporidial stromal keratitis: characterisation of clinical features, ultrastructural study by electron microscopy and efficacy of different surgical modalities

AIMS

To report the clinical manifestations, ultrastructure and evaluate the efficacy of therapeutic lamellar keratectomy (TLK) and penetrating keratoplasty (PK) for microsporidial stromal keratitis (MSK).

METHODS

Fourteen MSK cases between 2009 and 2018 were recruited. Each patient's clinical presentation, light microscopy, histopathology, PCR and electron microscopy (EM) of corneal samples were reviewed.

RESULTS

The patients were 70.0±4.7 years old (average follow-up, 4.5 years). Time from symptoms to presentation was 10.6±13.0 weeks. The corneal manifestations were highly variable. Corneal scrapings revealed Gram stain positivity in 12 cases (85.7%) and modified Ziehl-Neelsen stain positivity in 9 (64.3%). Histopathology revealed spores in all specimens, while sequencing of small subunit rRNA-based PCR products identified Vittaforma corneae in 82% of patients. EM demonstrated various forms of microsporidial sporoplasm in corneal keratocytes. All patients were treated with topical antimicrobial agents or combined with oral antiparasitic medications for >3 weeks. As all patients were refractory to medical therapy, they ultimately underwent surgical intervention (TLK in 7, PK in 6 and 1 received TLK first, followed by PK). Postoperatively, the infection was resolved in 78.6% of the patients. Nevertheless, a high recurrence rate (21.4%) was noted during 3-year follow-up, with only two patients retained a final visual acuity ≥20/100.

CONCLUSION

MSK usually presents with a non-specific corneal infiltration refractory to antimicrobial therapy. The diagnosis relies on light microscopic examinations on corneal scrapings and histopathological analyses. Surgical intervention is warranted by limiting the infection; however, it was associated with an overall poor outcome.

Tailored internal limiting membrane flap technique for primary macular hole

PURPOSE

To investigate the outcomes of primary full-thickness macular hole (MH) after surgical intervention with tailored internal limiting membrane (ILM) flap technique.

METHODS

Patients were reviewed for their clinical characteristics and surgical outcomes. The technique included incomplete circular peeling of the perifoveal ILM which was then trimmed according to the size of the MH. Fluid-gas exchange was done without further manipulation.

RESULTS

Nineteen eyes of 19 patients were included. The patients were in average 61 years old (range 41-83) and had an average follow-up period of 11.0 months. At baseline visit, minimal linear diameter of the MH was 311.6 μm (range 80-768). After a single surgery, the MH closed in all cases with improvement of mean visual acuity (from 0.9 to 0.4 logarithm of the minimum angle of resolution units, p < 0.0001, Wilcoxon signed-rank test). At the final visit, 15 (78.9%) eyes achieved a visual acuity ≥ 20/40. Outer retinal gliosis was found to be associated with less favorable postoperative visual acuity. Factors related to the formation of outer retinal gliosis were worse preoperative visual acuity and a large MH with a diameter > 400 μm.

CONCLUSION

Tailored ILM flap technique is an effective method for favorable anatomical and visual outcomes for treatment of primary MH.

Scleritis and anterior uveitis may herald the development of an epibulbar tumor in patients with extranodal Rosai-Dorfman disease: a case report

Background

Rosai-Dorfman disease is a rare non–Langerhans cell histiocytosis. Ocular involvement is even rarer, mostly involving the orbit and eyelids, although marginal corneal ulcers, uveitis, and epibulbar masses have also been reported, and is characterized by multiple recurrences. However, the disease course and optimal treatment strategies remain undetermined, in light of the rarity of this disease.

Case presentation

We reported a 36-year-old male patient with the extranodal form of Rosai-Dorfman disease, presenting with scleritis and anterior uveitis in the left eye, who experienced subsequent development of an epibulbar tumor in the same eye. The patient was also complicated by a relapsing facial nodule on the right cheek. After the pathological diagnosis of Rosai-Dorfman disease was obtained, the patient underwent surgical excision of the epibulbar tumor and the facial nodule, accompanied by systemic immunosuppression therapy. At the last follow-up, the patient was asymptomatic without signs of recurrence.

