Ophthalmoscopic Examination Research Articles

Comparative analysis for the fundus characteristics of acquired immune deficiency syndrome with cytomegalovirus retinitis between first-visit and non-first-visit in ophthalmology

Objective To comparatively analyze for the fundus characteristics of acquired immune deficiency syndrome (AIDS) with cytomegalovirus retinitis (CMVR) between first-visit and non-first-visit in ophthalmology. Methods A retrospective study was performed for 22 patients (41 eyes) diagnosed as CMVR with AIDS by ophthalmology in the Affiliated Municipal Hospital of Xuzhou Medical University from July 2004 to September 2017. The patients were divided into two groups: one with the first-visit in ophthalmology (FVO) and the other with the first-visit in non-ophthalmology (FVNO). All patients underwent visual acuity, intraocular pressure, slit lamp microscope and indirect ophthalmoscope examinations. Thirty-nine eyes of 21 patients with clear refractive media were examined by color fundus photography, of which 5 patients were examined by FFA. Five patients examined by OCT and B-mode ultrasound. The CMVR were characterized as fulminant type or indolent type. All the 22 patients (41 eyes) except 2 patients (4 eyes) accepted highly active antiroviral therapy, and all patients were treated with ganciclovir intravenously. Nine patients (12 eyes) received intravitreal injection of ganciclovir, 7 patients (10 eyes) underwent vitrectomy because of retinal detachment, 6 patients (7 eyes) gave up surgery because of extensive retinal detachment, and the other 12 eyes did not undergo any eye surgery. All patients were followed for 6-58 months (average 23±39 months). The incidences and fundus characteristics of the patients with fulminant or indolent CMVR were compared and analyzed. Between the two groups, the difference of visual acuity and CD4+T cell count at the first vist and the last follow-up were analyzed by a t-test, and the macular involvement and spread of the two groups were compared by a chi-square test. Results Fulminant CMVR showed dense yellow-white necrotic lesions along the great vessels with or without satellite lesions, while indolent CMVR showed sparse yellow-white granular lesions with a little bleeding. The concomitant signs included frost-like dendritic vascular sheath, retinal artery occlusion and optic disc edema. Fourteen eyes of 7 patients in FVO group were fulminant, including 2 patients (2 eyes) with retinal artery occlusion and 1 patient (two eyes) with optic disc edema. In FVNO group, there were 27 eyes of 15 patients, including 21 eyes of 13 cases identified as fulminant type and 6 eyes of 4 patients as indolent type. In the fulminant type, there were 4 patients (6 eyes) with frost-like dendritic vascular sheath, 10 patients (12 eyes) with retinal artery occlusion and 4 patients (4 eyes) with optic disc edema. There was no significant difference in initial visual acuity (t=-1.534, P=0.133), but there was a significant difference in visual acuity at the last follow-up (t=-3.420, P=0.001). There was no significant difference in CD4+ T cells between the two groups at the first visit (t=-0.902, P=0.378). The proportions of macular involvement and 3-4 quadrant involvement in FVO group were significantly higher than those in FVNO group (χ2=7.552, 7.865; P=0.006, 0.005). Conclusion For AIDS patients with CMVR, the first-visit in ophthalmology showed more dense necrotic lesions involving macular and a wider range of lesions than the first-visit in non-ophthalmology. Key words: Acquired immunodeficiency syndrome/complications; Cytomegalovirus retinitis; First-visit in ophthalmology; Fundus features

Plus Disease in Retinopathy of Prematurity: Convolutional Neural Network Performance Using a Combined Neural Network and Feature Extraction Approach.

PurposeRetinopathy of prematurity (ROP), a leading cause of childhood blindness, is diagnosed by clinical ophthalmoscopic examinations or reading retinal images. Plus disease, defined as abnormal tortuosity and dilation of the posterior retinal blood vessels, is the most important feature to determine treatment-requiring ROP. We aimed to create a complete, publicly available and feature-extraction-based pipeline, I-ROP ASSIST, that achieves convolutional neural network (CNN)-like performance when diagnosing plus disease from retinal images.MethodsWe developed two datasets containing 100 and 5512 posterior retinal images, respectively. After segmenting retinal vessels, we detected the vessel centerlines. Then, we extracted features relevant to ROP, including tortuosity and dilation measures, and used these features in the classifiers including logistic regression, support vector machine and neural networks to assess a severity score for the input. We tested our system with fivefold cross-validation and calculated the area under the curve (AUC) metric for each classifier and dataset.ResultsFor predicting plus versus not-plus categories, we achieved 99% and 94% AUC on the first and second datasets, respectively. For predicting pre-plus or worse versus normal categories, we achieved 99% and 88% AUC on the first and second datasets, respectively. The CNN method achieved 98% and 94% for predicting two categories on the second dataset.ConclusionsOur system combining automatic retinal vessel segmentation, tracing, feature extraction and classification is able to diagnose plus disease in ROP with CNN-like performance.Translational RelevanceThe high performance of I-ROP ASSIST suggests potential applications in automated and objective diagnosis of plus disease.

