We report the case of a 4-year-old boy diagnosed with keratitis-ichthyosis-deafness (KID) syndrome with long-term follow-up, including multiple surgical and nonsurgical treatments. Genetic testing revealed a missense GJB2 mutation (p.Asp50Asn). His ocular condition deteriorated to the point that, at 37 years of age, he required bilateral keratoprosthesis (KPro) implantation, resulting in best-corrected visual acuity of 20/25 in the right eye and 20/40 in the left eye. Our findings suggest that more advanced cases of KID syndrome may benefit from treatment options that rely less on ocular surface stability, such as KPro implantation, whereas therapies that treat the ocular surface may be preferred in early-stage disease.
Purpose:To characterize the epidemiology of pickleball-related eye injuries in the United States. Methods:Data from the National Electronic Injury Surveillance System were analyzed for individuals treated in US emergency departments (ED) for pickleball-related eye injuries from 2010 through 2023. Results:Based on a sample of 117 actual cases, there were an estimated 6,015 individuals treated in US emergency departments for pickleball-related eye injury. From 2022 to 2023, the rate of injuries increased by 37.3%. The mean age of individuals was 59.9 years. Approximately 54.7% of individuals were male. The most common mechanisms of injury were fall with facial trauma (n = 71 [60.7%]), direct impact from a pickleball paddle (n = 18 [15.4%]), and direct impact from a pickleball (n = 12 [10.3%]). The most frequently associated primary diagnoses were laceration (n = 45 [38.5%]), contusions or abrasions (n = 27 [23.1%]), blunt trauma (n = 17 [14.5), and fractures (n = 14 [12.0%]). The top two specific ocular surface or intraocular diagnoses were abrasions and iritis. Most individuals (n = 115 [98.3%]) were treated and released or examined and released without treatment. Conclusion:Based on our analysis of a national database, the frequency of pickleball-related eye injuries treated in US EDs has increased, although most ocular injuries are clinically minor.
A 5-year-old girl, previously in complete remission from common B-cell acute lymphoblastic leukemia (B-ALL), presented at the University Hospital of Leuven with a unilateral, painless red left eye. Over several weeks, the clinical picture evolved from common conjunctivitis into a painful red eye with iris heterochromia and increased iris vascularization unresponsive to topical and oral antibiotics. No signs of leukemic relapse were detected on comprehensive systemic work-up, including bone marrow and lumbar puncture. Aqueous sampling at this time could not confirm the clinical suspicion of isolated ocular relapse of ALL. Oral prednisolone was initiated, with good clinical response. After discontinuation of steroids, the affected eye developed a hypopyon-like mass in the anterior chamber. Urgent anterior chamber washout was performed. Cytology now confirmed the presence of a leukemic infiltrate, indicating an isolated ocular relapse of common B-ALL. Not only because this was the fourth relapse, but primarily because this patient had already undergone extensive prior treatments, including an allogeneic stem cell transplant just 6 months earlier, there were no systemic therapeutic options available. Palliative radiotherapy to the left orbit was therefore initiated. Two months later, the girl presented with similar symptoms in the right eye, which was also treated with radiotherapy.
We report the case of a 75-year-old man with conjunctival squamous cell carcinoma in his anophthalmic socket that had resulted from enucleation at age 5. He had a 6-week history of a palpable, right orbital mass and periocular pain. Examination revealed a right inferolateral orbital mass and keratinization of the inferior fornix. Magnetic resonance imaging revealed an extensive mass in the inferolateral orbit. Biopsy showed squamous cell carcinoma. The patient underwent exenteration with temporalis flap reconstruction followed by adjunctive radiotherapy. A metastasis to the right parotid was excised at 6 months. This case illustrates the potential for extensive orbital invasion and perineural spread by ocular surface squamous neoplasia in an anophthalmic socket despite minimal conjunctival signs.
We report a case of presumed retinal vasculitis and precipitous complete vision loss following a single intravitreal injection of pegcetacoplan. A 76-year-old woman received intravitreal pegcetacoplan in the right eye for geographic atrophy. Visual acuity was 20/50 right eye. Ten days after the injection, she experienced initial signs of subjective vision loss. On day 11, she presented with elevated intraocular pressure and visual acuity of hand motions, worsening to no light perception (NLP) by day 12. Anterior chamber and vitreous fluid taps for Gram stain and culture were negative. On day 22, the patient had diffuse retinal hemorrhages along a retinal vascular distribution. At day 83, visual acuity remained NLP. This patient developed presumed occlusive retinal vasculitis, progressing from visual acuity of 20/50 to NLP within 2 days of initial subjective vision loss and 12 days of a single intravitreal pegcetacoplan injection.
