Background: Cataracts are one of the leading causes of blindness in the world and disproportionately affect the elderly people and women. Sex- and race-related differences in cataract formation are not well understood. Furthermore, race and socioeconomic factors can play a role in developing systemic diseases. Earlier studies have supported a link between certain systemic diseases and cataract formation. Our study examined race-related differences in ocular and systemic comorbidities and analyzed differences among races and insurance types for cataract surgery visual outcomes among female patients with cataracts. Materials and Methods: Data were collected retrospectively and patients were grouped by race and insurance classifications. Female patients at a large tertiary center with an International Classification of Disease, 9th Edition (ICD-9) or ICD-10 cataract diagnosis or cataract extraction procedure code between January 2013 and June 2018 were included. A total of 909 female patients were included in the study. Frequency of systemic and ocular comorbidities was analyzed. Demographic factors were also compared among races. Finally, characteristics of cataract surgery patients, such as age at surgery, preoperative best-corrected visual acuity (BCVA), and visual outcomes among races and insurance types were analyzed. Results: There are differences among races for frequency of smoking, hemoglobin A1c, hypertension, and diabetes mellitus in female patients with cataracts and differences among races and insurance types for preoperative BCVA for patients who underwent cataract surgery (p < 0.001 for all). Conclusions: Female minority and non-minority patients with cataracts have a high frequency of systemic and ocular comorbidities at our county hospital. Patients with no insurance and white and Hispanic patients had worse preoperative BCVA.

The coronavirus (COVID-19) pandemic temporarily suspended medical student involvement in clinical rotations, resulting in the need to develop virtual clinical experiences. The cancellation of clinical ophthalmology electives and away rotations reduces opportunities for exposure to the field, to network with faculty, conduct research, and prepare for residency applications. We review the literature and discuss the impact and consequences of COVID-19 on undergraduate medical education with an emphasis on ophthalmic undergraduate medical education. We also discuss innovative learning modalities used from medical schools around the world during the COVID-19 pandemic such as virtual didactics,online cases, and telehealth. Finally, we describe a novel, virtual neuro-ophthalmology elective created to educate medical students on neuro-ophthalmology foundational principles, provide research and presentation opportunities, and build relationships with faculty members. These innovative approaches represent a step forward in further improving medical education in ophthalmology during COVID-19 pandemic and beyond. (C) 2020 Elsevier Inc. All rights reserved.

Objective: This study aimed to characterize ophthalmology consultations ordered after Hurricane Harvey compared to consultations ordered during the same time period of the prior year. Methods: A retrospective chart review was performed at an urban, level 1 trauma center of a county hospital. All patients were included who received an electronic health record, documented ophthalmology consultation order between September 2017 and October 2017 (the time period immediately following Hurricane Harvey) or September 2016 and October 2016. Patient demographic risk factors were collected. Patient ICD10 clinical diagnoses were categorized as extraocular, intraocular, infectious, physiological, or other, and then subcategorized as trauma or non-trauma-related. A geographical heat map was generated to compare the changes in diagnosis volume by zip code to the magnitude of rainfall in the county. Results: Following Hurricane Harvey, ophthalmology consultation volume decreased, number of infectious ophthalmology diagnoses increased (P < 0.001), percentage of patients on immunosuppression increased (P < 0.001), and the number of private insurance payers increased while the number of county-funded insurance payers decreased (P = 0.003). Conclusions: The risk of infectious eye diagnosis was double the risk of traumatic eye diagnosis from Hurricane Harvey flooding. During public disaster planning, different ophthalmological medical resources and responses should be considered for flooding versus high-wind events.