Primary care physicians' knowledge, attitudes, and practices related to diabetic retinopathy in Buraidah city, Qassim region, Saudi Arabia

Background: Diabetic retinopathy (DR) is one of the severe complications of diabetes that can result in complete blindness when it presents late in the course of the disease. The role of primary care physicians (PCPs) in the screening, prevention, and possibly referral of patients with this complication is of great importance. Materials and Methods: An analytic cross-sectional study was conducted in all primary care clinics in Buraidah city, Qassim region, Saudi Arabia. The sampling technique used is convenience sampling. The sample is PCPs (PCPs). Data were collected using a pretested, semi-structured questionnaire with sections for assessment of knowledge, attitudes, and practices toward DR in the PCPs. Results: Out of a total of 106 physicians, 100 have answered the questionnaire with a response rate of 94%, 75% have received postgraduate training. Eighty-seven percent of the PCPs have agreed that an ophthalmoscope is needed in their clinic while only (35%) have agreed that they can do an ophthalmoscopic examination confidently to detect DR in patients with diabetes. Around 23% have disagreed that diabetic patients can have DR despite having a good vision, and only 56% have agreed that pregnancy can actually worsen DR. Conclusions: The knowledge, attitudes, and practices of PCPs are sub-optimal. Dilated Fundus Examination using a slit-lamp ophthalmoscope is the best technique used in the screening of DR. Primary care centers should be equipped with more technologically advanced ophthalmic devices, and tele-screening should be utilized to precisely diagnose DR. Moreover, the communication with and referral to ophthalmology should be done on findings that are suggestive of DR. PCPs should stress the importance of screening to their diabetic patients. Finally, more efforts should be placed to increase knowledge in certain areas like DR effects in pregnant patients.

Nutritional anemia as a cause of reversible blindness

We report a case of 42-year-old male presented with acute onset breathlessness and blurring of vision in both eyes. Upon evaluation, the patient is found to have vitamin B12 and iron deficiency anemia; ophthalmoscopic examination revealed bilateral preretinal hemorrhages and Roth spots. This case documents the occurrence of retinopathy in nutritional dimorphic anemia causing blindness which is reversible after correction of anemia.

Increased rate of any retinopathy risk in patients with masked hypertension

ABSTRACT Purpose Hypertension is a common chronic disorder with end organ damage. Hypertensive retinopathy is a response to elevated blood pressure characterized retinal arteriolar intimal thickening, hyperplasia of the intima-media end with sclerosis. There is a relationship between high blood pressure and retinopathy grade. Masked hypertension is a phenomenon of normal blood pressure in the office but high in out of office that associated with an increases risk of cardiovascular disease. In this study, we aimed to investigate retinopathy in masked hypertensive patients. Methods We enrolled 92 patients with masked hypertension and 87 healthy controls in to the study. We use ambulatory blood pressure monitoring (ABPM) to detect the masked hypertension. Bilateral fundus examination was performed. Hypertensive retinopathy (HTRP) grading was determined according to the Keith–Wagener–Barker classification. We examined retinopathy grade in patients with masked hypertension and without. Results 55 (11.6%) participants had signs of retinopathy. Fifty (54.3%) subjects had any retinopathy in patients with masked hypertension and five (5.7%) subjects had any retinopathy in controls (p < .001). Median of KWB grade was 1 (0–4) in patients with masked hypertension and 0 (0–2) in controls (p < .001). There were a positive significant correlation between KWB grade and day-time systolic blood pressure (r = 0.460, p < .001), day-time diastolic blood pressure (r = 0.448, p < .001), presence of masked hypertension (r = 0.527, p < .001). Conclusions There was a considerable rate of any retinopathy in masked hypertension. Consequently, ophthalmoscopic examination should be as part of the care in patients who have a risk for masked hypertension.

