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A Comparison of Two New Contrast Sensitivity Card Tests: The Ohio Contrast Cards and the Mayer-Kran Double Happy Cards
Published 2023 by Sajini Jayakody
Co-Author(s): Angela Brown
Program Number: 235241
Article Type: Scientific Program
Board: 227
PURPOSE:
Contrast sensitivity (CS), the ability to discriminate an object from its surroundings, is an important marker for functional vision loss. Reduced CS is linked with greater difficulty doing everyday tasks caused by several ophthalmic diseases. The gold standard for measuring a patient's CS is the Pelli-Robson (PR) chart or the Mars chart. These are letter charts, so they cannot be used on patients who are too young, who are cognitively impaired, or who cannot read English letters. To circumvent this issue, the Ohio Contrast Cards (OCC) and the Double Happy Cards (DH) have been developed to measure CS without letters. The OCC uses a 0.15 cy/deg square wave grating target, and the DH cards use a letter-like diagram of a face. Does the difference between stimulus targets affect patient performance?
METHOD:
49 adult patients from the OSU College of Optometry Vision Rehabilitation and Bioptic Driving Clinics participated in this study. Ages: 19—93; visual acuity logMAR: 0.1—1.6; PR CS: median=1.5, interquartile range: 1.20—1.65. Participants wore their habitual correction. After obtaining consent, two examiners tested each participant, the first using either the OCC or DH and the second using the other card test. All cards were calibrated using a SpectraScan PR-670 spectroradiometer. The card tests were used in a left/right, yes/no protocol, similar to the Teller Acuity Cards, at a test distance of 0.57 meters (OCC) and 0.4 meters (DH). The orders of testers and card tests were independently randomized across participants. Participants were compensated $10. The study was powered (0.90) to reveal differences >= 0.15 Log10 Weber contrast units between tests.
RESULTS:
There was no clinically or statistically significant overall difference between the OCC (median CS=1.66) and DH (median CS=1.65). The maximum CS value of 1.96 was achieved by 7 participants using the OCC and 16 participants using the DH. Examining the data pairwise within participants: the median difference was 0.008 Log10 units (95% bootstrapped range: -0.054—+0.059), the OCC and DH results were significantly associated with one another (Spearman's rho=0.565, p<0.001), and the agreement between the two tests was substantial (quadratic weighted kappa=0.620, p=10^-6).
CONCLUSION:
The OCC target stimulus was a very low-spatial-frequency square wave, whereas the DH target stimulus was a face-like pattern of marks, designed to be similar to the letters of the letter charts. The two card tests were presented and scored identically. Therefore, this study was a direct comparison of those two stimuli. The two stimuli performed equally well: the results of two tests were highly correlated and agreed very well. Therefore, both stimuli are equally suitable for use on adult patients with vision loss.
PURPOSE:
Contrast sensitivity (CS), the ability to discriminate an object from its surroundings, is an important marker for functional vision loss. Reduced CS is linked with greater difficulty doing everyday tasks caused by several ophthalmic diseases. The gold standard for measuring a patient's CS is the Pelli-Robson (PR) chart or the Mars chart. These are letter charts, so they cannot be used on patients who are too young, who are cognitively impaired, or who cannot read English letters. To circumvent this issue, the Ohio Contrast Cards (OCC) and the Double Happy Cards (DH) have been developed to measure CS without letters. The OCC uses a 0.15 cy/deg square wave grating target, and the DH cards use a letter-like diagram of a face. Does the difference between stimulus targets affect patient performance?
METHOD:
49 adult patients from the OSU College of Optometry Vision Rehabilitation and Bioptic Driving Clinics participated in this study. Ages: 19—93; visual acuity logMAR: 0.1—1.6; PR CS: median=1.5, interquartile range: 1.20—1.65. Participants wore their habitual correction. After obtaining consent, two examiners tested each participant, the first using either the OCC or DH and the second using the other card test. All cards were calibrated using a SpectraScan PR-670 spectroradiometer. The card tests were used in a left/right, yes/no protocol, similar to the Teller Acuity Cards, at a test distance of 0.57 meters (OCC) and 0.4 meters (DH). The orders of testers and card tests were independently randomized across participants. Participants were compensated $10. The study was powered (0.90) to reveal differences >= 0.15 Log10 Weber contrast units between tests.
RESULTS:
There was no clinically or statistically significant overall difference between the OCC (median CS=1.66) and DH (median CS=1.65). The maximum CS value of 1.96 was achieved by 7 participants using the OCC and 16 participants using the DH. Examining the data pairwise within participants: the median difference was 0.008 Log10 units (95% bootstrapped range: -0.054—+0.059), the OCC and DH results were significantly associated with one another (Spearman's rho=0.565, p<0.001), and the agreement between the two tests was substantial (quadratic weighted kappa=0.620, p=10^-6).
CONCLUSION:
The OCC target stimulus was a very low-spatial-frequency square wave, whereas the DH target stimulus was a face-like pattern of marks, designed to be similar to the letters of the letter charts. The two card tests were presented and scored identically. Therefore, this study was a direct comparison of those two stimuli. The two stimuli performed equally well: the results of two tests were highly correlated and agreed very well. Therefore, both stimuli are equally suitable for use on adult patients with vision loss.
A Cross-sectional Study of Changes in Spatial and Depth Vision with Varying Severities of Keratoconus
Published 2023 by Shrikant Bharadwaj
Co-Author(s): Preetam Kumar, Christopher Hull, Peter Campbell, Pravin Vaddavalli
Program Number: 230038
Article Type: Scientific Program
PURPOSE:
Change of corneal structure and loss of visual function in keratoconus have been evaluated independently, but the inter-relationship has received less attention. This study tested the hypothesis that the spatial- and depth-related visual functions have a triphasic pattern of deterioration with increasing corneal deformation in keratoconus: an early “ceiling” phase where visual functions are immune to structural deformation; an intermediate phase where structural and functional losses are proportional to each other; and a late “flooring” phase where no further deterioration in visual functions occur.
