Slit Lamp Exam Research Articles

Endogenous Endophthalmitis caused by Abiotrophia/Granulicatella

Purpose To describe a case of endogenous endophthalmitis caused by the bacterium Abiotrophia/Granulicatella adiacens, which clinically appeared consistent with fungal endophthalmitis, in a young patient with a history of intravenous (IV) drug use. Observations A 22-year-old male presented with one week of pain and decreased vision in the left eye. He had a history of IV heroin use. Slit lamp and dilated fundus exam revealed significant intraocular inflammation concerning for endogenous endophthalmitis. The initial clinical impression was of fungal endophthalmitis given the appearance of vitreous opacities consistent with fungal balls. However, vitreous sampling revealed Abiotrophia/Granulicatella adiacens, a species of fastidious gram-positive cocci formerly known as nutritionally variant streptococci. Conclusion We describe Abiotrophia/Granulicatella species causing endogenous endophthalmitis in a patient with a history of IV drug use. Abiotrophia/Granulicatella have not been described previously to cause endophthalmitis. This atypical case expands the spectrum of microorganism’s clinicians should consider when diagnosing and treating endogenous endophthalmitis.

Capsular Waves: A Warning Indicator for Potentially Malpositioned Intraocular Lenses.

To share examination findings of the lens capsule which may act as an indicator for malpositioned intraocular lenses (IOL). Single large multi-specialty private practice, Houston, Texas, USA. Focused, observational case series. A review of pre-operative images of malpositioned single-piece IOLs with at least one haptic in the ciliary sulcus was conducted. The review included five cases who were referred to a single large multi-specialty private practice from June 2023 to December 2024 for an evaluation of posterior capsular opacification (PCO) and potential Nd:YAG capsulotomy. A total of five eyes which previously had undergone cataract surgery and were referred for Nd:YAG capsulotomy for PCO were identified on slit lamp examination to have capsular waves, defined as a centripetal and circumferential striated pattern of PCO that results from a fused anterior and posterior capsule with at least part of the IOL anterior to the capsule. While one eye exhibited transillumination defects and pigment dispersion, the remainder of eyes did not. In some cases, the capsular wave was the only clue to IOL malpositioning due to a small pupil. These eyes had single-piece IOLs with at least one haptic in the sulcus and required subsequent IOL repositioning or exchange. If capsular waves are seen on slit lamp exam, a thorough inspection of IOL placement should be conducted, especially before treatment with Nd:YAG capsulotomy. Capsular waves result from anterior and posterior capsule contact with an anteriorly situated IOL. This finding is a potential indicator of at least part of an IOL positioned anterior to the anterior capsule.

Emergency Department Slit Lamp Interdisciplinary Training Via Longitudinal Assessment in Medical Practice.

Eye emergencies make up nearly 3% of US emergency department (ED) visits. While emergency physicians (EP) should diagnose and treat these ophthalmologic emergencies, many trainees report limited ocular exposure and insufficient training throughout their residency to confidently conduct a thorough slit-lamp exam. We created an interdisciplinary, simulation-based mastery learning (SBML) curriculum to teach emergency attending physicians how to operate the slit lamp with multimodal learning methodology at a tertiary academic center. The EPs first demonstrate their initial slit-lamp competency with a 20-item checklist, and they then review the necessary curricular content to pass their independent readiness test before completing their in-person teaching and demonstration session with an ophthalmology attending to demonstrate procedural mastery (minimal passing score >90%). Fifteen EPs were enrolled; all completed the final exam of the curriculum. The pre- and post-curriculum checklist scores increased by an average of seven points (P = .002); 86.7% of EPs felt confident in completing a slit-lamp exam after the curriculum, compared to 20% at the beginning. Five of 15 reported teaching learners within the two-month post-curricular period, ranging from 5-30 students. The hands-on teaching was the most positively reviewed element of the curriculum. The SBML program successfully trained EPs on performing a comprehensive slit-lamp exam with promising results of downstream education to junior learners. We encourage other institutions to leverage SBML as a teaching modality for procedural-based training and advocate cross-discipline education initiatives.

Lack of evidence for GWAS signals of exfoliation glaucoma working via monogenic loss-of-function mutation in the nearest gene.

