Infective endophthalmitis is an uncommon complication following intraocular surgery. Chronic endophthalmitis may present some time after intraocular surgery, making the diagnosis challenging. Cutibacterium acnes is a well-recognised causative agent of these chronic infections. Practitioners should be aware of the conditions required to culture this slow-growing organism. We report a case of delayed low-grade endophthalmitis presenting 11 years after cataract surgery. Cutibacterium acnes and Staphylococcus warneri were cultured from Descemet's membrane biopsy following three failed previous attempts at microbiological studies. Clinical features of the infection included discrete white granules on the iris, endothelium, and within the capsular bag of the patient's right eye. The patient presented with no signs of systemic infection and the left eye was normal on examination. Bullous keratopathy, secondary to endothelial dysfunction was a feature of this infection. This retrospective case report illustrates the prolonged periods for which Cutibacterium acnes can remain latent before causing clinical signs. While uncommon, endothelial involvement may occur and clinicians should consider low-grade infective endophthalmitis in cases with corneal oedema.

Purpose/Objectives: to evaluate new onset uveitis or reactivated uveitis by biologic agents and characterize their features. Materials and Methods: This is a multicenter, retrospective case series. Patients under biologic therapy were included if they developed uveitis for the first time or experienced intraocular inflammation which was different in location or laterality to previous inflammation. Results: Sixteen patients were identified. The underlying disorders included ankylosing spondylitis, juvenile idiopathic arthritis, rheumatoid arthritis, and Behcet's Disease. The biologic agents associated with a first episode of uveitis (n = 11) or with a new recurrence of uveitis (n = 5) were etanercept, adalimumab, abatacept, infliximab, and golimumab. Sarcoidosis based on bihilar lymphadenopathy, other computer tomography-findings, or biopsy was diagnosed in five patients under therapy with etanercep, adalimumab, and abatacept. Additionally, seven patients developed clinical changes in their uveitis pattern, suggesting sarcoid uveitis. Conclusions: Biologic treatment-induced uveitis often presents as granulomatous disease.

Purpose: To evaluate the comparative effectiveness of 3 regional corticosteroid injections for uveitic macular edema (ME): periocular triamcinolone acetonide (PTA), intravitreal triamcinolone acetonide (ITA), and the intravitreal dexamethasone implant (IDI). Design: Multicenter, randomized clinical trial. Participants: Patients with uveitic ME. Methods: Patients were randomized 1:1:1 to receive 1 of the 3 therapies. Patients with bilateral ME were assigned the same treatment for both eyes. Main Outcome Measures: The primary outcome was the proportion of baseline (PropBL) central subfield thickness (CST) at 8 weeks (CST at 8 weeks/CST at baseline) assessed with OCT by masked readers. Secondary outcomes included >= 20% improvement and resolution of ME, best-corrected visual acuity (BCVA), and intraocular pressure (IOP) events over 24 weeks. Results: All treatment groups demonstrated improved CST during follow-up. At 8 weeks, each group had clinically meaningful reductions in CST relative to baseline (PropBL: 0.77, 0.61, and 0.54, respectively, which translates to reductions of 23%, 39%, and 46% for PTA, ITA, and IDI, respectively). Intravitreal triamcinolone acetonide (PropBL ITA/PropBL PTA, hazard ratio [HR], 0.79; 99.87% confidence interval [CI], 0.65-0.96) and IDI (PropBL IDI/PropBL PTA, HR, 0.69; 99.87% CI, 0.56-0.86) had larger reductions in CST than PTA (P < 0.0001). Intravitreal dexamethasone implant was noninferior to ITA at 8 weeks (PropBL IDI/PropBL ITA, HR, 0.88; 99.87% CI, 0.71-1.08). Both ITA and IDI treatments also were superior to PTA treatment in improving and resolving uveitic ME. All treatment groups demonstrated BCVA improvement throughout follow-up. Both ITA and IDI groups had improvements in BCVA that was 5 letters greater than in the PTA group at 8 weeks (P < 0.004). The risk of having IOP >= 24 mmHg was higher in the intravitreal treatment groups compared with the periocular group (HR, 1.83; 95% CI, 0.91-3.65 and HR, 2.52; 95% CI, 1.29-4.91 for ITA and IDI, respectively); however, there was no significant difference between the 2 intravitreal treatment groups. Conclusions: Intravitreal triamcinolone acetonide and the IDI were superior to PTA for treating uveitic ME with modest increases in the risk of IOP elevation. This risk did not differ significantly between intravitreal treatments. (C) 2018 by the American Academy of Ophthalmology