METHODS:
Monocular high-contrast visual acuity, Contrast Sensitivity Function (CSF) and binocular stereoacuity of 155 subjects (16-31yrs) with mild to advanced bilateral keratoconus was assessed with their best-corrected spectacles and natural pupils using standard psychophysical tests in this cross-sectional study. Disease severity was quantified using the multi-metric D-index. A five-parameter logistic regression equation constituting the three phases of the structure-function relationship was fitted to the data that were normalized to the value of historic controls.
RESULTS:
The regression equation explained ≥66% of variance in visual acuity and area under the CSF with increasing D-index, which varied from 1.9 – 29.3 (p<0.001 for both regression fits). The ceiling phase of the triphasic loss was apparent for visual acuity, but not for contrast sensitivity. Subsequent loss of function occurred at the rate of 1.8 units per unit change in D-index for visual acuity and 0.28 units per unit change in D-index for area under CSF. While stereoacuity was poorly correlated with the better eye's D-index and the inter-ocular difference in D-index (r≤0.2, for both), a cluster-analysis indicated that cases with relatively better stereoacuity had an overall lower D-index and a reduced inter-ocular difference in D-index.
CONCLUSION:
Losses in contrast sensitivity may be a more sensitive marker of early keratoconus compared to visual acuity. The relatively faster rate of decline in visual acuity over CSF suggests that the former may be dictated by the optical degradation of the keratoconic eye while the latter may undergo neural recalibration to optimize low frequency details with increasing disease severity. Both the overall disease severity and interocular disease asymmetry may contribute to a loss of stereoacuity in keratoconus.
Change of corneal structure and loss of visual function in keratoconus have been evaluated independently, but the inter-relationship has received less attention. This study tested the hypothesis that the spatial- and depth-related visual functions have a triphasic pattern of deterioration with increasing corneal deformation in keratoconus: an early “ceiling” phase where visual functions are immune to structural deformation; an intermediate phase where structural and functional losses are proportional to each other; and a late “flooring” phase where no further deterioration in visual functions occur.
METHODS:
Monocular high-contrast visual acuity, Contrast Sensitivity Function (CSF) and binocular stereoacuity of 155 subjects (16-31yrs) with mild to advanced bilateral keratoconus was assessed with their best-corrected spectacles and natural pupils using standard psychophysical tests in this cross-sectional study. Disease severity was quantified using the multi-metric D-index. A five-parameter logistic regression equation constituting the three phases of the structure-function relationship was fitted to the data that were normalized to the value of historic controls.
RESULTS:
The regression equation explained ≥66% of variance in visual acuity and area under the CSF with increasing D-index, which varied from 1.9 – 29.3 (p<0.001 for both regression fits). The ceiling phase of the triphasic loss was apparent for visual acuity, but not for contrast sensitivity. Subsequent loss of function occurred at the rate of 1.8 units per unit change in D-index for visual acuity and 0.28 units per unit change in D-index for area under CSF. While stereoacuity was poorly correlated with the better eye's D-index and the inter-ocular difference in D-index (r≤0.2, for both), a cluster-analysis indicated that cases with relatively better stereoacuity had an overall lower D-index and a reduced inter-ocular difference in D-index.
CONCLUSION:
Losses in contrast sensitivity may be a more sensitive marker of early keratoconus compared to visual acuity. The relatively faster rate of decline in visual acuity over CSF suggests that the former may be dictated by the optical degradation of the keratoconic eye while the latter may undergo neural recalibration to optimize low frequency details with increasing disease severity. Both the overall disease severity and interocular disease asymmetry may contribute to a loss of stereoacuity in keratoconus.
A Curious Case of Unilateral Proptosis
Published 2023 by Lor Sildiryan
Article Type: Lectures & Workshops
COPE ID: 86542-GO
A 4 year old female who presents for ophthalmic evaluation due to mild ocular trauma to the left eye receives a life-changing diagnosis.
A 4 year old female who presents for ophthalmic evaluation due to mild ocular trauma to the left eye receives a life-changing diagnosis.
A Delphi Method for Development and Validation of a Questionnaire for Assessing Parents Awareness and Perception of Pediatric Screening and Exams
Published 2023 by Hadas Ben-Eli
Co-Author(s): Ahuva Ravid-Saffir, Shulamit Sella, Ariela Gordon-Shaag
Program Number: 235180
Article Type: Scientific Program
Board: 166
PURPOSE:
Parent's perceptions regarding the importance of vision screening and early intervention may constitute a significant barrier to seeking vision exams and pursuing treatment. The aim of this study was to develop and validate a questionnaire for assessing parent's perception of children's vision tests and willingness to adhere to recommendations.
METHOD:
The questionnaire was developed using Delphi method with experts from the fields of pediatric ophthalmology, optometry, orthoptics, pediatric medicine, social sciences and Mother Child Health Care centers. Experts were provided with drafts of the questions iteratively, in three-rounds until a consensus was reached independently on the relevant items that would be included in the questionnaire. The experts were also asked to comment on poor wording or redundancies and to suggest missing questions. Initial face and content validity were examined by calculating consensus between experts.
RESULTS:
The first, second and third stages of the Delphi process, 17, 15 and 13 experts participated in the panel, respectively. Face and content validity were achieved by wide consensus among the panel on the relevance of each question, of 75%, 85% and 90%, for the three rounds, respectively. At the end of the Delphi process, a questionnaire consisting of 31 questions was obtained that included questions regarding demographic, health literacy, perceptions of parents regarding vision tests, medical history of the child and family and adherence of parents with vision exams.
CONCLUSION:
The Delphi process used in this study created a validated new questionnaire for assessing parents' perception and adherence to vision exams. In the future, the questionnaire will be piloted on groups of parents of young children.
PURPOSE:
Parent's perceptions regarding the importance of vision screening and early intervention may constitute a significant barrier to seeking vision exams and pursuing treatment. The aim of this study was to develop and validate a questionnaire for assessing parent's perception of children's vision tests and willingness to adhere to recommendations.