Exfoliation syndrome (XFS) is a systemic disease of elastin-rich tissues involving a deposition of fibrillar exfoliative material (XFM) in the anterior chamber of the eye, which can promote glaucoma. The purpose of this study was to create mice with CRISPR/Cas9-induced variations in candidate genes identified from human genome-wide association studies (GWAS) and screen them for indices of XFS. Variants predicted to be deleterious were sought in the Agpat1, Cacna1a, Loxl1, Pomp, Rbms3, Sema6a, and Tlcd5 genes of C57BL/6J mice using CRISPR/Cas9-based gene editing. Strains were phenotyped by slit-lamp, SD-OCT imaging, and fundus exams at 1-5 mos of age. Smaller cohorts of 12-mos-old mice were also studied. Deleterious variants were identified in six targets; Pomp was recalcitrant to targeting. Multiple alleles of some targets were isolated, yielding 12 strains. Across all genotypes and ages, 277 mice were assessed by 902 slit-lamp exams, 928 SD-OCT exams, and 358 fundus exams. Homozygosity for Agpat1 or Cacna1a mutations led to early lethality; homozygosity for Loxl1 mutations led to pelvic organ prolapse, preventing aging. Loxl1 homozygotes exhibited a conjunctival phenotype of potential relevance to XFS. Multiple other genotype-specific phenotypes were variously identified. XFM was not observed in any mice. This study did not detect XFM in any of the strains. This may have been due to species-specific differences, background dependence, or insufficient aging. Alternatively, it is possible that the current candidates, selected based on proximity to GWAS signals, are not effectors acting via monogenic loss-of-function mechanisms.

Rare presentations of Sjogren syndrome

Sjögren’s syndrome is a chronic systemic autoimmune disease characterized by lymphocytic infiltration of exocrine glands. It most commonly presenting with sicca symptoms. Sicca refers to dryness most often involving the eyes and mouth due to inflammation and resultant pathology of the lacrimal and salivary glands. Up to one-half of affected individuals also develop extra-glandular involvement in organs such as the joints, skin, lungs, gastrointestinal (GI) tract, nervous system, and kidneys. This condition is frequently associated with other autoimmune disorders including rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) - called the secondary Sjogrens syndrome. Evaluation of a patient with suspected Sjogren syndrome should include an evaluation of oral and ocular dryness and function. In addition to the history, this may include the performance of a Schirmer test, slit-lamp exam with vital dye staining, salivary flow rate, and/or nuclear scintigraphic evaluation of the salivary glandular function. Assessment of autoantibodies (ANA, RF, SS-A, and SS-B) should also be performed. Of these, SS-A is probably the most sensitive and specific antibody for Sjogren's but alone is not diagnostic since it may be present in other autoimmune disorders and may be absent in up to a third of Sjogren cases. The most specific single test is a minor salivary gland (lip) biopsy which will demonstrate focal lymphocytic sialadenitis (FLS). Therapies are directed toward replacing moisture at affected glandular sites and suppressing the autoimmune response locally as well as systemically. This activity reviews the evaluation and management of Sjogren syndrome and explains the different rare presentations in which it can present.

Identification of potential core genes in pseudoexfoliation using bioinformatics analysis and retrospective analysis of 84 patients with this disease.

Pseudoexfoliation (XFS) is a common cause of glaucoma in nowadays. Because of XFS causing irreversible blindness secondary to glaucoma (XFG), this study aims to identify the current prevalence of XFS among Xinjiang Province of China, and identify the hub genes involved in XFS. A retrospective chart review was conducted from 2007 to 2019 for patients aged 50 and older. All patients with XFS or XFG diagnosed by slit lamp exam were identified through chart review. Of the 84 patient charts available for review, 50% of the patients identified as male, with a mean age of 67years. The top ten genes evaluated by connectivity degree in the PPI network were identified. The results showed that Tyrobp was the most outstanding gene, followed by Ptprc, Fcgr3, Itgb2, Emr1, Cd68, Syk, Fcerlg, Hck, and Lyz2. All of these hub genes were downregulated in XFS. Our findings show a considerably biomarkers of XFS for diagnosis and treatment.