We report the case of a 4-year-old boy diagnosed with keratitis-ichthyosis-deafness (KID) syndrome with long-term follow-up, including multiple surgical and nonsurgical treatments. Genetic testing revealed a missense GJB2 mutation (p.Asp50Asn). His ocular condition deteriorated to the point that, at 37 years of age, he required bilateral keratoprosthesis (KPro) implantation, resulting in best-corrected visual acuity of 20/25 in the right eye and 20/40 in the left eye. Our findings suggest that more advanced cases of KID syndrome may benefit from treatment options that rely less on ocular surface stability, such as KPro implantation, whereas therapies that treat the ocular surface may be preferred in early-stage disease.
A previously healthy 6-year-old white boy presented emergently after trauma to his right eye. On examination, intraocular pressure (IOP) was 49 mm Hg, and visual acuity was 20/50. He was diagnosed with a 3 mm layering hyphema. Despite medical therapy and lifestyle modifications, the patient's IOP continued to rise, peaking at 77 mm Hg on day 3 after presentation. Given his elevated IOP despite the addition of new topical medications on daily follow-up, the patient was screened for sickle-cell disease to assess for an underlying pathology that could be exacerbating his elevated IOP. After testing positive for sickle cell trait, the patient was promptly taken to the operating room for anterior chamber washout. The following day, IOP normalized to 14 mm Hg, and visual acuity was 20/25. Hyphemas generally respond well to medical therapy, but patients with sickle cell hemoglobinopathy are at greater risk for permanent vision loss from pressure spikes. This case reinforces the need to collect thorough past medical and family histories and consider early sickle cell screening in all patients failing to respond to IOP-reducing medication or if hemoglobin status is unknown on initial presentation.
Anti-TNF-α therapies, though known for their anti-inflammatory effects, have been associated with paradoxical inflammatory reactions, of which anterior uveitis is the most common. We report a case of recurrent bilateral cicatricial conjunctivitis linked to systemic adalimumab (ADA) treatment in a 66-year-old man with rheumatoid arthritis (RA). The patient experienced worsening bilateral red eyes, blurry vision, and discomfort following each ADA injection. Examination revealed signs of cicatricial inflammation, which responded to corticosteroids but recurred after subsequent ADA doses. Despite these ocular events, adalimumab was continued due to its effective control of systemic RA, with close ophthalmic monitoring. This case suggests a potential direct association between ADA and cicatricial conjunctivitis, a previously undescribed complication. Aggressive topical corticosteroid treatment may allow the continuation of ADA without compromising systemic disease control.
PurposeThe period 2002-2021 saw an annual growth rate of 51.46% in listings of open access (OA) journals in the Directory of Open Access Journals (DOAJ), with a steeper rate of growth corresponding with the onset of COVID-19. The introduction of OA and hybrid models, which give authors traditional subscription and OA options, may have led to increased article processing charges (APCs). This study aimed to analyze the APCs for ophthalmology journal articles after the COVID pandemic and analyze changes in publication modality and cost. MethodsAPC, frequency of publication, and impact factor (IF) were analyzed for 83 MEDLINE-indexed ophthalmology journals. Data were stratified based on publication modality (OA, hybrid, or traditional), and geodistribution, intermodality, and correlation between APC and IF were compared. ResultsAverage APC for OA, hybrid, and traditional journals was $1,310.49, $3,550.71, and $7.18, respectively (P < 0.001). Univariate analysis demonstrated a statistically significant impact of hybrid mode (P < 0.001), traditional mode (P = 0.046), and IF >1 (P < 0.001). Multivariate analysis demonstrated a statistically significant effect of the modality of publication on journal APC. Intermodality analysis showed significantly higher APC for hybrid journals than OA or traditional journals, without statistically significant differences in frequency of publication or IF. ConclusionsOphthalmology journals are experiencing a subject-wide transition from traditional publication to hybrid modality. Since the COVID pandemic, APCs across all publication modes have increased, and there has been a transition from the traditional publishing model to a more lucrative hybrid model.