METHOD:
The questionnaire was developed using Delphi method with experts from the fields of pediatric ophthalmology, optometry, orthoptics, pediatric medicine, social sciences and Mother Child Health Care centers. Experts were provided with drafts of the questions iteratively, in three-rounds until a consensus was reached independently on the relevant items that would be included in the questionnaire. The experts were also asked to comment on poor wording or redundancies and to suggest missing questions. Initial face and content validity were examined by calculating consensus between experts.
RESULTS:
The first, second and third stages of the Delphi process, 17, 15 and 13 experts participated in the panel, respectively. Face and content validity were achieved by wide consensus among the panel on the relevance of each question, of 75%, 85% and 90%, for the three rounds, respectively. At the end of the Delphi process, a questionnaire consisting of 31 questions was obtained that included questions regarding demographic, health literacy, perceptions of parents regarding vision tests, medical history of the child and family and adherence of parents with vision exams.
CONCLUSION:
The Delphi process used in this study created a validated new questionnaire for assessing parents' perception and adherence to vision exams. In the future, the questionnaire will be piloted on groups of parents of young children.
A Diagnostic Clue of Ocular Syphilis: Syphilitic Posterior Placoid Chorioretinitis
Published 2023 by Michelle Dang
Program Number: R2023217
Article Type: Residents Day
Board: R-201
Purpose:
A patient with new onset hazy vision and photosensitivity presents with characteristic clinical findings of syphilitic retinitis, prompting serologic work-up. The patient tests positive for syphilis, and initiation of treatment significantly improves the vision.
Case History:
34-year-old Hispanic male • CC: gray spot in center of vision in both eyes, sensitivity to light, mild soreness and redness • POH: glaucoma suspect due to ocular hypertension • PMH: hypertension, kidney disease, kidney transplant • Meds: amlodipine, mycophenolate
Pertinent Findings:
Clinical Findings • BCVA: OD 20/400, OS 20/200 • Pupils: OD 5.5mm in dark, slow/uneven constriction to light (-) APD; OS 3mm in dark, good constriction to light, (-) APD • IOP: OD 10mmHg, OS 12mmHg • SLE: 1+ injection OU; 3+ AC cell OD, 2+ AC cell OS • DFE: 1+ vit cell OU; whitening surrounding the macula in a circinate pattern OU • Macula OCT: RPE disruption with paracentral thickening Laboratory Testing Results • RPR titer – reactive • FTA-ABS – reactive • Quantiferon gold – WNL • CBC w/ diff – mildly low hemoglobin and hematocrit, otherwise WNL Referral • Infectious disease specialist for initiation of treatment
Differential Diagnosis:
• Primary/Leading: syphilis, tuberculosis, herpes simplex, sarcoidosis • Others: Vogt-Koyanagi-Harada (VKH) syndrome, Behcet's disease, toxoplasmosis
Diagnosis & Discussion:
Syphilis is a sexually transmitted disease caused by the bacteria T. pallidium. Syphilitic posterior placoid chorioretinitis, a manifestation of ocular syphilis, is characterized by a placoid lesion in the posterior pole coupled with RPE disruption. This lesion can have ill-defined borders and appear white in color. The chorioretinitis may also be present with varying levels of intraocular inflammation, including disc edema and serous retinal detachments. To confirm the infection, serologic testing must be ordered. Serologic testing for syphilis is divided into two categories: nontreponemal and treponemal. Nontreponemal testing, such as RPR and VDRL, is sensitive. Treponemal testing, such as FTA-ABS, is specific. Therefore, studies recommend ordering both to determine active syphilis infection.
Treatment, Management:
Once active syphilitic infection is confirmed, treatment should be initiated immediately. The current adult regimen for treating active infection is administration of 18-24 million units of penicillin G intravenously per day for 10-14 days. In patients with syphilitic posterior placoid chorioretinitis, treatment for syphilis results in significant improvement of signs and symptoms with minimal damage to the RPE. Case studies typically report complete recovery to baseline vision before infection. In addition to treatment of syphilis, topical steroids may be used to treat the intraocular inflammation.
Conclusion:
Ocular syphilis is often called ‘the great imitator' because its ocular manifestations can vary widely – however, syphilitic posterior placoid chorioretinitis has diagnostic features that are characteristic of this sexually transmitted disease. Syphilis should be a top differential in patients who present with an acute panuveitis or posterior uveitis when RPE disruption is also present.
Purpose:
A patient with new onset hazy vision and photosensitivity presents with characteristic clinical findings of syphilitic retinitis, prompting serologic work-up. The patient tests positive for syphilis, and initiation of treatment significantly improves the vision.
Case History:
34-year-old Hispanic male • CC: gray spot in center of vision in both eyes, sensitivity to light, mild soreness and redness • POH: glaucoma suspect due to ocular hypertension • PMH: hypertension, kidney disease, kidney transplant • Meds: amlodipine, mycophenolate
Pertinent Findings:
Clinical Findings • BCVA: OD 20/400, OS 20/200 • Pupils: OD 5.5mm in dark, slow/uneven constriction to light (-) APD; OS 3mm in dark, good constriction to light, (-) APD • IOP: OD 10mmHg, OS 12mmHg • SLE: 1+ injection OU; 3+ AC cell OD, 2+ AC cell OS • DFE: 1+ vit cell OU; whitening surrounding the macula in a circinate pattern OU • Macula OCT: RPE disruption with paracentral thickening Laboratory Testing Results • RPR titer – reactive • FTA-ABS – reactive • Quantiferon gold – WNL • CBC w/ diff – mildly low hemoglobin and hematocrit, otherwise WNL Referral • Infectious disease specialist for initiation of treatment
Differential Diagnosis:
• Primary/Leading: syphilis, tuberculosis, herpes simplex, sarcoidosis • Others: Vogt-Koyanagi-Harada (VKH) syndrome, Behcet's disease, toxoplasmosis
Diagnosis & Discussion:
Syphilis is a sexually transmitted disease caused by the bacteria T. pallidium. Syphilitic posterior placoid chorioretinitis, a manifestation of ocular syphilis, is characterized by a placoid lesion in the posterior pole coupled with RPE disruption. This lesion can have ill-defined borders and appear white in color. The chorioretinitis may also be present with varying levels of intraocular inflammation, including disc edema and serous retinal detachments. To confirm the infection, serologic testing must be ordered. Serologic testing for syphilis is divided into two categories: nontreponemal and treponemal. Nontreponemal testing, such as RPR and VDRL, is sensitive. Treponemal testing, such as FTA-ABS, is specific. Therefore, studies recommend ordering both to determine active syphilis infection.