Purpose of Review Given the epidemiology and demographic trends of diabetes mellitus and cataracts, ophthalmologists are likely to encounter patients with both comorbidities at an increasing frequency. Patients with diabetes represent a higher risk population than healthy patients for cataract surgery. In this review, we discuss key risks and risk-mitigation practices when performing cataract surgery on these patients. Recent Findings Patients with diabetes continue to represent a high-risk surgical population: Nagar et al. suggest a dose-dependent relationship may exist between number of intravitreal injections and likelihood of posterior capsular rupture. However, novel treatments are improving outcomes for patients with diabetes. Several studies have reported intracameral phenylephrine/ketorolac may reduce the incidence of post-operative cystoid macular edema while others have discussed the efficacy of pre-treatment and post-treatment with intravitreal bevacizumab on improving cataract surgery outcomes in patients with diabetic retinopathy. Pre-operatively, ophthalmologists should perform an enhanced evaluation, consider timing and lens selection decisions, and complete any appropriate pre-operative treatment. Peri-operatively, surgeons should be aware of pupillary dilation adjustments, combination surgery options, and potential complications. Post-operatively, clinicians should address pseudophakic cystoid macular edema, diabetic macular edema, diabetic retinopathy, and posterior capsular opacification.

Purpose/Aim of the study To quantify the cost of performing an intravitreal injection (IVI) utilizing activity-based costing (ABC), which allocates a cost to each resource involved in a manufacturing process. Materials and Methods A prospective, observational cohort study was performed at an urban, multi-specialty ophthalmology practice affiliated with an academic institution. Fourteen patients scheduled for an IVI-only visit with a retina ophthalmologist were observed from clinic entry to exit to create a process map of time and resource utilization. Indirect costs were allocated with ABC and direct costs were estimated based on process map observations, internal accounting records, employee interviews, and nationally-reported metrics. The primary outcome measure was the cost of an IVI procedure in United States dollars. Secondary outcomes included operating income (cost subtracted from revenue) of an IVI and patient-centric time utilization for an IVI. Results The total cost of performing an IVI was $128.28; average direct material, direct labor, and overhead costs were $2.14, $97.88, and $28.26, respectively. Compared to the $104.40 reimbursement set by the Centers for Medicare and Medicaid Services for Current Procedural Terminology code 67028, this results in a negative operating income of -$23.88 (-22.87%). The median clinic resource-utilizing time to complete an IVI was 32:58 minutes (range [19:24-1:28:37]); the greatest bottleneck was physician-driven electronic health record documentation. Conclusions Our study provides an objective and accurate cost estimate of the IVI procedure and illustrates how ABC may be applied in a clinical context. Our findings suggest that IVIs may currently be undervalued by payors.

In the United States, drug costs account for approximately 10% of health care expenditures and are expected to grow over the next decade. 1 Cuckler G.A. Sisko A.M. Poisal J.A. et al. National health expenditure projections, 2017-26: despite uncertainty, fundamentals primarily drive spending growth. Health Aff (Millwood). 2018; 37: 482-492 Crossref PubMed Scopus (65) Google Scholar Because of a combination of rising drug prices, increased out-of-pocket costs, and increased use of specialty drugs, a growing number of Americans cannot afford their medications. This issue is particularly relevant for the treatment of skin diseases, where retail prices of select brand name dermatologic medications increased an average of 363% in real terms between 2009 and 2015, while the general and average pharmaceutical inflation rose only 11% and 23%, respectively. 2 Rosenberg M.E. Rosenberg S.P. Changes in retail prices of prescription dermatologic drugs from 2009 to 2015. JAMA Dermatology. 2016; 152: 158-163 Crossref PubMed Scopus (38) Google Scholar ,3 Frakt A.B. We can't have it all: the economic limits of pharmaceutical innovation. JAMA. 2016; 315: 1936-1937 Crossref PubMed Scopus (4) Google Scholar In this article—part of a health policy series reviewing a wide-range of policy topics impacting clinical dermatology 4 Nguyen H.P. Barbieri J.S. Forman H.P. Bolognia J.L. VanBeek M.J. Future considerations for clinical dermatology in the setting of 21st century American policy reform: Accountable Care Organizations. J Am Acad Dermatol. 2017; 76: 170-176 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar —we provide an overview of how drug prices are set, with an emphasis on microeconomic factors that drive their complexity in the United States, and discuss trends in drug pricing that are relevant to both the present and future delivery of dermatologic care. The potential impact of same-class substitution of topical steroids on health care spendingJournal of the American Academy of DermatologyVol. 83Issue 6PreviewTo the Editor: We enjoyed the detailed review by Nguyen et al1 of drug pricing factors that shape the care of our patients and agree that while dermatologists share a responsibility in understanding the financial consequences of their prescribing habits, “careful prescribing is not easy.” Here, we highlight a significant challenge familiar to many dermatologists—prescribing cost-efficient topical steroids—and propose achievable reform. Full-Text PDF