Self‐perforation of eye in patients with mental disorders

AbstractPurposeThe purpose of the study was to inform ophthalmologists about the self‐perforation of the eye in patients with mental disorders based on a clinical case.MethodsAn overview, biomicroscopy of the ocular surface, ophthalmoscopy examination, ocular X‐ray examination, MRI, general‐clinical studies, consultation with psychiatrist and anesthesiologist.ResultsA schizophrenic young guy came with his mother in Ophthalmology department, the patient was catatonic and no cooperative, so no history could be obtained. Mother of the patient has noticed bloody discharge on pillow and in lower eyelid of the right eye.External examination O.D: no changes in the eyelid, in the conjunctiva of the lower arch in the internal third there was noticed a limited hemorrhage, trauma of conjunctiva, the mobility of the eyeballs was not disturbed, the bottom part of the face was unchanged .Antibacterial and anti‐inflammatory drops were prescribed (Signicef, Clodifen). On second day O.D: hematoma of the eyelid, chemosis of the conjunctiva, limitation of the eyeball movements, lack of the of the pupil reaction to the light, pallor optic disc, blindness. Under the skin in the projection of superior medial of orbit was palpated a foreign body with diameter 5 mm. O.S: hematoma of lower and upper eyelids and blindness. X‐RAY examination of the orbit: was noticed a foreign body measuring 4 by 2 mm which was localized in projection of the left orbit. MRI: was noticed the shadow of foreign body on the right orbit 4.5 by 0.5 mm which was localized near the inner wall of the orbit and reached its top, as a result damage 2/3rd of the right optic nerve. To the left of the orbit was determined the shadow of foreign body that intersects with the optic nerve. During the surgery half of the plastic pen was removed from the right orbit. On the left orbit was present the end of the pen ball (the other half of the pen) but was decided not to remove it. The psychiatrist found out that the patient had auditory hallucinations which ordered him to scratch his eyes, which he did by the pen. Total damage of the optic nerve of the right eye and damage of the rods on the left eye.ConclusionsPatients with mental disorders are able to self‐attack and resulting in loss of the vision. In the absence of the contact the collection of anamnesis and diagnosis the problem it is complicated. In patients suspected of injuries it is recommended to be used all the methods of examinations so not to lose time.

Relationship between progression of type 2 diabetes mellitus and olfactory function

In the literature, diabetes mellitus was mentioned as one of the etiologic factors of olfactory disorder. However, association between olfactory dysfunction and complications of type 2 diabetes mellitus is unclear. The aim of this study was to determine if there is any correlation between olfactory dysfunction and complications of diabetes mellitus. The study population included eighty-five (85) patients with type 2 diabetes mellitus (56 females and 29 males, mean age 55.4±9.4years). The routine laboratory and ophthalmoscope examinations were used in the study. The Connecticut Chemosensory Clinical Research Center odor test was performed to all patients. Patients were grouped (normal, anosmia, mild hyposmia, moderate hyposmia, severe hyposmia) in respect to olfactory function. Distribution of the patients was 34.1% male (29) and 65.9% female (56). Mean Hemoglobin A1c value was 9.0±2.7. The distribution of complications was 38.8% nephropathy, 25.9% retinopathy, 24.7% microalbuminuria. In Odor Test classification, statistically significant difference was not detected in nephropathy, retinopathy and microalbuminuria ratios (p=0.523, p=0.057, p=0.993). This study revealed that in odor test classification, statistically significant difference was not detected between the patients with complications (nephropathy, retinopathy, and microalbuminuria) and the patients without complications.

Unilateral visual impairment in a patient undergoing chemotherapy: a case report and clinical findings

BackgroundVisual impairment occurred as an infrequent form of chemotherapeutic toxicity and was often underestimated despite of several reports. We described a case of acute unilateral visual impairment after one cycle of intravenous chemotherapy of a normal dose, aiming at raising attention to chemotherapy-induced ocular toxicity.Case presentationThe patient developed a progressive vision loss in the right eye during the chemotherapy. After one cycle of intravenous chemotherapy, her visual acuity decreased by 0.6 in the right eye (VOD = 0.4) compared to the previous value of 1.0 (VOD = 1.0). No evidence of ocular infiltration was observed from the cerebral magnetic resonance imaging (MRI). During her follow-up period, we documented the ophthalmologic examinations including visual acuity, visual field (VF), visual evoked potential (VEP), electroretinogram (ERG), fundus photograph (FP), fundus fluorescein angiography (FFA) and optical coherence tomography (OCT). Ophthalmoscope examination and fundus photograph showed optic disc edema, fuzzy boundary and linear hemorrhages in her right eye. Fundus fluorescein angiography (FFA) revealed capillary underdevelopment at the nasal and superior temporal area of the optic disc in the early phase and capillary fluorescein leakage in the late phase. The result of VEP test suggested the impaired function of the optic nerve. Thus, a diagnosis of nonarteritic anterior ischemic optic neuropathy (NAION) was made by the ophthalmologist according to these results. The patient was prescribed prednisone combined with neuroprotective drugs, which did not work. After the cessation of chemotherapy, her impaired vision gradually recovered.ConclusionsThis is the first reported case of acute visual impairment in a patient who underwent chemotherapy of a normal dose. It is indicated that while receiving benefits from chemotherapy, cancer patients simultaneously suffer from the risk of vision loss.