Treatment, Management:
Once active syphilitic infection is confirmed, treatment should be initiated immediately. The current adult regimen for treating active infection is administration of 18-24 million units of penicillin G intravenously per day for 10-14 days. In patients with syphilitic posterior placoid chorioretinitis, treatment for syphilis results in significant improvement of signs and symptoms with minimal damage to the RPE. Case studies typically report complete recovery to baseline vision before infection. In addition to treatment of syphilis, topical steroids may be used to treat the intraocular inflammation.
Conclusion:
Ocular syphilis is often called ‘the great imitator' because its ocular manifestations can vary widely – however, syphilitic posterior placoid chorioretinitis has diagnostic features that are characteristic of this sexually transmitted disease. Syphilis should be a top differential in patients who present with an acute panuveitis or posterior uveitis when RPE disruption is also present.
A Double Negative Case of Diplopia
Published 2023 by Ashley Maglione
Program Number: 235345
Article Type: Scientific Program
Board: 61
PURPOSE:
Myasthenia gravis (MG) is an autoimmune disorder characterized by fatiguable voluntary muscle weakness. More than half of patients with MG present with ocular symptoms. There are two forms of MG: generalized MG, which is characterized by symptoms throughout the body, and ocular MG which is specific to voluntary muscles associated with the eye. Weakness occurs as the result of antibodies against receptors in the post-synaptic neuro-muscular junction. Most often, antibodies may bind, block, or modulate acetylcholine receptors (AChR). Muscarinic specific kinase (MuSK) receptor antibodies and lipoprotein receptor-related protein 4 (LRP4) receptor antibodies have been identified as alternate targets in AChR antibody negative MG patients. The purpose of this poster is to increase awareness of LRP4 antibody positive MG.
CASE REPORT:
A 45- year-old female presented with intermittent diplopia that worsened at the end of the day. Previous serum testing including AChR binding antibody and MuSK receptor antibody were normal. She denied ptosis, difficulty breathing/swallowing, or weakness of the body. Afferent examination was unremarkable. Extraocular motilities demonstrated reduced abduction OU. Cover testing revealed a comitant esophoria at distance. Exophthalmometry and levator function were normal. Palpebral aperture measurements were symmetric and unchanged post-fatigue and post-ice pack testing. However, post-fatigue testing, she demonstrated a new hyper deviation which resolved after ice pack application. Anterior segment and dilated posterior segment examination were noncontributory. Further blood work was ordered including serum AChR antibody blocking and modulating, anti-MuSK, and anti-LRP4. Serum Anti-LRP4 was positive and the diagnosis of double sero-negative (AChR/MuSK) LRP4-positive MG was made.
CONCLUSION:
As MG is among the differential diagnosis in patients with complaints of ptosis and/or diplopia, clinicians should inquire about difficulty breathing/swallowing, weakness, and if symptoms worsen with activity and/or at the end of the day. Careful versions and ductions, looking for subtle restrictions, and measurement of palpebral apertures, looking for ptosis, are vital clinical exam components in these patients. Even if these are unrevealing, clinicians should also consider performing fatigue and ice pack testing to assess for palpebral aperture and/or extraocular muscle changes that are characteristic of MG, as was seen in the above case. If there are possible features of MG during history or ophthalmic examination, blood work looking for LRP4 antibodies, even if prior antibody testing was negative, may be indicated. Up to half of double seronegative (AChR/MuSK) MG patients are LRP4 antibody positive. As ocular signs and symptoms may be the presenting sign of MG, eye care providers must be aware of these alternate antibody receptor targets.
PURPOSE:
Myasthenia gravis (MG) is an autoimmune disorder characterized by fatiguable voluntary muscle weakness. More than half of patients with MG present with ocular symptoms. There are two forms of MG: generalized MG, which is characterized by symptoms throughout the body, and ocular MG which is specific to voluntary muscles associated with the eye. Weakness occurs as the result of antibodies against receptors in the post-synaptic neuro-muscular junction. Most often, antibodies may bind, block, or modulate acetylcholine receptors (AChR). Muscarinic specific kinase (MuSK) receptor antibodies and lipoprotein receptor-related protein 4 (LRP4) receptor antibodies have been identified as alternate targets in AChR antibody negative MG patients. The purpose of this poster is to increase awareness of LRP4 antibody positive MG.
CASE REPORT:
A 45- year-old female presented with intermittent diplopia that worsened at the end of the day. Previous serum testing including AChR binding antibody and MuSK receptor antibody were normal. She denied ptosis, difficulty breathing/swallowing, or weakness of the body. Afferent examination was unremarkable. Extraocular motilities demonstrated reduced abduction OU. Cover testing revealed a comitant esophoria at distance. Exophthalmometry and levator function were normal. Palpebral aperture measurements were symmetric and unchanged post-fatigue and post-ice pack testing. However, post-fatigue testing, she demonstrated a new hyper deviation which resolved after ice pack application. Anterior segment and dilated posterior segment examination were noncontributory. Further blood work was ordered including serum AChR antibody blocking and modulating, anti-MuSK, and anti-LRP4. Serum Anti-LRP4 was positive and the diagnosis of double sero-negative (AChR/MuSK) LRP4-positive MG was made.
CONCLUSION:
As MG is among the differential diagnosis in patients with complaints of ptosis and/or diplopia, clinicians should inquire about difficulty breathing/swallowing, weakness, and if symptoms worsen with activity and/or at the end of the day. Careful versions and ductions, looking for subtle restrictions, and measurement of palpebral apertures, looking for ptosis, are vital clinical exam components in these patients. Even if these are unrevealing, clinicians should also consider performing fatigue and ice pack testing to assess for palpebral aperture and/or extraocular muscle changes that are characteristic of MG, as was seen in the above case. If there are possible features of MG during history or ophthalmic examination, blood work looking for LRP4 antibodies, even if prior antibody testing was negative, may be indicated. Up to half of double seronegative (AChR/MuSK) MG patients are LRP4 antibody positive. As ocular signs and symptoms may be the presenting sign of MG, eye care providers must be aware of these alternate antibody receptor targets.