To compare goblet cell (GC) number and area in the covered superior (SB) versus exposed temporal (TB) bulbar conjunctiva in control versus aqueous tear deficient eyes (ATD) and evaluate correlation with tear MUC5AC protein. SB and TB impression cytology performed on control eyes, Sjögren syndrome (SS) ATD, and non-SS ATD was stained with period acid Schiff. GC number and area were measured with image analysis software. Protein-normalized MUC5AC level was measured in Schirmer strip-collected tears. Compared to control conjunctiva, GC number and area were significantly lower in SS, non-SS, and combined ATD groups in exposed TB, and were also significantly lower in SS and combined ATD groups in covered SB. In all ATD, GC number and area were significantly correlated, but differences between SB and TB were non-significant. Normalized tear MUC5AC protein was lower in all ATD groups versus control eyes, and correlated only with GC area. GCs are significantly decreased in the covered and exposed conjunctiva in SS. GC area may be a better disease measure than number for ATD. Correlation between tear MUC5AC concentration and GC area suggests tear MUC5AC mucin can be used as a disease-relevant biomarker for conjunctiva GC health.

Background While the Association of American Medical Colleges encourages medical schools to incorporate quality improvement and patient safety (QI/PS) into their curriculum, medical students continue to have limited QI/PS exposure. To prepare medical students for careers that involve QI/PS, the Institute for Healthcare Improvement chapter at an allopathic medical school and school of allied health professions initiated self-directed learning by offering student-led workshops to equip learners with skills to improve the quality and safety of healthcare processes. Methods In this prospective cohort study, workshops were hosted for medical students between 2015 and 2018 on five QI/PS topics: Process Mapping, Root-Cause Analysis (RCA), Plan-Do-Study-Act (PDSA) Cycles, Evidence Based Medicine (EBM), and Patient Handoffs. Each workshop included a hands-on component to engage learners in practical applications of QI/PS skills in their careers. Change in knowledge, attitudes, and behaviors was assessed via pre- and post-surveys using 5-point Likert scales, and analyzed using either the McNemar test or non-parametric Wilcoxon signed-rank test. Surveys also gathered qualitative feedback regarding strengths, future areas for improvement, and reasons for attending the workshops. Results Data was collected from 88.5% of learners (n = 185/209); 19.5% of learners reported prior formal instruction in these topics. Statistically significant improvements in learners' confidence were observed for each workshop. Additionally, after attending workshops, learners felt comfortable teaching the learned QI/PS skill to colleagues (mean pre/post difference 1.96, p < 0.0001, n = 139) and were more likely to pursue QI/PS projects in their careers (mean pre/post difference 0.45, p < 0.0001, n = 139). Lastly, learners demonstrated a statistically significant increase in knowledge in four out of five skills workshop topics. Conclusion Few medical students have formal instruction in QI/PS tools. This pilot study highlights advantages of incorporating an innovative, student-directed modified 'flipped classroom' methodology, with a focus on active experiential learning and minimal didactic instruction.

PURPOSE:Recognize a rare yet existing risk of severe visual loss as a postoperative complication of bilateral lung transplant. OBSERVATIONS:A 62-year-old male had undergone bilateral lung transplant for end-stage idiopathic pulmonary fibrosis and emphysema overlap syndrome. The operation was initially off-pump; however, during the left lung transplantation, cardiopulmonary bypass conversion was necessary to maintain intraoperative hemodynamic stability. On post-operative day 4, shortly after extubation and full recovery from sedation, the patient reported bilateral no light perception vision. There were no other associated neurologic symptoms. A computed tomographic (CT) of the head, cranial magnetic resonance (MR) scan of the head, MR angiogram of the circle of Willis and neck were negative. Neuro-ophthalmologic examination revealed no light perception vision in both eyes(OU). The pupils were non-reactive to light (amaurotic pupils). The intraocular pressure measured 18 mm Hg OU, and complete bilateral ophthalmoplegia was present. The fundus exam showed bilateral pallid optic disc edema, cherry red spots, with arteriolar attenuation, and mildly dilated and tortuous veins. Stroke work up was negative. CONCLUSIONS AND IMPORTANCE:A case of post-operative visual loss and ophthalmoplegia carrying significant and permanent quality of life implications. It questions the role disruption of homeostasis during cardiopulmonary bypass contributes for this outcome.