Purpose We hypothesize that: (1) Anterior chamber depth (ACD) is correlated with the relative anteroposterior position of the pupillary image, as viewed from the temporal side. (2) Such a correlation may be used as a simple quantitative tool for estimation of ACD. Methods Two hundred sixty-six phakic eyes had lateral digital photographs taken from the temporal side, perpendicular to the visual axis, and underwent optical biometry (Nidek AL scanner). The relative anteroposterior position of the pupillary image was expressed using the ratio between: (1) lateral photographic temporal limbus to pupil distance (“E”) and (2) lateral photographic temporal limbus to cornea distance (“Z”). In the first chronological half of patients (Correlation Series), E:Z ratio (EZR) was correlated with optical biometric ACD. The correlation equation was then used to predict ACD in the second half of patients (Prediction Series) and compared to their biometric ACD for agreement analysis. Results A strong linear correlation was found between EZR and ACD, R = −0.91, R2 = 0.81. Bland-Altman analysis showed good agreement between predicted ACD using this method and the optical biometric ACD. The mean error was −0.013 mm (range −0.377 to 0.336 mm), standard deviation 0.166 mm. The 95% limits of agreement were ±0.33 mm. Conclusions Lateral digital photography and EZR calculation is a novel method to quantitatively estimate ACD, requiring minimal equipment and training. Translational Relevance EZ ratio may be employed in screening for angle closure glaucoma. It may also be helpful in outpatient medical clinic settings, where doctors need to judge the safety of topical or systemic pupil-dilating medications versus their risk of triggering acute angle closure glaucoma. Similarly, non ophthalmologists may use it to estimate the likelihood of acute angle closure glaucoma in emergency presentations.

Purpose: To present the largest series reported so far of brimonidine induced granulomatous anterior uveitis. Methods: Retrospective chart review of patients with chronic glaucoma on treatment with brimonidine presenting with anterior uveitis. Results: 19 eyes of 12 patients with chronic glaucoma developed anterior uveitis with granulomatous keratic precipitates after being treated with brimonidine for periods of 7 days to 5 years (mean 19.7 months, +18.6 months). One patient had a gap of 1 year between onset in one eye and onset in the other. Ten eyes (52.6%) had concurrent granulomatous conjunctivitis; 16 eyes were pseudophakic. Stopping brimonidine led to complete, rapid resolution of uveitis in all patients, in most cases (11 eyes, 58%) without topical corticosteroids. No recurrences have occurred after withdrawal of brimonidine, over a follow-up period of 12-52 months (mean 27.9 months, +13.8 months). Conclusions: Ophthalmologists should be aware of this easily reversible uveitis syndrome that is induced by a common glaucoma medication. Familiarity with this entity is essential in making the correct diagnosis and avoiding unnecessary investigations and interventions.

BACKGROUND:Non-penetrating ocular injuries from badminton shuttlecocks can result in severe damage and life-long complications. This case series highlights the morbidity of such injuries, particularly in regard to post-traumatic glaucoma.METHODS:This is a retrospective case series of 12 patients with shuttlecock-related blunt eye injuries sustained during badminton play without eye protection. By approaching colleagues through conference presentations and networking, the authors have attempted to gather all known cases of shuttlecock ocular injury managed in tertiary ocular emergency departments or private ophthalmological clinics in Victoria and New South Wales, Australia in 2015.RESULTS:This is the first multicentre case series to describe badminton-related ocular injuries in Australia. Our case series demonstrates, in particular, long-term glaucoma-related morbidity for patients over a large age range (16 to 77 years), with one patient requiring ongoing management 26 years following their initial injury. The cases reported further add to the literature promoting awareness of badminton-related ocular injury.CONCLUSIONS:We encourage player education and advocacy on badminton-related eye injuries and appropriate use of eye protection to reduce associated morbidity.