Screening for juvenile idiopathic arthritis associated uveitis with laser flare photometry in the pediatric rheumatology office: a prospective observational study

BackgroundJuvenile Idiopathic Arthritis (JIA) Associated Uveitis (JIA-U) remains one of the most serious complications of JIA in children. Historically, pediatric JIA is diagnosed by an Optometrist or Ophthalmologist; however, barriers to scheduling increase wait times that may delay diagnosis and treatment. The purpose of this study was to evaluate laser flare photometry (LFP) use to diagnose JIA-U in the Pediatric Rheumatology clinic for patients with JIA.MethodsThis prospective, observational study assessed pediatric patients diagnosed with JIA without a previous history of uveitis between January 2020 and September 2022. All patients underwent at least one evaluation of both eyes using a Kowa FM-600 laser flare photometer during a routine Rheumatology appointment, as well as a standard slit lamp examination (SLE) by optometry or ophthalmology during routine clinical care. Data collected at patient visits included demographics, JIA characteristics, treatment, LFP readings, and anterior chamber (AC) cell grade score utilizing the SUN grading system. Data were summarized using descriptive analyses and the uveitis false positive rate was calculated.ResultsThe study cohort included 58 pediatric patients diagnosed with JIA. The mean age was 8.4 years (1.2–16.3 years) at diagnosis and 11.9 (4.8–16.5 years) at enrollment. The mean duration of disease at time of enrollment was 42 months (range; 0-157 months). Participants were predominantly female (n = 43, 74.1%) and white/Caucasian race (n = 37, 63.8%). The most common JIA subtypes included persistent oligoarticular JIA (n = 19, 32.8%), and RF negative polyarticular JIA (n = 12, 20.7%). There were 12 ANA positive patients (20.7%). At enrollment, 16 patients (27.6%) were not on medications, with 20 (34.5%) on methotrexate, 20 (34.5%) on adalimumab, 6 (10.3%) on tocilizumab, and 5 (8.6%) on etanercept. During the study period, no eye exams detected active uveitis based on SLE with a SUN grade over 0. However, of the 135 LFP readings, 131 (97.0%) were normal, yielding a false positive rate of 3% (95% CI: 0.8%, 7.4%).ConclusionsLFP is a non-invasive tool that can be utilized in the pediatric rheumatology clinic to evaluate for JIA-U. There is a low false positive rate of LFP when compared with standard slit lamp exam.

Normative retinal nerve fiber layer thickness in a healthy pediatric South Asian cohort: a spectral-domain optical coherence tomography study.

Currently, the normative values for retinal nerve fiber layer (RNFL) thickness in our population have not been widely studied. Our study aimed to assess the peripapillary RNFL thickness (RNFLT) with Optopol Copernicus REVO80® spectral-domain optical coherence tomography (SD-OCT) amongst healthy children and its associations. One hundred eighty-two eyes of 91 consecutive healthy children 3 to 16 years of age with a refractive error ≤ ± 5 D were included after a thorough eye exam including visual acuity, refraction, tonometry, pachymetry, axial length estimation, and slit lamp exam including fundus assessment. RNFLT was measured via Optopol Copernicus REVO80® high resolution SD-OCT by a single experienced observer with 3D disc mode within a circular area of diameter 3.45 mm and the ring further divided into four quadrants: inferior, superior, nasal, and temporal. The mean age was 11.12 ± 3.12 years (range, 3-16). The average RNFLT was 120.13 ± 12.6 μm. The mean superior RNFL was the thickest at 138.21 ± 16.6 μm, next was the mean inferior RNFLT at 137.62 ± 17.2 μm, followed by the nasal 91.61 ± 18.5 μm and then the temporalat 74.58 ± 11.7 μm. No significant differences in RNFLT were noted between the two eyes. The mean RNFLT was significantly higher in males as compared to females, in vertical quadrants and at an average (p < 0.05). No significant relationship was found between the average RNFLT and factors such as age, axial length, corneal thickness, cup-to-disc ratio, intraocular pressure, or refractive error. This study establishes normative values of RNFLT for this subgroup of Pakistani children for the Optopol Copernicus REVO80® SD-OCT device.

Visual Performance of Two Designs of Myopia Management Soft Contact Lenses Compared with a Monofocal One in Young Adults.