Background Vertebrobasilar insufficiency (VBI) after rotation or hyperextension of the neck during otherwise routine activities is uncommon "hairdresser syndrome" (HDS). We report three such cases presenting with neuro-ophthalmic complaints (Horner syndrome, ophthalmoplegia, and transient vision loss). Methods A retrospective review was performed of the electronic health records of three patients seen in the neuro-ophthalmology clinic of Houston Methodist Hospital with acute neuro-ophthalmological signs after neck hyperextension. A literature review was also performed. Results While various ischemic signs of VBI have been previously documented, to our knowledge, these are the first cases in the English ophthalmic literature to describe the presenting neuro-ophthalmologic signs of HDS. Conclusion Clinicians should consider the possibility of neck hyperextension as a potential mechanism and precipitating event for acute neuro-ophthalmic presentations of VBI. Patients with a history of occupational (e.g., carpenter), recreational (e.g., bow hunter), or cosmetic (hairdresser) neck hyperextension (i.e., possible HDS) should undergo structural and vascular neuroimaging of both the head and neck (e.g., CT/CTA or MRI/MRA) to look for evidence of posterior fossa ischemia and/or vertebrobasilar lesion (e.g., occlusion, dissection, FMD, and pseudoaneurysm).

BACKGROUND Horner syndrome arises from a disruption along the oculosympathetic efferent chain and can be caused by a variety of pathological and iatrogenic etiologies. We present 3 cases of postoperative Horner syndrome after bilateral lung transplantation. METHODS The electronic health records of 3 patients with iatrogenic Horner syndrome after lung transplantation were examined, including notes from each patient's medical history, operative and postoperative records, and ophthalmology consultation results. A literature review was performed. RESULTS All 3 of our patients displayed anisocoria and ptosis, symptoms consistent with Horner syndrome, and the patients from Cases 1 and 2 showed reversal of anisocoria after an application of topical apraclonidine. CONCLUSIONS Ophthalmologists should be aware of the risk of Horner syndrome after lung transplantation.

Nonarteritic anterior ischemic optic neuropathy (NAION) is a relatively common cause of acute, painless vision loss in patients typically older than 50 years. Presentation is often associated with predisposing vasculopathic risk factors, but has also been reported as a complication of pregnancy. We describe a young, healthy female with disc drusen who suffered bilateral NAION due to postpartum blood loss. To our knowledge this is the first such case to be reported in the English-language ophthalmic literature. Clinicians should be aware that patients with disc drusen may be at additional risk of developing NAION, including postpartum NAION. A 31-year-old, pregnant Norwegian female presented with acute, painless, bilateral, simultaneous vision loss after a complicated pregnancy and delivery. Her medical history was unremarkable, and she had no prior anemia, deep venous thrombosis, pulmonary embolus, or other vasculopathic risk factors. Her body mass index was 20.55 kg/m2. Her surgical history was significant for adenoidectomy and tonsillectomy. She was not taking any medications. She had no known medical allergies. Her obstetric history was unremarkable, and she had no prior pregnancies or miscarriages. She immigrated from Norway 1 year earlier and was working as a nurse anaesthetist. The patient was married, used alcohol socially, and denied a history of smoking and illicit drug use. Her mother had optic disk drusen, but no other significant family history was noted. Her review of symptoms was unremarkable. Her ocular history was significant for normal eye examinations except for bilateral optic disc drusen (ODD), which were asymptomatic. The patient's labor and delivery took place in Norway. According to her transferred medical records, the patient had an uneventful pregnancy and there was no proteinuria, eclampsia, or preeclampsia noted. She