Delayed Retinal Breaks and Detachments after Acute Posterior Vitreous Detachment

To determine the incidence and timing of delayed retinal breaks and retinal detachments (RDs) after acute posterior vitreous detachment (PVD) and associated risk factors. Retrospective case-control study. Acute PVD eyes treated between October 2015 and August 2018 at a single academic retina practice. Eyes with a PVD diagnosis and history of extended ophthalmoscopic examination on presentation were identified using diagnostic billing codes. The number of eyes with a history of laser retinopexy, cryotherapy for retinal tear, or RD repair was determined using procedural billing codes, and the duration between initial and treatment visits was measured. Records of eyes with a delayed retinal break or RD and of a reference group comprising the first 100 presenting eyes with no initial or delayed retinal break or RD were reviewed to determine and compare the presence of select risk factors on initial examination. Development of a delayed retinal break or RD. Of 7999 eyes with acute PVD, 1280 (16.0%) showed a retinal break and 499 (6.2%) showed an RD on presentation. Delayed retinal breaks and RDs were found in 209 (2.6%) and 80 (1.0%) eyes, respectively. Of delayed breaks, 116 (55.5%) were found in 6 weeks or less and 93 (44.5%) were found more than 6 weeks after presentation. Of delayed RDs, 26 (32.5%) were found in 6 weeks or less and 54 (67.5%) were found more than 6 weeks after presentation. Compared with the reference group, vitreous hemorrhage (hazard ratio, 2.53 [P < 0.001] and 2.80 [P= 0.001]) and male gender (hazard ratio, 1.36 [P= 0.03] and 1.87 [P= 0.02]) were risk factors for delayed retinal breaks and RDs, respectively. Pseudophakia (hazard ratio, 2.10; P= 0.004) was also a risk factor for delayed RD; older age (odds ratio, 0.96; P= 0.01) was slightly protective. Vitreous hemorrhage was a risk factor for earlier retinal breaks (≤6 weeks vs. >6 weeks; odds ratio, 3.58; P < 0.001). Clinically significant rates of newly detected retinal breaks and RDs may occur after acute PVD, suggesting that repeat examination may be prudent in these patients.

Neuromyelitis Optica Spectrum Disorder: A Case Report of Effective Combination Immunosuppressant, Corticosteroids, and Therapeutic Plasma Exchange.

BACKGROUND:Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune disease that causes severe demyelination, especially in the optic nerve and spinal cord with typical clinical manifestations of acute optic neuritis and transverse myelitis. The symptoms can occur simultaneously or separated by a variable period. NMOSD is associated with serum aquaporin antibodies 4 immunoglobulin G (AQP4-IgG).CASE PRESENTATION:We report a case of a 22-year-old male with complaints of weakness of all four limbs, impaired vision, urinary incontinence, and dyspnea. The Expanded Disability Status Scale (EDSS) was nine. Spinal magnetic resonance imaging (MRI) showed longitudinal extensive transversal myelitis. The brain MRI showed a normal impression, whereas the brain magnetic resonance spectroscopy (MRS) examination showed a description of the mild demyelination process. The serum antibody AQP4 (AQP4-IgG) results were seronegative, the cerebrospinal fluid examination was normal, and the oligoclonal band was negative. The ophthalmoscopic examination found bilateral papillary atrophy but optical coherence tomography (OCT) was still normal. Somatosensory evoked potential and visual evoked potential examinations were abnormal. The patient was diagnosed with NMOSD and was given combination immunosuppressant therapy, corticosteroids, and therapeutic plasma exchange. The patient experienced significant improvement with EDSS decreased to six.CONCLUSION:In the case of relapsing NMOSD patient, combination therapy of immunosuppressant’s, corticosteroids, and TPE was used. There were significant improvements from EDSS nine to six.

Clinical Features of Combined Central Retinal Artery and Vein Occlusion.