Conclusions

This report highlights the progression of ocular manifestations of Rosai-Dorfman disease and emphasizes the importance of systemic therapy.

Postoperative Mycobacteroides abscessus subsp. abscessus endophthalmitis: Clinical analysis of 12 clustered adults and a proposed therapeutic algorithm

PURPOSE

Postoperative endophthalmitis caused by nontuberculous mycobacterium is a rare but devastating complication after intraocular surgery. However, optimal treatment strategies remain undetermined in view of its rarity.

METHODS

We investigated the cases of culture-proven postoperative Mycobacteroides abscessus subsp. abscessus endophthalmitis in southern Taiwan, focusing on clinical manifestations and microbiological study, and aimed to describe clinical staging and to propose a therapeutic modality for this disease.

RESULTS

Twelve cases, including two published cases, were treated in two medical centers in southern Taiwan between Aug. 2011 and Dec. 2016, and all ever received cataract surgery at one clinic. Their disease courses could be categorized into four distinct stages, i.e., the initial, quiescent, recurrent, and end stage, and some cases experienced 1-4 cycles of quiescent-recurrent stages. Although all eyes ended up with phthisis or were eviscerated, the affected eyes receiving pars plana vitrectomy (PPV) tended to become quiescent and survived longer than those without PPV (adjusted hazard ratio: 13.9, p < 0.05). Eight isolates of eight patients were available for microbiological study. All isolates were susceptible to amikacin, and inducible clarithromycin resistance was observed in 100% of isolates.

CONCLUSION

Despite the preservation of vision in postoperative M.abscessus endophthalmitis remained a challenge, a stage-based approach is proposed, which may facilitate decision-makings for the future study.

Orbital complications of paranasal sinusitis in Taiwan, 1988 through 2015: Acute ophthalmological manifestations, diagnosis, and management

Purpose

Paranasal sinusitis is widespread and can lead to orbital complications, blindness, and death. However, the correlation between ophthalmological findings and disease staging remains unclear. This study aimed to investigate the staging, acute ophthalmological manifestations, diagnosis, management, and outcomes of orbital complications of paranasal sinusitis during a 27-year period.

Methods

We retrospectively reviewed the medical records of all patients with orbital complications of paranasal sinusitis hospitalized at the National Cheng Kung University Hospital, a medical center in Taiwan during 1988–2015. Sex, age, symptoms, history, ophthalmological findings, laboratory and imaging findings, treatments, and outcomes were analyzed by staging.

Results

Eighty-three patients aged 9 days to 80 years had stage I (preseptal cellulitis, n = 39 patients), II (postseptal orbital cellulitis, n = 8), III (subperiosteal abscess, n = 16), IV (orbital abscess, n = 8), or V (intracranial involvement, n = 12) complications. Peak incidences occurred in patients aged 0–19 and 60–69 years. Chronic sinusitis and diabetes mellitus were common preexisting diseases. Extraocular movement limitation and proptosis predicted postseptal (stage II or more) involvement. The likelihood of elevated intraocular pressure increased with stage. Reduced visual acuity and presence of relative afferent pupillary defect indicated consideration of magnetic resonance imaging to investigate possible intracranial extension. Ipsilateral maxillary (81.7%) and ethmoidal (75.6%) sinuses were the most common sources of infection, and the most frequently implicated pathogens were coagulase-negative Staphylococcus spp. (25.3%) and Staphylococcus aureus (20.5%). All patients received intravenous antimicrobial therapy (multi-drug therapy in 88.0%), and 55.4% underwent surgery, most commonly endoscopic sinus surgery. One (1.2%) diabetic man with stage V complications died of fungal sinusitis with intracranial invasion. Five (6.0%) patients, all stage V, lost vision despite intensive treatment. The average length of hospital stay was 13.8 days (range 2–72 days), and significantly longer stays were associated with stages II–V as compared to stage I.