underwent epidural anaesthesia and delivered via spontaneous vaginal delivery. The delivery was complicated by a difficult, protracted labor, and her blood pressure rose to a maximum of 150/85 mm Hg. Uterine atony and postpartum hemorrhage were noted. She experienced 2 litres of blood loss, and her hemoglobin was low, at 8.2 g/dL. No blood transfusion was administered. Her baby weighed 4 kg and required a forceps delivery due to cephalopelvic disproportion. In the recovery room, the patient immediately noted new onset blurred vision in both eyes. Magnetic resonance imaging (MRI) of the head was normal except for some T2 signal change consistent with ischemic optic neuropathy. No posterior nerve ischemia was noted. There was no evidence for stroke or pituitary apoplexy. A diagnosis of presumed NAION was made but no treatment was initiated. Testing for a hypercoagulable state was negative. One year after the visual loss, the patient was referred to our clinic. Neuro-ophthalmic examination revealed best-corrected visual acuity of 20/20 OU. Ishihara color plates were correctly identified in 14/14 plates OU. Humphrey visual field testing showed bilateral arcuate defects superiorly and inferiorly with a mean deviation of −9.73 dB OD and −20.23 dB OS. The pupils measured 3 mm in the dark and 2 mm in the light bilaterally, and a relative afferent pupillary defect was noted OS. Motility examination was full. Intraocular pressure measured 11 mm Hg OD and 13 mm Hg OS. External and slit-lamp examinations were unremarkable OU. Fundus examination (Fig. 1) showed ODD and superimposed optic atrophy OU. Optical coherence tomography demonstrated global retinal nerve fibre layer loss at 56 μm OD and 39 μm OS. Orbital ultrasonography confirmed calcified optic disk drusen bilaterally (Fig. 2). A repeat MRI of the head (Fig. 3) revealed no acute ischemia or abnormal postcontrast enhancement. A stable, linear focus of T2-weighted-fluid-attenuated inversion recovery (T2 FLAIR) hyperintensity in the left parietal, periventricular white matter was noted, likely due to chronic insult of unclear etiology. No abnormal signals or masses were noted in the optic nerves, intraorbital contents, cavernous sinuses, optic chiasm, or sellar and supersellar regions. Both optic nerves were noted as slightly smaller in size, compatible with the given clinical history of optic atrophy. No serial change in optic nerve intensity was noted.Fig. 2Ultrasonography of the left and right orbits shows calcified optic disk drusen bilaterally.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 3A stable, linear focus of T2 FLAIR hyperintensity is visible in the left parietal, periventricular white matter. Both optic nerves were noted as slightly smaller in size, compatible with the given clinical history of optic atrophy.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We did not see this patient acutely, and so the possibility of both anterior (disc edema) and posterior levels of ischemia cannot be excluded. However, based on the available patient history and our findings, NAION remains the presumed diagnosis. NAION has been associated with a variety of complications, including hypercholesterolemia, diabetes mellitus, hypertension, coagulation disorders,1Glueck C.J. Wang P. Bell H. Rangaraj V. Goldenberg N. Nonarteritic anterior ischemic optic neuropathy: associations with homozygosity for the C677T methylenetetrahydrofolate reductase mutation.J Lab Clin Med. 2004; 143: 184-192Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar nocturnal systemic hypotension, migraine, and acute blood loss.2Gupta M. Puri P. Rennie I.G. Anterior ischemic optic neuropathy after emergency caesarean section under epidural anesthesia.Acta Anaesthesiol Scand. 2002; 46: 751-752Crossref PubMed Scopus (10) Google Scholar Our patient's case of NAION is notable due to the patient's young age, the presence of ODD, and the rarity of NAION from delivery complications. ODD, a congenital disc abnormality involving crowded and cup-less nerve heads, has been associated with NAION. In ODD, an abnormal nerve head may exacerbate the small cup-disc ratio often seen in NAION, increasing the probability of decreased perfusion pressure of the optic nerve head and NAION-causing ischemia.3Purvin V. King R. Kawasaki A. Yee R. Anterior ischemic optic neuropathy in eyes with optic disc drusen.Arch Ophthalmol. 