A Foggy Journey: Remote Co-Management for Reactivated Ocular Toxoplasmosis Retinochoroiditis Lesion with Spillover Iridocyclitis
Published 2023 by Sayf Al-Khazraji
Program Number: R2023159
Article Type: Residents Day
Board: R-143
Purpose:
A patient with active toxoplasmosis retinochoroiditis and longstanding macular toxoplasmosis chorioretinal scar is managed atypically due to poor visual potential and socioeconomic constraints. An alternative approach can be beneficial in reactivated ocular toxoplasmosis management.
Case History:
• 24-year-old Hispanic male • CC: 1 day acute severe pain, photophobia and redness OS • POH: Long-standing decreased central vision OS after similar presentation of acute case 10 years ago in Honduras from ocular toxoplasmosis OS contracted from undercooked meat • PMH: Unremarkable • Medications: None
Pertinent Findings:
• Clinical o BCVA: 20/20 OD, CF at 2 feet OS o Initial IOP: 17 mmHg OD, 40 mmHg OS o Slit lamp: 2+ cell in anterior chamber, diffuse trace corneal edema, 1+ diffuse conjunctival injection OS o DFE: large macular chorioretinal toxoplasmosis scar OS, active inflammatory lesion 1DD in size inferiorly adjacent to scar with overlying vitritis, small single vitreous heme inferotemporal to active lesion, inferotemporal rim excavation
Differential Diagnosis:
Histoplasmosis, toxocariasis, acute retinal necrosis, progressive outer retinal necrosis, CMV retinitis, syphilis, sarcoidosis, tuberculosis
Diagnosis & Discussion:
Ocular toxoplasmosis is an infection caused by Toxoplasma gondii, a parasite commonly contracted from cat feces contact, undercooked meat, or congenitally. Although toxoplasmosis primarily affects the posterior segment, spillover iridocyclitis is not uncommon. Commonly arising from parasitic reactivation from immunocompromised patients yielding acute retinochoroiditis, symptoms can vary from blurry vision, photophobia, pain (secondary to elevated IOP from secondary anterior uveitis) to remaining asymptomatic. The asymmetric unilateral presentation often makes diagnosis challenging due to mimicry of other various conditions. Diagnosis involves clinical retinal analysis and OCT findings of active necrotizing retinal lesions often near retinal vasculature in the posterior pole, manifesting as “foggy” areas of overlying vitritis. Serological testing for Toxoplasma antibody titer and PCR analysis on aqueous humor can provide definitive confirmation of diagnosis alongside clinical findings.
Treatment, Management:
The patient was provided with 2 sets of apraclonidine, timolol, and dorzolamide spaced 25 minutes apart, followed by 500mg acetazolamide in office (7/14), resulting in IOP of 22 mmHg OS 2 hours after initial IOP reading, followed by atropine OS. Patient began Simbrinza BID OS and azithromycin 250mg BID first day, then 250mg QD x 30 days. Azithromycin chosen due to patient's financial constraints and lack of insurance. Remote co-management with retina performed due to poor visual potential and financial limitations. Subsequent visits had worsening AC reaction 3 days after initial visit (3+ cells, 1+ non-granulomatous KPs) with controlled IOP (19 mmHg) and improved patient comfort. Patient prescribed prednisolone acetate Q2H but began its use 3 days after. Steroid taper initiated to QID after no AC reaction on 7/28. Exam showcased coalesced vitreal debris, decreased haze, and scarring retinal lesion (8/04). Patient comfort and IOP remained stable throughout follow-ups (average 13 mmHg).
Conclusion:
Spillover iridocylcitis from reactivated toxoplasmosis necrotizing retinitis can yield a variety of presenting symptoms. Treatment of secondary anterior segment involvement and alternative oral antibiotic intervention are beneficial in management of visually and financially constrained patients with active ocular toxoplasmosis. Atypical treatment to active ocular toxoplasmosis such as azithromycin can be permissible for patients with socioeconomic limitations and poor visual acuity potential.
Purpose:
A patient with active toxoplasmosis retinochoroiditis and longstanding macular toxoplasmosis chorioretinal scar is managed atypically due to poor visual potential and socioeconomic constraints. An alternative approach can be beneficial in reactivated ocular toxoplasmosis management.
Case History:
• 24-year-old Hispanic male • CC: 1 day acute severe pain, photophobia and redness OS • POH: Long-standing decreased central vision OS after similar presentation of acute case 10 years ago in Honduras from ocular toxoplasmosis OS contracted from undercooked meat • PMH: Unremarkable • Medications: None
Pertinent Findings:
• Clinical o BCVA: 20/20 OD, CF at 2 feet OS o Initial IOP: 17 mmHg OD, 40 mmHg OS o Slit lamp: 2+ cell in anterior chamber, diffuse trace corneal edema, 1+ diffuse conjunctival injection OS o DFE: large macular chorioretinal toxoplasmosis scar OS, active inflammatory lesion 1DD in size inferiorly adjacent to scar with overlying vitritis, small single vitreous heme inferotemporal to active lesion, inferotemporal rim excavation
Differential Diagnosis:
Histoplasmosis, toxocariasis, acute retinal necrosis, progressive outer retinal necrosis, CMV retinitis, syphilis, sarcoidosis, tuberculosis
Diagnosis & Discussion:
Ocular toxoplasmosis is an infection caused by Toxoplasma gondii, a parasite commonly contracted from cat feces contact, undercooked meat, or congenitally. Although toxoplasmosis primarily affects the posterior segment, spillover iridocyclitis is not uncommon. Commonly arising from parasitic reactivation from immunocompromised patients yielding acute retinochoroiditis, symptoms can vary from blurry vision, photophobia, pain (secondary to elevated IOP from secondary anterior uveitis) to remaining asymptomatic. The asymmetric unilateral presentation often makes diagnosis challenging due to mimicry of other various conditions. Diagnosis involves clinical retinal analysis and OCT findings of active necrotizing retinal lesions often near retinal vasculature in the posterior pole, manifesting as “foggy” areas of overlying vitritis. Serological testing for Toxoplasma antibody titer and PCR analysis on aqueous humor can provide definitive confirmation of diagnosis alongside clinical findings.