Purpose To describe the clinical features of combined central retinal artery and vein occlusion (CCRAVO). Methods This retrospective study included 33 admitted patients (33 eyes) who had CCRAVO. Clinical data, such as age, gender, best-corrected visual acuity (BCVA), intraocular pressure (IOP), findings on fundus color photography and fundus fluorescein angiography (FFA), and information about follow-up, were collected and analyzed. Results The age of the patients with CCRAVO ranged from 22 to 78 years, with a mean of 48.8 ± 14.1 years. At presentation, BCVA of the involved eyes ranged from no light perception (NLP) to 20/20. In addition, 45.5% (15/33) of the eyes had BCVA of finger counting (FC) or below, whereas 12.1% (4/33) had BCVA of 20/60 or above. The IOP was lower in the involved eyes than in the fellow eyes (15.0 ± 3.0 mmHg vs. 16.4 ± 2.3 mmHg, p=0.03). Ophthalmoscopic examination showed changes in both central retinal artery occlusion (CRAO) and central retinal vein occlusion (CRVO), including retinal hemorrhage, retinal ischemic whitening, optic disc hyperemia and/or edema, venous dilation and tortuosity, cotton wool spot (CWS), and Roth's spot. FFA showed prolonged arm-to-retina time (ART) and retinal arteriovenous passage time (RAP) (17.1 ± 4.9 s and 12.1 ± 8.8 s, respectively). Capillary nonperfusion (CNP) was seen in 21 eyes (63.6%), and in 14 (42.2%) of these, CNP was larger than 10 disc areas. At 2 to 3 weeks after presentation, BCVA improved in 23 eyes (71.9%) and further deteriorated in 5 eyes (15.6%). Retinal ischemic whitening improved in more than half of the eyes, whereas retinal hemorrhage increased in nearly half of the eyes. Follow-up ranged from 6 to 56 months. Seven patients were lost to follow-up. At final follow-up, six eyes had a visual acuity of 20/60 or greater, but 6 eyes had FC or worse. Four eyes developed neovascularization on follow-up. Conclusion CCRAVO is a sight-threatening entity. Manifestations of CRAO and CRVO can be seen simultaneously in the early stage of disease, and CRVO may play a more important role in the development of CCRAVO.

Comparison of a Smartphone-Based Photography Method with Indirect Ophthalmoscopic Assessment in Referable Retinopathy of Prematurity: A Smart Retinopathy of Prematurity Model Pilot Study

Abstract This study sought to evaluate the agreement between smartphone-based device assisted remote screening and gold standard indirect ophthalmoscopic examination in cases of referable Retinopathy of Prematurity (ROP).

Visual Acuity Outcomes after Anti–Vascular Endothelial Growth Factor Treatment for Neovascular Age-Related Macular Degeneration: Age-Related Eye Disease Study 2 Report Number 19

To analyze best-corrected visual acuity (BCVA) outcomes after anti-vascular endothelial growth factor (VEGF) treatment for neovascular age-related macular degeneration (AMD). Prospective cohort study of participants enrolled in a clinical trial of oral supplements and receiving anti-VEGF therapy in routine clinical practice. Age-Related Eye Disease Study 2 (AREDS2) participants (50-85 years of age) whose eyes met AREDS2 inclusion criteria at baseline (no late AMD, BCVA ≥20/100, no previous anti-VEGF injections) but received at least 1 anti-VEGF injection for incident neovascular AMD during follow-up. Participants underwent refracted BCVA testing, ophthalmoscopic examination, and stereoscopic color fundus photography at baseline and annual study visits over 5 years. Self-reports of anti-VEGF injections (numbers, dates, and names of drug) were collected at baseline and annual study visits and during telephone calls every 6 months. Primary outcome measures were mean refracted BCVA and proportions of eyes with BCVA of 20/40 or better and 20/200 or worse. An exploratory outcome measure was the mean number of self-reported anti-VEGF injections. One thousand one hundred five eyes of 986 AREDS2 participants met the inclusion criteria; of these, 977 participants (99.1%) underwent at least 1 posttreatment visit. At the first and subsequent annual examinations after the first injection, mean refracted BCVAs were 68.0 letters (Snellen equivalent, 20/40), 66.1 letters, 64.7 letters, 63.2 letters, and 61.5 letters (Snellen equivalent, 20/60). Proportions of eyes with BCVA of 20/40 or better were 59.3%, 55.1%, 53.5%, 50.6%, and 49.7%, and those with BCVA of 20/200 or worse were 5.5%, 8.6%, 9.4%, 12.4%, and 14.4%. Mean annual numbers of self-reported anti-VEGF injections per eye were 2.9, 3.9, 3.3, 3.1, and 3.0. Refracted BCVA data were obtained in a clinical trial environment but were related to anti-VEGF treatment administered in normal clinical practice. Visual outcomes declined slowly with increased follow-up time: mean BCVA decreased by approximately 1.5 to 2 letters per year. At 5 years, half of eyes achieved BCVA of 20/40 or better, but approximately one sixth showed BCVA of 20/200 or worse. These data may be useful in assessing the long-term effects of anti-VEGF therapy.