We present the case of an 88-year-old female living in metropolitan Melbourne, Australia who developed vitamin A deficiency manifesting as 'itchy eyes' due to a bizarre dietary habit. Slit lamp examination revealed Bitot's spots and a subsequent vitamin A serum level test revealed severe deficiency. An electroretinogram showed grossly reduced a- and b-wave amplitudes consistent with generalised rod and cone dysfunction - these parameters showed marked improvement 5 months post supplementation. This case highlights the presence of vitamin A deficiency in the developed world and that a careful dietary history should be taken when assessing a patient complaining of 'itchy eyes'. Timely diagnosis and treatment may result in dramatic resolution of symptoms and signs as well as prevention of serious morbidity.

Posing a question can introduce a powerful bias into the diagnostic process. A clinical case is presented to demonstrate how a colleague’s diagnostic question can focus the clinicians’ attention on one detail, distracting and blinding them even to the most obvious and important clinical findings. This “inattentional blindness” is similar to the phenomenon demonstrated by Simons in the famous “invisible gorilla” psychological experiment. As much as practical, clinicians should attempt to assess referred patients independently before considering previous clinical information; including the question/s they were asked.

Background Poor authenticity in high stake clinical exams adversely effects validity. We propose including known misleading diagnostic factors and contextual biases in the assessment of diagnostic skills amongst advanced specialty trainees. We hypothesise that this strategy offers a more realistic and critical assessment of diagnostic skill than strategies in which candidates are presented with directive, bias free information, allowing for assumptions which cannot be made in real life. Methods Eleven patient based practice clinical exam stations were presented to nine advanced ophthalmology trainees. Four patients had a history of misdiagnosis or near misdiagnosis of key ophthalmic findings, presumed to result from identifiable biases and misleading information. In those four stations, candidates were presented with authentic, file based information and were asked authentic questions, similar to those with which the patients presented. If the candidates were unsuccessful in identifying key findings, the questions were converted into directive questions about the same key findings (i.e. “examine the patient’s eyelids, what is your diagnosis?”), and the candidates re-assessed the patient and re-answered. Results Ninety-eight doctor-patient encounters took place. Of those, 35 encounters were analysed for the purpose of this study. In 63% of those encounters, key findings were missed when the question included authentic biases or misleading background information, but rephrasing the question to a directive exam format led to their correct identification (Fail converted to pass). Key findings were detected despite contextual biases or misleading background information in only 23% of encounters. In 14% the findings were missed with either question phrasing. Conclusions Presentation authentic questions provide a more realistic and less forgiving measure of diagnostic skills than directive exam questions. Given the prevalence of diagnostic errors and their importance to patient outcomes, known mechanisms contributing to diagnostic errors should be used as one of the assessment tools of advanced speciality trainees.