Treatment, Management:
The patient was provided with 2 sets of apraclonidine, timolol, and dorzolamide spaced 25 minutes apart, followed by 500mg acetazolamide in office (7/14), resulting in IOP of 22 mmHg OS 2 hours after initial IOP reading, followed by atropine OS. Patient began Simbrinza BID OS and azithromycin 250mg BID first day, then 250mg QD x 30 days. Azithromycin chosen due to patient's financial constraints and lack of insurance. Remote co-management with retina performed due to poor visual potential and financial limitations. Subsequent visits had worsening AC reaction 3 days after initial visit (3+ cells, 1+ non-granulomatous KPs) with controlled IOP (19 mmHg) and improved patient comfort. Patient prescribed prednisolone acetate Q2H but began its use 3 days after. Steroid taper initiated to QID after no AC reaction on 7/28. Exam showcased coalesced vitreal debris, decreased haze, and scarring retinal lesion (8/04). Patient comfort and IOP remained stable throughout follow-ups (average 13 mmHg).
Conclusion:
Spillover iridocylcitis from reactivated toxoplasmosis necrotizing retinitis can yield a variety of presenting symptoms. Treatment of secondary anterior segment involvement and alternative oral antibiotic intervention are beneficial in management of visually and financially constrained patients with active ocular toxoplasmosis. Atypical treatment to active ocular toxoplasmosis such as azithromycin can be permissible for patients with socioeconomic limitations and poor visual acuity potential.
A Large-Scale in Practice Evaluation of a Novel Daily Disposable Spherical Contact Lens
Published 2023 by Kurt Moody
Co-Author(s): Drew Hotte, DAVID RUSTON, Patricia Martin, John Buch
Program Number: 235116
Article Type: Scientific Program
Board: 102
PURPOSE:
To evaluate the clinical performance over multiple comfort and vision metrics, of a new and novel daily disposable (DD) silicone hydrogel contact lens (SiHy CL) in a real-world clinical environment.
METHOD:
99 Eye Care Professionals (ECPs) were recruited in the US in 2022 who had a mixture of different leading DD CL product preferences. They were asked to fit patients with these new generation senofilcon A CLs, either sphere or multifocal, using their habitual clinical protocol and charge their established fitting fees as well as their normal lens costs. The doctors and patients were asked to fill out surveys and a nominal fee was provided to them. The spherical results are presented here. In total, 1216 patients were fitted with the spherical product. ECPs were surveyed three times: firstly, at baseline, then post fitting and then at the end of the investigation. Patients were surveyed 10 days after fitting. All surveys were completed online.
RESULTS:
605 survey results from 81 ECPs were received. Key findings were: 90% of ECPs agreed that ACUVUE® OASYS MAX 1-Day CLs (MAX 1-Day) provide unprecedented levels of comfort. 96% agreed they deliver on the needs of patients with intense digital device usage. 91% also agreed they are their first choice for upgrading patients. After being fitted with MAX 1-Day CLs, 96% of patients stated they would recommend their eye doctor to their friends or family.
CONCLUSION:
An in-practice assessment as described here differs from a formal clinical study in that the ECP follows their own fitting protocol and the patients are charged their normal fees, thus representative of what occurs in typical real-world patient encounters. Both ECPs and patients in this assessment exhibited highly favorable responses to the new spherical SiHy DD contact lens. This is likely to be a consequence of the lens incorporating a combination of two innovative technologies enabled by using Johnson & Johnson Vision's newest manufacturing technology which includes a double-sided curing process using LED lights.
PURPOSE:
To evaluate the clinical performance over multiple comfort and vision metrics, of a new and novel daily disposable (DD) silicone hydrogel contact lens (SiHy CL) in a real-world clinical environment.
METHOD:
99 Eye Care Professionals (ECPs) were recruited in the US in 2022 who had a mixture of different leading DD CL product preferences. They were asked to fit patients with these new generation senofilcon A CLs, either sphere or multifocal, using their habitual clinical protocol and charge their established fitting fees as well as their normal lens costs. The doctors and patients were asked to fill out surveys and a nominal fee was provided to them. The spherical results are presented here. In total, 1216 patients were fitted with the spherical product. ECPs were surveyed three times: firstly, at baseline, then post fitting and then at the end of the investigation. Patients were surveyed 10 days after fitting. All surveys were completed online.
RESULTS:
605 survey results from 81 ECPs were received. Key findings were: 90% of ECPs agreed that ACUVUE® OASYS MAX 1-Day CLs (MAX 1-Day) provide unprecedented levels of comfort. 96% agreed they deliver on the needs of patients with intense digital device usage. 91% also agreed they are their first choice for upgrading patients. After being fitted with MAX 1-Day CLs, 96% of patients stated they would recommend their eye doctor to their friends or family.
CONCLUSION:
An in-practice assessment as described here differs from a formal clinical study in that the ECP follows their own fitting protocol and the patients are charged their normal fees, thus representative of what occurs in typical real-world patient encounters. Both ECPs and patients in this assessment exhibited highly favorable responses to the new spherical SiHy DD contact lens. This is likely to be a consequence of the lens incorporating a combination of two innovative technologies enabled by using Johnson & Johnson Vision's newest manufacturing technology which includes a double-sided curing process using LED lights.
A Myopic Mystery: Less Common Presentations of Nuclear Sclerotic Cataracts
Published 2023 by Jacob Wilson
Program Number: R2023032
Article Type: Residents Day
Board: R-16
Purpose:
To familiarize providers with the 'milky' presentation of nuclear cataracts, in lieu of yellowing or brunescence. These cataracts often go missed or misdiagnosed, resulting in frustration and confusion for both patients and doctors.