Prevalence and associated factors of visually impaired cataract of the better eye among adults aged 40 years and above in Mahara Medical Officer of Health Area, Sri Lanka: a cross-sectional study

Introduction: Cataract is the main cause of visual impairment in the world, accounting for 51% of global blindness. Objectives: To determine the prevalence and associated factors of visually impaired cataract of the better eye among adults aged 40 years and above in Mahara Medical Officer of Health (MOH) Area in Sri Lanka Methods: This was a community-based descriptive cross-sectional study conducted in an MOH area during the period August-October 2009. The study population consisted of 602 adults aged 40 years and above selected using cluster sampling technique. Study instruments were interviewer-administered questionnaire and a record sheet. The presence of lens opacities following ophthalmoscope examination with visual acuity less than 6/18 in the better eye was considered as cataract. Multivariate logistic regression was applied for assessment of factors associated with cataract. Results were expressed as adjusted odds ratio (aOR) and 95% confidence interval (CI). Results: The overall prevalence of visually impaired cataract of the better eye was 14.6% (95% CI=11.78, 17.42). It was 35.1% (95% CI=28.3, 41.86) among the age group of 60 years and above and 15% (95% CI=11.28, 18.72) among females and 14.4% (95% CI=9.77, 18.43) among males. After controlling confounding factors, age 60 years and above (aOR=4.72; 95% CI=3.18, 7.01), lower level of education (aOR=2.01; 95% CI=1.39, 2.89) and duration of diabetes mellitus of more than six years (aOR=2.13; 95% CI=1.11, 4.07) were found to be the associated factors. Conclusions: The burden due to prevalence of visually impaired cataract in the better eye was considered serious as it will affect the quality of life. Being elderly, lower education and longer duration of diabetes mellitus were associated with visually impaired cataract.

Management of candidaemia with reference to the European confederation of medical mycology quality indicators

Background: Candidaemia is associated with high mortality. The European Confederation of Medical Mycology (ECMM) has recently proposed the ECMM Quality of Clinical Candidemia Management (EQUAL) scoring criteria which provide an objective measure of adherence to various good practice recommendations. The maximum score is 22 in patients with a central venous catheter (CVC) and 19 in patients without a CVC. Our objective was to audit the management of patients with candidaemia against the ECMM recommendations.Methods: We interrogated our prospective database against individual ECMM recommendations. The audit period was from April 2011 to February 2019. Data were collected from electronic records and case-notes.Results: A total of 131 patients were audited. The mean (maximum) scores for the individual good practice recommendations were as follows: adequate volume of blood culture 0.98 (3) points, identification of Candida species 3 (3) points, antifungal susceptibility testing 1.98 (2) points, echocardiogram 0.51 (1) point, ophthalmoscopy 0.3 (1) point, initial treatment with echinocandin 1.32 (3) points, step-down therapy 0.74 (2) points, treatment for 14 days following first negative follow-up culture 1.37 (2) points, removal of CVC 1.79 (3 for removal within 24 hours or 2 for removal within 72 hours) points, and daily follow up blood cultures 0 (2) points. The overall mean EQUAL score was 11.04. The mean scores of survivors and non-survivors were 11.21 and 10.54 respectively. Performance of ophthalmoscopic examination was associated with a favourable outcome.Conclusion: The audit highlights the need for improvement in the clinical aspects of management of candidaemia.

A Phase 3, Randomized, Double-Masked Study of OTX-101 Ophthalmic Solution 0.09% in the Treatment of Dry Eye Disease

To evaluate the safety and efficacy of OTX-101, a novel aqueous nanomicellar formulation of cyclosporine (0.09%), in the treatment of patients with dry eye disease (DED). A randomized, multicenter, vehicle-controlled, double-masked, phase 3 clinical trial. Adults (18-90 years of age) with a history and clinical diagnosis of DED, a global symptom score of 40 or more (range, 0-100), and a lissamine green conjunctival staining score of 3 or more and 9 or less (range, 0-12) in at least 1 eye. Eligible patients entered a run-in period of 14 to 20 days in which all patients administered vehicle twice daily. Patients who remained eligible at the baseline (day 0) visit were randomized in a 1:1 ratio to twice-daily treatment with OTX-101 0.09% or vehicle for 84 days. Efficacy assessments included signs (unanesthetized Schirmer tear test, corneal and conjunctival staining) and symptoms (global symptom score) of DED. The primary end point was the proportion of eyes with a clinically meaningful improvement (increase of ≥10 mm) in Schirmer test score at day 84. Safety evaluations included adverse events (AEs), visual acuity, and intraocular pressure monitoring, slit-lamp, dilated ophthalmoscopy, and fundus examinations. A total of 744 patients were randomized and received study medication (371 to OTX-101 0.09% and 373 to vehicle). The primary end point was achieved; a significantly greater percentage of eyes in the OTX-101 0.09% treatment group achieved an increase of 10 mm or more in the Schirmer test score at day 84 (OTX-101 0.09%, 16.6%; vehicle, 9.2%; P < 0.001). Significant improvements relative to vehicle also were observed for corneal (days 28, 56, and 84) and conjunctival (days 56 and 84) staining. The global symptom score was reduced from baseline in both treatment groups by approximately 30%; however, no significant separation between groups was observed. The OTX-101 0.09% formulation was well tolerated. Treatment-emergent AEs were primarily mild in intensity. Clinically and statistically significant improvements in tear production and ocular surface integrity were observed in patients treated with OTX-101 0.09% for DED.