2004; 122: 48-53Crossref PubMed Scopus (75) Google Scholar An earlier mean diagnosis age, better visual acuity, and higher likelihood of preceding, transient visual obscuration have been associated with patients with NAION and ODD compared to NAION alone, although the visual field loss topography patterns present similarly in both cohorts.3Purvin V. King R. Kawasaki A. Yee R. Anterior ischemic optic neuropathy in eyes with optic disc drusen.Arch Ophthalmol. 2004; 122: 48-53Crossref PubMed Scopus (75) Google Scholar, 4Schargus M. Gramer E. Increased risk in patients with optic disk drusen for an acute non arteritic anterior ischemic optic neuropathy.Invest Ophthalmol Vis Sci. 2009; 50: 4023Google Scholar This age discrepancy may be explained by drusen bodies increasing the risk of NAION earlier in life by directly causing vessel infarction, or by nerve fibre layer thinning typical of ODD decreasing infarction risk later in life through a reduced crowding in the optic disc over time.3Purvin V. King R. Kawasaki A. Yee R. Anterior ischemic optic neuropathy in eyes with optic disc drusen.Arch Ophthalmol. 2004; 122: 48-53Crossref PubMed Scopus (75) Google Scholar Prevalence of vascular risk factors has been noted as both insignificant3Purvin V. King R. Kawasaki A. Yee R. Anterior ischemic optic neuropathy in eyes with optic disc drusen.Arch Ophthalmol. 2004; 122: 48-53Crossref PubMed Scopus (75) Google Scholar and significant4Schargus M. Gramer E. Increased risk in patients with optic disk drusen for an acute non arteritic anterior ischemic optic neuropathy.Invest Ophthalmol Vis Sci. 2009; 50: 4023Google Scholar by separate studies. Our patient with ODD presented at an atypically young age without preceding episodes of transient visual obscuration and without prior vascular risk factors. While literature often cites 50 years and older as the age threshold for NAION presentation, rare cases of NAION in patients less than 50 years old have been reported,5Kim J.H. Kang M.H. Seong M. Cho H. Shin Y.U. Anomalous coagulation factors in non-arteritic anterior ischemic optic neuropathy with central retinal vein occlusion: a case report.Medicine. 2018; 97: e0437Google Scholar often associated with an underlying risk factor or abnormality, such as primary antiphospholipid syndrome,6Tugcu B. Acar N. Coskun C.T. Celik S. Yigit F.U. Nonarteritic anterior ischemic optic neuropathy as the presenting manifestation of primary antiphospholipid syndrome.Indian J Ophthalmol. 2014; 62: 642-644Google Scholar hemodialysis accompanying end-stage renal disease,7Jain M. Srinivasan R. Babu K.R. Parchand M.S. Sequential development of non-arteritic anterior ischemic optic neuropathy in a patient on hemodialysis.GMS Ophthalmol Cases. 2017; 7: Doc22Google Scholar hypercoagulable state,5Kim J.H. Kang M.H. Seong M. Cho H. Shin Y.U. Anomalous coagulation factors in non-arteritic anterior ischemic optic neuropathy with central retinal vein occlusion: a case report.Medicine. 2018; 97: e0437Google Scholar hepatitis C treatment,8Manoharan N. Subramanian P.S. A case of non-arteritic anterior ischemic optic neuropathy after completion of Harvoni therapy.Am J Ophthalmol Case Rep. 2017; 6: 55-57Crossref Scopus (3) Google Scholar diabetes mellitus,9Janáky M. Fülöp Z. Pálffy A. Benedek K. Benedek G. Non-arteritic ischaemic optic neuropathy (NAION) in patients under 50 years of age.Acta Ophthalmol Scand. 2005; 83: 499-503Crossref PubMed Scopus (13) Google Scholar hyperhomocysteinemia,10Kawasaki A. Purvin V. Burgett R. Hyperhomocysteinaemia in young patients with non-arteritic anterior ischaemic optic neuropathy.Br J Ophthalmol. 