Case History:
A 47 year-old Native American male presents with a complaint of decreased vision and diplopia OS, stating that his vision worsened over the last 3-4 months. The patient has a history of bilateral exudative retinal detachments, with a failed repair OD in 2002 and a successful scleral buckle repair with silicone oil OS in 2017, with a subsequent ERM peel OS in 2018. The patient is also a glaucoma suspect OS. He has a history of hypothyroidism and psoriatic arthritis. He has no ocular medications.
Pertinent Findings:
VAcc: OD - NLP (stable from 2021) OS - 20/400, PH - 20/80-2 (BCVA 20/40 in 2021) Habitual Srx: OD - N/A OS: -10.00 -4.25 x150 AR: OD: N/A OS: -21.25 -4.50 x166 Manifest Srx: OD - Bal OS: -18.75 -4.00 x160, VA: 20/70-1 Pertinent anterior segment OS: Conjunctiva: Clear, no injection, inferior concretions Cornea: Clear all layers, 4 second TBUT Anterior Chamber: Deep and quiet Iris: Flat, intact, brown Lens: 3+ milky nucleus. Initially appeared less severe prior to closer inspection. IOP: 31 mmHg OD 21 mmHg OS Posterior segment OS (no view OD): Disc: 0.85 round, with superior being the thinnest. Pink, healthy rim tissue Vitreous: Superior peripheral silicon oil bubble Macula - Trace erm Vessels: AV 2/3 Periphery: Flat to scleral buckle with scarring 360 Fasting blood sugar: 106 mg/dl
Differential Diagnosis:
1. Myopic shift due to elevated FBS 2. Staphyloma, pathologic myopia 3. Axial elongation due to scleral buckle 4. Nuclear cataract with a 'milky' presentation
Diagnosis & Discussion:
The first three differentials for the patient's myopic shift are quickly ruled out due to a lack of elevated blood sugar, an OCT within normal limits, and the fact that the scleral buckle was placed nearly six years ago and any related complications would be unlikely to arise at this point. Therefore, the remaining diagnosis is a soft white or 'milky' cataract. Upon reexamination, a 3+ nuclear white cataract was noted. A milky, or soft white, cataract is a variation of a nuclear sclerotic cataract in which the lens takes on a white appearance that can be difficult to perceive. They generally allow a clear view of the posterior segment, even though the patient's acuity is significantly decreased. Milky cataracts are most common in younger patients with no underlying systemic condition, but it's worth noting that a past history of vitrectomy is also a risk factor for developing cataracts in general. It is unclear if our patient's current condition is linked to his past procedures.
Treatment, Management:
The most effective treatment for this condition is a cataract extraction with an intraocular lens implant, just as with other forms of cataracts. There should be no expectation of maximum visual improvement with blood sugar control, corrective lenses, or any other method short of surgical intervention. Due to the patient's past history of retinal detachment, he should be well educated on the signs and symptoms of retinal detachment after his surgery and should be followed closely with a dilated fundus exam at least yearly going forward. He was scheduled for a surgical consult with the hospital's ophthalmologist. Additionally, the patient was started on Xalatan 0.005% OS qhs. This was done due to increased IOP OS, the fragile nature of his nerve due to high myopia and increased axial length, and a potential area of thinning on an RNFL OCT. The patient will return for further evaluation with an IOP check, 24-2 visual field and gonioscopy following his cataract surgery and recovery.
Conclusion:
It is imperative that eye care providers be adept at detecting these subtle, yet visually significant lenticular changes. If not, patients and providers alike may spend unnecessary time and energy running through incorrect differentials rather than correcting the patient's vision with surgery as soon as possible. These 'milky' cataracts are difficult to visualize with biomicroscopy alone, but pertinent symptoms and history should point providers in the direction of this difficult diagnosis.
Purpose:
To familiarize providers with the 'milky' presentation of nuclear cataracts, in lieu of yellowing or brunescence. These cataracts often go missed or misdiagnosed, resulting in frustration and confusion for both patients and doctors.
Case History:
A 47 year-old Native American male presents with a complaint of decreased vision and diplopia OS, stating that his vision worsened over the last 3-4 months. The patient has a history of bilateral exudative retinal detachments, with a failed repair OD in 2002 and a successful scleral buckle repair with silicone oil OS in 2017, with a subsequent ERM peel OS in 2018. The patient is also a glaucoma suspect OS. He has a history of hypothyroidism and psoriatic arthritis. He has no ocular medications.
Pertinent Findings:
VAcc: OD - NLP (stable from 2021) OS - 20/400, PH - 20/80-2 (BCVA 20/40 in 2021) Habitual Srx: OD - N/A OS: -10.00 -4.25 x150 AR: OD: N/A OS: -21.25 -4.50 x166 Manifest Srx: OD - Bal OS: -18.75 -4.00 x160, VA: 20/70-1 Pertinent anterior segment OS: Conjunctiva: Clear, no injection, inferior concretions Cornea: Clear all layers, 4 second TBUT Anterior Chamber: Deep and quiet Iris: Flat, intact, brown Lens: 3+ milky nucleus. Initially appeared less severe prior to closer inspection. IOP: 31 mmHg OD 21 mmHg OS Posterior segment OS (no view OD): Disc: 0.85 round, with superior being the thinnest. Pink, healthy rim tissue Vitreous: Superior peripheral silicon oil bubble Macula - Trace erm Vessels: AV 2/3 Periphery: Flat to scleral buckle with scarring 360 Fasting blood sugar: 106 mg/dl
Differential Diagnosis:
1. Myopic shift due to elevated FBS 2. Staphyloma, pathologic myopia 3. Axial elongation due to scleral buckle 4. Nuclear cataract with a 'milky' presentation
Diagnosis & Discussion:
The first three differentials for the patient's myopic shift are quickly ruled out due to a lack of elevated blood sugar, an OCT within normal limits, and the fact that the scleral buckle was placed nearly six years ago and any related complications would be unlikely to arise at this point. Therefore, the remaining diagnosis is a soft white or 'milky' cataract. Upon reexamination, a 3+ nuclear white cataract was noted. A milky, or soft white, cataract is a variation of a nuclear sclerotic cataract in which the lens takes on a white appearance that can be difficult to perceive. They generally allow a clear view of the posterior segment, even though the patient's acuity is significantly decreased. Milky cataracts are most common in younger patients with no underlying systemic condition, but it's worth noting that a past history of vitrectomy is also a risk factor for developing cataracts in general. It is unclear if our patient's current condition is linked to his past procedures.