Purpose:To evaluate the incidence, clinical course, and treatment outcomes of glaucoma surgery-related infections at a tertiary academic center over a 13-year time period. Methods:Patients presenting at Duke Eye Center between January 1, 2010, and November 11, 2023, who underwent glaucoma surgery, including trabeculectomy, glaucoma drainage device (GDD) placement, GDD revision surgery, trabeculectomy bleb revision surgery, minimally invasive glaucoma surgery (MIGS), Xen gel stent implantation, and cycloablative procedures, were identified using an electronic medical record clinical database search. Diagnosis of blebitis, bleb-associated endophthalmitis, and tube malposition or tube exposure were determined using International Classification of Disease (9th and 10th editions) codes. Results:A total of 12,115 glaucoma surgeries (in 6,684 patients) were identified during the study period. GDD implantation comprised the majority of glaucoma surgeries (33%), followed by trabeculectomy (with and without Ex-PRESS mini glaucoma shunt) (25.7%), GDD revision (8.9%), trabeculectomy bleb revision (8.6%), and transscleral cyclophotocoagulation (5.9%). There were 488 MIGS with and without phacoemulsification (4%) and 76 Xen gel stent surgeries (0.6%). Endophthalmitis was diagnosed in 18 eyes (0.96%) that underwent trabeculectomy, 11 eyes that underwent GDD implantation (0.20%), and 1 eye that underwent Xen stent implantation. Blebitis was diagnosed in 7 eyes: 5 were related to trabeculectomy (0.27%), and 2 were related to GDD placement (0.05%). The incidence of GDD malposition or erosion was 10.2%. No cases of endophthalmitis were diagnosed in patients with MIGS. Conclusions:In our study cohort, infectious complications associated with trabeculectomy and GDD implant surgery were low; there were no cases of endophthalmitis associated with MIGS. The rate of GDD complications due to tube malposition or erosion was 10.2%.
Purpose:To analyze accuracy and readability of answers to cataract surgery queries produced by artificial intelligence (AI) models and determine whether AI models can significantly improve readability. Methods:Google Gemini Advanced, ChatGPT 4.0, and Microsoft Copilot Pro were prompted to answer 25 questions about cataract surgery, followed by a request to re-answer questions at a 6th-grade level. Objective readability of answers were measured with five validated reading formulas and word count. Accuracy and readability of each answer were further graded by three ophthalmologists. Comparisons were performed between original and 6th-grade versions and among the three AI models. Results:After being prompted to answer at a 6th-grade reading level, Google Gemini Advanced and Microsoft Copilot Pro had lower average reading level than ChatGPT 4.0 (8.04 vs 8.19 vs 9.43 [P < 0.001]). Microsoft Copilot answers had higher Flesch reading ease score (75.40 vs 71.24 vs 69.46 [P < 0.007]) and lower word count (130.28 vs 180.24 vs 166.08 [P < 0.001]) among AI models. Microsoft Copilot Pro and ChatGPT 4.0 answers had greater change in reading level (-6.13 vs -5.75 vs -3.31 [P < 0.001]) and Flesch reading ease score (39.67 vs 35.98 vs 23.67 [P < 0.001]) compared with Google Gemini Advanced. Graders determined that there were no changes in accuracy before and after being prompted to answer at a 6th-grade reading level. Conclusions:AI models can simplify reading level of responses to common cataract surgery queries while maintaining accuracy.
Purpose:To examine cataract surgery rates among Medicare beneficiaries alongside Google Trends data to unveil insights into patient engagement and healthcare dynamics before and during the COVID-19 pandemic (2014 to 2020). Methods:Data of Google Trends (GT) relative search volumes (RSV) was collected for 9 total Google search terms related to cataracts or cataract procedures. Univariate linear regression was used to determine the correlation between average annual Google RSV for each search term and the total annual case volumes among US Medicare beneficiaries. Seasonal and pandemic trends were also studied. Results:There were statistically significant positive correlations between search data and the annual case volumes for cataract surgeries among Medicare beneficiaries for 5 of the 9 search terms selected. There was greater search traffic in summer and fall. Annual case volumes remained consistent and increasing from 2019 to 2020 during the pandemic, but search traffic decreased sharply. Conclusions:The stable rate in cataract surgeries among Medicare beneficiaries despite decreased patient engagement during the pandemic represents successful maintenance of health-care continuity. Google Trends is useful in understanding public interest and determining resource allocation and healthcare needs.
We report the case of a 30-year-old woman with diabetes and newly diagnosed moyamoya disease who experienced submacular hemorrhage and acute vision loss. She presented with facial droop and slurred speech, and examination disclosed high-grade stenosis of the intracranial carotid artery. She was scheduled for urgent neurosurgery. The day before surgery, she lost vision in her left eye and was found to have diffuse multilayered hemorrhage with submacular hemorrhage. Pneumatic displacement was performed. Pars plana vitrectomy and drainage of the submacular hemorrhage were performed subsequently, with postoperative improvement in vision.
The XEN Gel Stent is a minimally invasive surgical implant for glaucoma designed to reduce intraocular pressure (IOP) while minimizing hypotony by creating an aqueous outflow pathway into the subconjunctival area. The XEN stent has been shown to reduce IOP effectively, with few adverse events reported; however, complications due to hypotony, such as choroidal detachment, may still occur. We report the case of an 86-year-old woman with primary open-angle glaucoma who underwent XEN stent placement followed by Nd:YAG laser lysis to clear the fibrin-obstructed lumen. Postoperatively, she experienced refractory choroidal detachment, which progressed despite cycloplegic and frequent topical steroid treatment but was successfully managed by a subconjunctival injection of triamcinolone acetonide surrounding the bleb. This is the first reported case of subconjunctival triamcinolone acetonide injection for the management of refractory choroidal detachment after XEN placement.