To compare the visual performance of two distinct types of soft contact lenses (CL) aimed at slowing down myopia progression with the performance of a monofocal soft CL. In a prospective double-masked, crossover trial, 18 myopic adults (aged 18-30 years old) were fitted in a randomized order with three types of disposable CL: MiSight (dual-focus), Mylo (extended depth of focus -EDOF-), and Clariti (single distance vision). Measurements were taken after wearing the CL for five days with five days off in between at two different optometry centers. High contrast distance visual acuity (VA) with spectacles and for each of the different CL, subjective refraction, slit lamp exam, aberrometry, stereopsis, monocular and binocular amplitude of accommodation and accommodative facility, and horizontal phorias were measured. The high contrast distance VAwas better for the single vision CL compared to the myopia control CL. No significant differences were observed between the r two myopia control CL. The overall root mean square (RMS) was higher for the double focus CL (RMS = 1.18 0.29 µm), followed by the EDOF CL (RMS = 0.76 0.35 µm) and then the single vision CL (RMS = 0.50 0.19 µm). The primary spherical aberration (SA) mean value was low for all of the three CL, without statistical differences among them. No other significant differences were detected. The overall RMS resulted in a higher value for the dual-focus than the EDOF CL, but no differences in high contrast distance VA and binocularity were detected between them. The monofocal CL's performance was better than the myopia control CL.

Pituitary Adenoma Hidden by Comorbid Cataract

Background: Background: A pituitary adenoma is an abnormal growth in the pituitary gland. Pituitary adenomas are the most common cause of sellar masses accounting for approximately 10% of all intracranial neoplasms. Early visual symptom of pituitary adenoma can be hidden by comorbid cataract in elderly patients. Case Case Report: Report: A 74 y.o. male presented to the eye clinic with blurry vision at all distances and has trouble with glare from lights. His best corrected visual acuity (BCVA) was 20/20-1 OD, 20/25-2 OS, but subjectively of poor quality. Slit lamp exam confirmed mild nuclear sclerotic cataract OU and normal fundus exam. Patient underwent uncomplicated cataract extraction with intraocular implant, OS first then OD. Post-op course was unremarkable until one month later when patient stated that his vision OS was blurry to the left. BCVA was 20/25 OD, 20/25-2 OS. Post-op exam was still normal including FCF. Humphrey visual field (HVF) however showed a bitemporal hemianopia. Patient was referred for a brain imaging. Brain MRI confirmed a 24 x 22 x 28 mm T2 isointense enhancing mass of the sella with suprasellar extension consistent with a pituitary macroadenoma. Patient underwent endonasal transphenoidal craniectomy for debulking of the tumor subsequently by an ENT specialist. Conclusion Conclusion: Clinicians need to be sure the cataract matches the visual complaint. When in doubt further ancillary testing such as comprehensive HVF is crucial to detect visual pathway disorder and brain tumors. Co-management with corresponding specialist is essential to preserve vision and save life.

Thirty-Year Experience of Radiotherapy for Primary Intraocular Lymphoma with and without Chemotherapy.