Treatment, Management:
The most effective treatment for this condition is a cataract extraction with an intraocular lens implant, just as with other forms of cataracts. There should be no expectation of maximum visual improvement with blood sugar control, corrective lenses, or any other method short of surgical intervention. Due to the patient's past history of retinal detachment, he should be well educated on the signs and symptoms of retinal detachment after his surgery and should be followed closely with a dilated fundus exam at least yearly going forward. He was scheduled for a surgical consult with the hospital's ophthalmologist. Additionally, the patient was started on Xalatan 0.005% OS qhs. This was done due to increased IOP OS, the fragile nature of his nerve due to high myopia and increased axial length, and a potential area of thinning on an RNFL OCT. The patient will return for further evaluation with an IOP check, 24-2 visual field and gonioscopy following his cataract surgery and recovery.
Conclusion:
It is imperative that eye care providers be adept at detecting these subtle, yet visually significant lenticular changes. If not, patients and providers alike may spend unnecessary time and energy running through incorrect differentials rather than correcting the patient's vision with surgery as soon as possible. These 'milky' cataracts are difficult to visualize with biomicroscopy alone, but pertinent symptoms and history should point providers in the direction of this difficult diagnosis.
A Nerve-racking Complication: Optic Neuritis Post-Endoscopic Sinus Surgery
Published 2023 by Carol Yu
Program Number: 235367
Article Type: Scientific Program
Board: 83
PURPOSE:
Major ocular complications following Endoscopic Sinus Surgery (ESS) are rare. However, it is critical for the practitioner to be aware of potential vision threatening side effects. The lamina papyracea (LP) represents a particularly vulnerable site during ESS due to its status as the weakest portion of the medial orbital wall. This vulnerability arises from its proximity to the optic nerve and visual obscuration from a thin layer of fat. A break in the LP can result in Optic Nerve damage from inflammation of the surgical site, ischemia due to injury of the posterior ciliary artery, or compression from a bony fragment or hematoma. The primary objective of this poster is to review a case of optic nerve edema from ESS.
CASE REPORT:
A 48-year-old female presents with mild decreased vision and eye pain in the left eye after a recent left ethmoidectomy involving the left maxillary and ethmoid sinuses. Past medical history is significant for photorefractive keratectomy and hypothyroidism. Upon examination, the patient's uncorrected distance visual acuity was 20/20 in each eye. The patient demonstrated normal pupil testing, color vision testing, binocular vision testing, intraocular pressure, and anterior segment evaluation. There was no relevant afferent pupillary defect. The patient noted mild pain in the left eye on right gaze as the eye moved towards the surgical site, but extraocular movements were full, and no diplopia was experienced by the patient. On red cap desaturation test, the patient reported 90% saturation in the left eye compared to the right. Fundus examination revealed a hyperemic, elevated left optic nerve, more so superiorly with vessel obscuration. Humphrey visual field revealed a correlated inferior nasal defect in the left eye. B-scan ultrasound of the eye was negative for disc drusen. An MRI and CT of the orbit was ordered, and the patient was started on oral steroids.
CONCLUSION:
Although exceptionally uncommon, optic nerve injury can arise from Endoscopic Sinus Surgery. This is due to the thin separation by the lamina papyracea between the ethmoid sinus and the orbit. Optic neuropathy can result from inflammation, ischemia, or compression. Subtle cases may even present without a relevant afferent pupillary defect if the difference in mean deviation between the two eyes is less than 0.30. Therefore, it is pivotal for the practitioner to possess a comprehensive understanding of orbital anatomy and to be mindful of potential complications when assessing symptomatic patients following ESS.
PURPOSE:
Major ocular complications following Endoscopic Sinus Surgery (ESS) are rare. However, it is critical for the practitioner to be aware of potential vision threatening side effects. The lamina papyracea (LP) represents a particularly vulnerable site during ESS due to its status as the weakest portion of the medial orbital wall. This vulnerability arises from its proximity to the optic nerve and visual obscuration from a thin layer of fat. A break in the LP can result in Optic Nerve damage from inflammation of the surgical site, ischemia due to injury of the posterior ciliary artery, or compression from a bony fragment or hematoma. The primary objective of this poster is to review a case of optic nerve edema from ESS.
CASE REPORT:
A 48-year-old female presents with mild decreased vision and eye pain in the left eye after a recent left ethmoidectomy involving the left maxillary and ethmoid sinuses. Past medical history is significant for photorefractive keratectomy and hypothyroidism. Upon examination, the patient's uncorrected distance visual acuity was 20/20 in each eye. The patient demonstrated normal pupil testing, color vision testing, binocular vision testing, intraocular pressure, and anterior segment evaluation. There was no relevant afferent pupillary defect. The patient noted mild pain in the left eye on right gaze as the eye moved towards the surgical site, but extraocular movements were full, and no diplopia was experienced by the patient. On red cap desaturation test, the patient reported 90% saturation in the left eye compared to the right. Fundus examination revealed a hyperemic, elevated left optic nerve, more so superiorly with vessel obscuration. Humphrey visual field revealed a correlated inferior nasal defect in the left eye. B-scan ultrasound of the eye was negative for disc drusen. An MRI and CT of the orbit was ordered, and the patient was started on oral steroids.
CONCLUSION:
Although exceptionally uncommon, optic nerve injury can arise from Endoscopic Sinus Surgery. This is due to the thin separation by the lamina papyracea between the ethmoid sinus and the orbit. Optic neuropathy can result from inflammation, ischemia, or compression. Subtle cases may even present without a relevant afferent pupillary defect if the difference in mean deviation between the two eyes is less than 0.30. Therefore, it is pivotal for the practitioner to possess a comprehensive understanding of orbital anatomy and to be mindful of potential complications when assessing symptomatic patients following ESS.