A 56-year-old woman with pathological myopia and macular neovascularization in the right eye was treated with 20 intravitreal injections of aflibercept following a treat-and-extend protocol, with no significant clinical improvement. A single intravitreal injection of faricimab was administered, after which the patient showed complete resolution of subretinal fluid and reduced neovascular lesions. Her visual acuity improved from 20/200 to 20/80 in the right eye, and she remained stable for 9 months without further signs of neovascular activity. Faricimab, which targets both VEGF-A and Ang-2, may be an effective alternative in myopic neovascular membranes resistant to aflibercept. Larger studies are needed to explore the long-term efficacy of faricimab in treating pathological myopia.
Topical medications are routinely used for the management of ocular hypertension and glaucoma, including prostaglandin analogues, beta blockers, alpha-2 agonists, and carbonic anhydrase inhibitors, and have been associated with various adverse effects. We present a rare case in which a 72-year-old patient developed bilateral periocular hypopigmentation in the setting of long-term use of latanoprost, timolol, and brinzolamide/brimonidine. A well-known side effect of prostaglandin analogues is skin hyperpigmentation, but a few documented cases of a paradoxical hypopigmentation effect have been reported. Timolol and brinzolamide/brimonidibe have not been associated with changes in skin pigmentation in the ophthalmic literature. Our case most likely represents a rare instance of paradoxical skin depigmentation associated with latanoprost use and adds to the limited literature on this clinical entity. Given the routine use of prostaglandin analogues in clinical practice, it is important for clinicians to be aware of this entity and educate patients on this possible, albeit rare, adverse reaction.
A 56-year-old man presented with unilateral subacute visual loss secondary to an exudative serous retinal detachment of the left eye. The clinical course was later complicated by choroidal thickening and uveal effusion. Laboratory investigations revealed acute myeloid leukemia. Systemic chemotherapy was initiated, resulting in regression of the initial ocular findings, while the more typical ocular manifestations associated with leukemia subsequently became apparent. Choroidal infiltration in acute leukemia is rare, particularly as a presenting feature. Retinal abnormalities resolved markedly following successful management of the leukemia, supporting the conclusion that the ocular manifestations were a direct consequence of leukemic infiltration of the choroid.
An asymptomatic 46-year-old woman was incidentally found on routine examination to have bilateral creamy white tortuous retinal vessels with preserved visual acuity. Multimodal imaging, including optical coherence tomography, optical coherence tomography–angiography, and fluorescein angiography, demonstrated hyperreflective dilated retinal vessels with normal retinal perfusion and no evidence of ischemia. In the setting of markedly elevated triglyceride levels and recurrent pancreatitis, the characteristic retinal vascular appearance supported a diagnosis of lipemia retinalis in the context of chylomicronemia syndrome. No ocular treatment was required and management focused on systemic metabolic control through dietary modification, lifestyle changes, and lipid-lowering therapy, resulting in resolution of the anomalous retinal vasculature. This case illustrates lipemia retinalis as a retinal manifestation within the broader spectrum of chylomicronemia syndrome and underscores the importance of recognizing these characteristic vascular findings as a marker of significant systemic lipid dysregulation requiring ongoing multidisciplinary management.
PurposeTo identify mathematically the baseline physiological predictors of the intraocular pressure (IOP)-lowering effectiveness of topical carbonic anhydrase inhibitors (CAIs). Materials and MethodsAssuming a steady state of aqueous humor flow, mathematical equations describing IOP were formulated by incorporating related physiological variables. Global sensitivity analysis was then performed, in which all variables were varied simultaneously across their clinically reported ranges. This computational approach quantified the percentage reduction in IOP achieved by CAIs and identified the key determinants underlying variability in their effectiveness. ResultsA reduction in the solute influx via active transport by the ciliary epithelium, mediated by CAIs, was positively associated with the magnitude of IOP reduction. Among the physiological parameters in this model—trabecular outflow facility, uveoscleral outflow fraction, episcleral venous pressure, mean arterial pressure, plasma protein concentration, albumin/globulin ratio, and plasma osmolarity—a higher baseline trabecular outflow facility was the strongest predictor of reduced effectiveness of CAIs, in terms of the percentage of IOP reduction. Other baseline physiological parameters had no significant effect on the effectiveness of CAIs. ConclusionsCertain patient characteristics may be associated with compromised effectiveness of CAIs in terms of percentage IOP reduction. These characteristics, potentially associated with higher trabecular outflow facility, may include a lower baseline IOP or prior use of other trabecular outflow-enhancing medications before CAI initiation. Further studies are required to validate the clinical significance of these findings.