Changes of serum vascular endothelial growth factor, apelin and heme oxygenase-1 levels in patients with type 2 diabetes mellitus and their relationship with diabetic retinopathy

Objective To observe the serum vascular endothelial growth factor (VEGF), apelin and heme oxygenase-1 (HO-1) levels in patients with type 2 diabetes mellitus (T2DM) and to explore their their relationship with diabetic retinopathy (DR). Methods A total of 208 patients with T2DM and 50 healthy subjects (control group) from the Central Hospital of Western Hainan during January 2014 and December 2017 were selected in this study. Vision, slit lamp microscope, indirect ophthalmoscope and FFA examinations were performed on all the subjects. According to the results of the examinations combined with the DR clinical staging criteria, the patients were divided into non-DR (NDR) group, non-proliferative DR (NPDR) group, and proliferative DR (PDR) group, with 72, 76 and 60 patients in each, respectively. The clinical data of each group were recorded, and the levels of fasting blood glucose (FPG), HbA1c, total cholesterol (TC), three acylglycerol (TG), high density lipoprotein (HDL-C), low density lipoprotein (LDL-C), VEGF, apelin and HO-1 were detected in each group. The receiver operating characteristic curve (ROC) were used to analyze the value of VEGF, apelin and HO-1 in predicting the occurrence of PDR. Correlation analysis of serum VEGF, Apelin and HO-1 with clinical parameters in PDR patients by Pearson correlation analysis. Results The level of VEGF (56.82±10.16 vs 91.74±22.83, 140.15±36.40, 195.28±42.26 pg/ml) and apelin (2.95±0.53 vs 4.68±0.74, 7.25±1.13, 10.16±1.35 ng/ml) in PDR group were significantly higher than those in NPDR, NDR and control groups (F=17.306, 21.814; P<0.05). The level of HO-1 (50.37±10.14 vs 43.58±8.16, 30.25±6.28, 22.60±4.72 mmol/L) in PDR group was significantly lower than those in NPDR, NDR and control groups (F=15.827, P<0.05). The ROC curve analysis showed that the best cut-off values of serum VEGF, apelin and HO-1 were 162.50 pg/ml, 8.30 ng/ml, 27.13 mmol/L, and the three combined to predict PDR of AUC (95%CI) was 0.906 (0.849−0.962), and their sensitivity (90.3%) and specificity (83%) were better. The correlation analysis showed that the VEGF, apelin and HO-1 of PDR patients were correlated with the course of diabetes (r=0.382, 0.416, −0.36; P<0.05), FPG (r=0.438, 0.460, −0.397; P<0.05) and HbAlc (r=0.375, 0.478, −0.405; P<0.05), and the serum VEGF were correlated with apelin and HO-1 (r=0.793, −0.594; P<0.01). Conclusion Elevated serum VEGF and apelin levels and reduced HO-1 levels are associated with the progression of DR, and the three combination helps predict the occurrence of PDR. Key words: Diabetic retinopathy/etiology; Diabetes mellitus, type 2; Vascular endothelial growth factors; Receptors, angiotensin; Heme oxygenase-1

An Internal Limiting Membrane Plug and Gas Endotamponade for Recurrent or Persistent Macular Hole.