Clinical & Experimental OphthalmologyVolume 41, Issue 2 p. 216-216 Letter to the Editor Use of optical coherence tomography for preoperative screening of patients undergoing cataract surgery: response Katarina Creese FEBO, Katarina Creese FEBO Department of Ophthalmology, The Royal Victorian Eye and Ear Hospital, The University of Melbourne, East Melbourne, Victoria, AustraliaSearch for more papers by this authorDaini Ong MBBS, Daini Ong MBBS Department of Ophthalmology, The Royal Victorian Eye and Ear Hospital, The University of Melbourne, East Melbourne, Victoria, AustraliaSearch for more papers by this authorEhud Zamir FRANZCO, Ehud Zamir FRANZCO Department of Ophthalmology, The Royal Victorian Eye and Ear Hospital, The University of Melbourne, East Melbourne, Victoria, AustraliaSearch for more papers by this author Katarina Creese FEBO, Katarina Creese FEBO Department of Ophthalmology, The Royal Victorian Eye and Ear Hospital, The University of Melbourne, East Melbourne, Victoria, AustraliaSearch for more papers by this authorDaini Ong MBBS, Daini Ong MBBS Department of Ophthalmology, The Royal Victorian Eye and Ear Hospital, The University of Melbourne, East Melbourne, Victoria, AustraliaSearch for more papers by this authorEhud Zamir FRANZCO, Ehud Zamir FRANZCO Department of Ophthalmology, The Royal Victorian Eye and Ear Hospital, The University of Melbourne, East Melbourne, Victoria, AustraliaSearch for more papers by this author First published: 12 July 2012 https://doi.org/10.1111/j.1442-9071.2012.02850.x Competing/conflicts of interest: No stated conflict of interest. Funding sources: No stated funding sources. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. References 1 Tan CSH, Ngo WK, Lim LW. Use of optical coherence tomography for preoperative screening of patients undergoing cataract surgery. Clin Experiment Ophthalmol 2012. doi:10.1111/j.1442-9071.2012.02849.x 2 Creese K, Ong D, Zamir E. Should macular optical coherence tomography be part of routine preoperative cataract assessment? Clin Experiment Ophthalmol 2012; 40: e118– 9. 3 Chizner MA. Cardiac auscultation: rediscovering the lost art. Curr Probl Cardiol 2008; 33: 326– 408. Volume41, Issue2March 2013Pages 216-216 ReferencesRelatedInformation

Purpose: To report a case of a child with near-simultaneous onset of Vogt Koyanagi Harada disease (VKH) and insulin-dependent diabetes mellitus (IDDM). Design: Interventional case report. Methods: An 11-year-old child with known psoriasis presented with headache and bilateral granulomatous panuveitis. Nine weeks later, he presented with diabetic ketoacidosis and IDDM. Diffuse choroidal depigmentation followed within months. HLA was positive for DRB1*0405. Despite aggressive local and systemic therapy, the ocular disease was complicated by bilateral cataracts, angle closure glaucoma, and choroidal neovascularization. Results: The patient is currently pseudophakic in one eye and aphakic in the other, with best-corrected visual acuity of 6/24 and 6/5, respectively. Conclusions: VKH may present in children with panuveitis in the setting of other autoimmune disorders. Treating such patients is complicated by the need to minimize systemic corticosteroid use. A combination of local therapy and systemic steroid-sparing agents should be the mainstay of treatment.

Our research goal is to develop a safe, reproducible surgical approach for implantation of a wide-field retinal stimulating array. The aim of this study was to evaluate the pathological response to acute implantation of a functional prototype electrode array in the suprachoroidal space.

We report a 57-year-old man with pathognomonic bilateral vitreo-lenticular amyloid opacities (pseudopodia lentis) in whom a novel transthyretin (TTR) mutation was identified. The patient presented due to bilateral floaters. The vitreous cavities of both eyes showed course, fibrilar opacities attached to the posterior lens surface with pseudopodia. There was a history of bilateral carpal tunnel syndrome. Nerve conduction studies showed upper and lower limb axonal polyneuropathy. Magnetic resonance imaging of the brain and spinal cord, renal and cardiac function were normal. Vitreous and conjunctival biopsies confirmed the diagnosis of TTR-related amyloidosis. Genetic analysis of exon 2 of the TTR gene revealed that the patient was heterozygous for a single nucleotide substitution c.160 A>G, resulting in replacement of arginine with glycine at position 34 of the mature protein (Arg34Gly). Five years later the patient developed increasing sensory and motor neuropathy of both lower limbs, and neovascular glaucoma in one eye. We hypothesize that the reason for his neovascular glaucoma was retinal ischaemia secondary to amyloid retinal vasculopathy.

Intraocular lens (IOL) confusions and errors are among the most common postoperative adverse events. Errors may occur at any stage from the decision to operate to the insertion of the IOL. The most common errors occur during IOL selection pre-operative preparation (anaesthesia given before recognition that the intended IOL is not available), or intraoperatively (wrong IOL implanted because of confusion in the operating room). We review the mechanisms of errors reported in the literature and describe the experience at The Royal Victorian Eye and Ear Hospital. We also describe the implementation of an error-detection protocol and provide qualitative data on its performance.