1999; 83: 1287-1290Crossref PubMed Scopus (53) Google Scholar menorrhagia,11Koh K.L. Sonny Teo K.S. Chong M.F. Wan Hitam W.H. Non-arteritic anterior ischaemic optic neuropathy secondary to menorrhagia in a young healthy woman.BMJ Case Rep. 2018; 2018 (pii: bcr-2018-225113)Google Scholar and abortion.12Onaran Z. Tan F.U. Yılmazbaş P. Onaran Y. Bilateral non-arteritic anterior ischemic optic neuropathy following second-trimester spontaneous abortion-related haemorrhage.J Clin Neurosci. 2012; 19: 1445-1447Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar In contrast, our patient's history at presentation and past medical records indicated no significant risk factors other than ODD. NAION reported in the context of pregnancy is rare. Presentation has been reported both predelivery13Beck R.W. Gamel J.W. Willcourt R.J. Berman G. Acute ischemic optic neuropathy in severe preeclampsia.Am J Ophthalmol. 1980; 90: 342-346Abstract Full Text PDF PubMed Scopus (51) Google Scholar and postdelivery,2Gupta M. Puri P. Rennie I.G. Anterior ischemic optic neuropathy after emergency caesarean section under epidural anesthesia.Acta Anaesthesiol Scand. 2002; 46: 751-752Crossref PubMed Scopus (10) Google Scholar, 14Giridhar P. Freedman K. Nonarteritic anterior ischemic optic neuropathy in a 35-year-old postpartum woman with recent preeclampsia.JAMA Ophthalmol. 2013; 131: 542-544Google Scholar with both vaginal14Giridhar P. Freedman K. Nonarteritic anterior ischemic optic neuropathy in a 35-year-old postpartum woman with recent preeclampsia.JAMA Ophthalmol. 2013; 131: 542-544Google Scholar and Caesarian section2Gupta M. Puri P. Rennie I.G. Anterior ischemic optic neuropathy after emergency caesarean section under epidural anesthesia.Acta Anaesthesiol Scand. 2002; 46: 751-752Crossref PubMed Scopus (10) Google Scholar, 13Beck R.W. Gamel J.W. Willcourt R.J. Berman G. Acute ischemic optic neuropathy in severe preeclampsia.Am J Ophthalmol. 1980; 90: 342-346Abstract Full Text PDF PubMed Scopus (51) Google Scholar delivery. Although some cases report pre-existing risk factors such as preeclampsia,13Beck R.W. Gamel J.W. Willcourt R.J. Berman G. Acute ischemic optic neuropathy in severe preeclampsia.Am J Ophthalmol. 1980; 90: 342-346Abstract Full Text PDF PubMed Scopus (51) Google Scholar, 14Giridhar P. Freedman K. Nonarteritic anterior ischemic optic neuropathy in a 35-year-old postpartum woman with recent preeclampsia.JAMA Ophthalmol. 2013; 131: 542-544Google Scholar other cases report no risk factors before NAION presentation. Prior cases have reported ODD15Mehta J.S. Bates A. Chan J. Kuteesa W. Acheson J.F. Pregnancy associated optic disc drusen related visual loss.Acta Ophthalmol Scand. 2006; 84: 271-273Crossref PubMed Scopus (5) Google Scholar as a possible risk factor, although in different circumstances compared to our patient (Table 1).Table 1Prior cases of pregnancy-related nonartertitic anterior ischemic optic neuropathy (NAION)This StudyGiridhar and Freedman14Giridhar P. Freedman K. Nonarteritic anterior ischemic optic neuropathy in a 35-year-old postpartum woman with recent preeclampsia.JAMA Ophthalmol. 2013; 131: 542-544Google ScholarGupta et al.2Gupta M. Puri P. Rennie I.G. Anterior ischemic optic neuropathy after emergency caesarean section under epidural anesthesia.Acta Anaesthesiol Scand. 2002; 46: 751-752Crossref PubMed Scopus (10) Google ScholarBeck et al.13Beck R.W. Gamel J.W. Willcourt R.J. Berman G. Acute ischemic optic neuropathy in severe preeclampsia.Am J Ophthalmol. 1980; 90: 342-346Abstract Full Text PDF PubMed Scopus (51) Google ScholarMehta et al.15Mehta J.S. Bates A. Chan J. Kuteesa W. Acheson J.F. Pregnancy associated optic disc drusen related visual loss.Acta Ophthalmol Scand. 2006; 84: 271-273Crossref PubMed Scopus (5) Google ScholarNAION timingPostdeliveryPredeliveryPostdeliveryPredeliveryPredeliveryDisc edemaNoneUnilateralUnilateralBilateralUnilateralVision lossBilateralUnilateralUnilateralBilateralUnilateralVasculopathic risk factorsNonePreeclampsia, gestational diabetes mellitusNone notedPreeclampsiaNone notedDrusenYesUnknownNoneUnknownYesDelivery methodVaginalVaginalCaesarean sectionCaesarean sectionUnknownBlood loss2000 mLUnknown500 mLUnknownUnknownDelivery complicationsUterine atony, postpartum hemorrhage, protracted laborUnknownHypotensive episode, possible dural puncture during epidural anaesthesiaUnknownUnknownTreatmentNoneNoneNoneUnknownUnknownResponseNo vision improvementPartial vision improvement at 6-month follow-upNo vision improvementVision improvement at 3-day follow-upUnknown Open table in a new tab There is no proven, effective treatment for NAION,16Atkins E.J. Bruce B.B. Newman N.J. Biousse V. Treatment of nonarteritic anterior ischemic optic neuropathy.Surv Ophthalmol. 