Conclusions

Orbital infection originating from paranasal sinusitis can cause vision loss and death due to intracranial extension. Acute ophthalmological findings predict staging and prognosis. Cooperative consultation between ophthalmologists, otorhinolaryngologists, and neurologists is essential. Urgent diagnostic studies and aggressive antimicrobial therapy are indicated, and surgery should be considered.

Motorized injector-assisted intrascleral intraocular lens fixation

For eyes with deficient capsular support, intraocular lens (IOL) implantation has long been a technical challenge. Recently, intrascleral fixation of the haptics of a three-piece posterior chamber IOL has become a popular option. In this procedure, externalization of the leading haptic during IOL injection is a stressful step. We present a modified technique to improve the ease and safety of this step. Our modified technique involves IOL injection with a motorized injector with several important modifications described here. With these modifications, a surgeon can easily maintain the correct orientation of the IOL in a well-controlled manner during IOL injection. The records of 13 patients who underwent this technique were retrospectively evaluated. Corrected-distance visual acuity improved significantly after surgery (p<0.05). No postoperative retinal detachment, endophthalmitis, IOL decentration, or vitreous hemorrhage was noted during the follow-up period. In conclusion, the motorized injector-assisted intrascleral IOL fixation technique is a safe and effective alternative to the conventional procedure. This technique makes the process of leading haptic externalization easier and more controllable.

Discovery of HLA-B*58:80, a novel HLA-B*58 variant, in a Taiwanese bone marrow donor

One nucleotide substitution at residue 133 of HLA-B*58:01:01:01 results in a novel allele, HLA-B*58:80.

Discovery of a novel HLA-DRB1*09 variant, HLA-DRB1*09:28, in a Taiwanese individual

One nucleotide substitution at residue 332 of HLA-DRB1*09:01:02 results in a novel allele, HLA-DRB1*09:28.

A novel HLA-B*38 variant, B*38:15, detected in a Taiwanese individual

One nucleotide substitution at residue 346 of HLA-B*38:02:01 results in a novel allele, HLA-B*38:15.

Recognition of a novel HLA-A*11 variant, HLA-A*11:196, in a Taiwanese unrelated bone marrow stem cell donor

One nucleotide substitution at residue 484 of HLA-A*11:01:01:01 results in a novel allele, HLA-A*11:196.

HLA-A*11:235Q, a novel HLA-A*11 variant, detected in a Taiwanese individual

Nucleotide deletions from residue 120 to 125 of HLA-A*11:01:01:01 result in a novel allele, HLA-A*11:235Q.

HLA-A*33:03:31, a novel variant of HLA-A*33:03, discovered in a Taiwanese individual

One nucleotide substitution of HLA-A*33:03:01 results in a novel allele, HLA-A*33:03:31.

Detection of a novel HLA-C*07:341 variant, HLA-C*07:341:02, in a Taiwanese hematopoietic stem cell donor

Two nucleotide replacements in codon 138 of the HLA-C*07:341:01 result in a novel allele, HLA-C*07:341:02.

HLA-A*24:333, a novel HLA-A*24 variant, discovered in a Taiwanese individual

Four nucleotide replacements of HLA-A*24:02:01:01 result in a novel allele, HLA-A*24:333.

HLA-B*46:65, a novel HLA-B*46 variant, detected in a Taiwanese unrelated bone marrow stem cell donor

One nucleotide exchange at residue 550 of the HLA-B*46:65 results in a novel allele, HLA-B*46:65.

HLA-C*07:486, a novel HLA-C*07 variant, detected in a Taiwanese individual

One nucleotide exchange at residue 812 of the HLA-C*07:02:01:01 results in a novel allele, HLA-C*07:486.