Introduction Recurrent or persistent macular holes (MHs) are rare today due to the tendency to carefully peel the internal limiting membrane. Conversely, their treatment is still a challenge for a vitreoretinal surgeon. Materials and Methods This is a retrospective, consecutive, and nonrandomized study of patients affected by recurrent or persistent MHs treated using small-gauge pars plana vitrectomy (25- or 23-gauge) and an autologous ILM plug, at the Eye Clinic of Azienda Ospedaliera Universitaria Careggi (Florence, Italy) between January 2016 and May 2018. We included 8 eyes of 8 patients in the study. Five patients had a recurrent MH while 3 had a persistent MH. The case series includes patients with myopic eyes and with large macular holes (>400 μ). Patients were followed up with ophthalmoscopic examinations and swept-source optical coherence tomography (SS-OCT). Results The mean age of the patients was 74 years (±4.81 standard deviation (SD)), 3 patients were men and 5 women. The average axial length was 26.28 mm (±2.84 SD). Four patients had an AL ≧ 26 mm. The mean MH diameter was 436.5 (±49.82 SD). Average preoperative best-corrected visual acuity (BCVA) was 0.81 logMAR (±0.16 SD) and 20/125 Snellen. The ILM plug has been found integrated in the MH in all the follow-ups. Conclusion In our study, an ILM autologous macular transplant was used successfully in 5 cases of macular hole recurrence and 3 cases of macular hole persistence. The anatomical success was achieved in all the cases; 4 patients improved their BCVA, and 4 patients maintained it. No macular alterations such as RPE or retinal atrophy/dystrophy were observed after 6 months.

Assessment of vascular leakage and its development with FFA among patients treated with intravitreal anti-VEGF due to aggressive posterior ROP.

Evaluation of vascular leakage and retinal vascular development with fundus fluorescein angiography for infants diagnosed with aggressive posterior retinopathy of prematurity who underwent intravitreal anti-VEGF treatment. Medical recordings of 30 patients who received RetCam fluorescein angiography during follow-up and had been treated with anti-VEGF on diagnosis of aggressive posterior ROP in the zone I or zone II between the dates of April 2014-January 2017 were evaluated retrospectively. Fifty-nine eyes of 30 patients were included in the study. Mean birth weight was 1145g; gestation week was 28.4. Recurrence occurred in 30.5% of the patients, and 10.1% of them were given a second dose of injection of anti-VEGF. Leakage was detected in 15.3% of the eyes during angiography, and all of these eyes were treated with laser photocoagulation. Evaluation of vascular development revealed that in the temporal, complete retinal vascular development was achieved in only 8% of the eyes. It was detected that complete retinal vascularization was not observed in any of the cases which were given second dose of injection due to recurrence. The patients were distributed into groups according to postmenstrual week taken to angiography as 32 eyes of 16 patients in group 1, 17 eyes of 9 patients in group 2 and 10 eyes of 5 patients in group 3. The vascular leakage rate of group 3 patients was statistically significantly higher (p < 0.05) and vascular development between groups was not statistically significant (p > 0.05). With the initiation of FFA usage in pediatric cases, especially treated with anti-VEGF due to retinopathy of prematurity (ROP), more findings (vascular arrest, leakage, and abnormalities, etc.) are obtained than those achieved via ophthalmoscopic examination. In the light of these findings, early intervention with laser photocoagulation in early stages becomes possible enabling prevention of possible blindness.

Spectral domain optical coherence tomography evaluation of the feline optic nerve and peripapillary retina

To describe and to establish normative data for the feline optic nerve and peripapillary retina using SD-OCT (Spectralis® HRA+OCT2). Slit-lamp biomicroscopy and rebound tonometry were performed in seven male-intact (0.65±0.02years;4.34±0.33kg) and seven female-spayed (0.74±0.03years; 3.13±0.28kg) cats. All eyes were pharmacologically dilated with 1% tropicamide prior to indirect ophthalmoscopy examination. Animals were then placed under general anesthesia. Optic nerve and peripapillary retinal morphology was evaluated using SD-OCT device by infrared imaging and volumetric scans (circle and radial). Optic disc area, optic cup depth, peripapillary retinal thickness (RT), and retinal nerve fiber layer thickness (RNFLT) were measured. The RNFLT:RT ratio was calculated in the superior, nasal, temporal, and inferior peripapillary region. Intraocular pressure in all cats was 20.68±4.87mmHg (mean±SD). Mean RT and RNFL were thickest in the superior retina (264.7±13.95µm and 70.22±11.78µm, respectively) (P<0.0001). Inferior RT was significantly thinner than nasal and temporal retina (P=0.0013 and P=0.0010, respectively). The RNFLT:RT was significantly higher in the superior retina (0.27±0.04) (P<0.0001). Optic disc area OU was 1.39±0.26mm2 . Optic cup depth OU was 168.36±67.74µm. All parameters tested were not affected by gender, intraocular pressure, body weight, or tested eye. Most eyes had a Bergmeister papilla that was only visible on OCT. Some animals had a recessed area over the center of the ONH meniscus. Normative peripapillary ONH OCT data have been introduced. A Bergmeister papillae is commonly seen in young cats on OCT examination. OCT is a helpful tool to evaluate the retina in cats.