2010; 55: 47-63Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar and the topic remains heavily contested: some studies have concluded that the risks of steroid treatment outweigh the benefits,17Kinori M. Ben-Bassat I. Wasserzug Y. Chetrit A. Huna-Baron R. Visual outcome of mega-dose intravenous corticosteroid treatment in non-arteritic anterior ischemic optic neuropathy—retrospective analysis.BMC Ophthalmol. 2014; 14: 62Crossref PubMed Scopus (23) Google Scholar whereas other literature has documented steroid treatment for patients, with the rationale that early treatment may improve or prevent disk edema.18Hayreh S.S. Zimmerman M.B. Non-arteritic anterior ischemic optic neuropathy: role of systemic corticosteroid therapy.Graefes Arch Clin Exp Ophthalmol. 2008; 246: 1029-1046Crossref PubMed Scopus (190) Google Scholar Our patient was not treated with steroids, and her vision has not improved 1 year after onset. Our patient intends to pursue a second pregnancy. Possible countermeasures to prevent or mitigate postpartum hemorrhage were discussed, including hospital delivery, treatment of pre-existing anemia, iron supplementation including blood-typing, and cross-matching before delivery in preparation for autologous blood transfusion, if necessary. In summary, we report a case of a young, healthy female with ODD presenting with bilateral NAION from postpartum blood loss. Clinicians should be aware of the risk for NAION in patients with ODD, especially pregnant and postpartum patients. Patient Consent: This report does not contain any personal information that could lead to the identification of the patient. Thus, consent to publish this case was not obtained. The authors have no proprietary or commercial interest in any materials discussed in this article.

Basketball is one of the most common causes of sport-related eye injuries in the United States. 1 Larrison W.I. Hersh P.S. Kunzweiler T. Shingleton B.J. Sports-related ocular trauma. Ophthalmology. 1990; 97: 1265-1269 Abstract Full Text PDF PubMed Scopus (63) Google Scholar Although the correlation between basketball and ophthalmic injury is well documented, limited information is available regarding the circumstances and scenarios that drive these injuries, especially at the highest level of competition. We performed a prospective cohort study of National Basketball Association (NBA) players across all 1230 games of the 2018–2019 NBA regular season, compliant under the Baylor College of Medicine Institutional Review Board and Declaration of Helsinki. Injury information was tracked daily throughout the season by 5 of the authors with a comprehensive online database hosted by Rotoworld (NBC Universal, New York, NY), a fantasy sports news corporation. Eye injury–related updates were corroborated by press releases and news reports. Game film of each eye injury was analyzed through the NBA's online, "League Pass" broadcast subscription. Additional injury information was obtained through interviews with NBA team eye care providers to fill information gaps from the aforementioned methodologies, when needed.

Primary CNS lymphoma (PCNSL) is a rare form of extranodal, high-grade, non-Hodgkin lymphoma (NHL), accounting for approximately 3% of newly diagnosed brain tumors and 2 to 3% of all NHL.1 PCNSL can also arise from posttransplant lymphoproliferative disorder (PTLD), a disorder in patients with secondary immunodeficiency after a solid organ or hematopoietic stem cell transplant.2 PCNSL is characterized by rapid growth usually confined to the CNS and can originate in the brain, leptomeninges, spinal cord, or eyes.