Primary intraocular lymphoma (PIOL) is a rare presentation of primary central nervous system lymphoma (PCNSL). We previously reported that ocular radiation therapy (RT) is an excellent option that can spare appropriate patients' upfront toxicity of whole brain radiotherapy (WBRT) and aggressive chemotherapy. A decade later, we expanded this series with almost double median follow up time. We identified all patients seen at our institution from 1990-2022 treated for PCNSL or who received RT to the orbits. Detailed chart review was completed for cases with isolated ocular involvement at presentation (PIOL) who received RT to unilateral or bilateral orbits. Patients with disease on MRI brain or CSF cytology were excluded. Analysis included Kaplan-Meier method, log-rank-test, and Wilcoxon rank sum test. Overall survival (OS) was measured from diagnosis. Freedom-from-recurrence (FFR) measured time from RT start to first recurrence identified on imaging (parenchymal), slit-lamp exam (ocular), or biopsy. A total of 75 patients were treated with RT to the orbits as part of management of PCNSL. 29 had PIOL with median follow up of 52 months from diagnosis. Of this subset, 22 (76%) received RT at our institution, median age at diagnosis was 65 (31-84) and 18 (62%) had bilateral disease. The majority were diagnosed by vitrectomy or vitreoretinal biopsy with B-cell lymphoma or unspecified lymphoma and 3 were clinically diagnosed. 17 patients received RT alone, 10 received RT after induction chemotherapy and 2 with induction and consolidation chemotherapy. Younger patients received chemotherapy (median age 60 vs 70, p = 0.03). RT dose ranged from 30 to 45 Gy, and 20 (69%) received 36 Gy, primarily with 1.8 Gy fractions. 22 (76%) received RT to bilateral orbits. 21 (72%) developed recurrence (Table 1), of which 6 (28.5%) recurred in a RT-treated eye and 11 (52.4%) isolated in the brain. 2 got salvage orbital RT and 4 got WBRT. Median OS was 5.4 years (95% CI 3.9, 7.6) and FFR was 8.4 months (95% CI 5.0, 25). There was no difference in OS (p = 0.4) or FFR (p = 0.3) between combined modality therapy versus RT alone. In this updated experience, we demonstrate that RT alone remains an effective option for isolated PIOL, especially for those at risk of poor toleration of chemotherapy. Systemic therapy or WBRT can be utilized at recurrence, which primarily occurs in the brain. Future comparisons are needed to compare orbital RT to intravitreal therapies, and to investigate how these methods can complement each other to further improve management.

Evaluation of an Instructional Video and Simulation Model for Teaching Slit Lamp Examination to Medical Students.

Purpose This article assesses the efficacy of an instructional video and model eye simulation for teaching slit lamp exam to medical students as compared to traditional preceptor teaching. Methods First through 4th year students from the University of California, San Francisco School of Medicine were recruited via email to participate in the study. Students were randomized into two groups. The experimental "model eye" group watched an instructional video on slit lamp exam, spent 10 minutes practicing on the model eye, then practiced for 25 minutes with a student partner. The control "preceptor teaching" group received 25 minutes of in-person preceptor teaching on slit lamp exam, then spent 25 minutes practicing with a student partner. Students were objectively assessed by a blinded grader who scored their examination skills with a 31-item checklist. Qualtrics surveys that measured student perceptions were distributed before and after the intervention. Results Seventeen medical students participated in the study. Students in the model eye group achieved higher mean objective assessment scores than students in the preceptor teaching group on skills relating to slit lamp set up (1.75, standard deviation [SD] = 0.50 and 1.50, SD = 0.80 out of 2 points, p = 0.03) and on the total score (1.69, SD = 0.6 and 1.48, SD = 0.8 out of 2 points, p < 0.01). Both groups reported a significant increase in their understanding of what a slit lamp is used for ( p < 0.01) and in their confidence using a slit lamp ( p < 0.01). All students felt their skills improved with the workshop, 94% found the workshop to be useful, and 88% enjoyed the workshop, with no intergroup differences on these metrics. Conclusion An instructional video combined with a simulation model is as effective as traditional preceptor teaching of the slit lamp exam. Such a teaching module may be considered as an adjunct to traditional methods.

Ocular manifestations of children with atopic dermatitis in Saudi Arabia.

To examine the incidence of ocular abnormalities in children with atopic dermatitis (AD) in Saudi Arabia and its association with the severity of AD. This is a cross-sectional study on 50 children with AD who were between 5 and 16 years of age. The severity of AD was evaluated using the SCORing Atopic Dermatitis (SCORAD) index. All the children underwent slit lamp exams, visual acuity assessment, intraocular pressure measurement, and corneal topography. The children were considered to have an ophthalmic abnormality if one or more of the following signs were present: glaucoma, keratoconus suspicion, in addition to lid, conjunctival, corneal, lenticular, or retinal abnormalities. Based on the SCORAD severity index, 14% of children had mild AD (7/50), 38% had moderate AD (19/50), and nearly half had severe AD. More than half the children exhibited facial involvement, and half had peri-orbital signs. The mean SCORAD index was 35.75. The mean age was 10.48±3.6y, and the cohort showed a slight male predominance (54% males). Both eyes of the 50 children in the cohort were studied. Based on the ocular examinations, 92% of the patients showed ocular abnormalities: lid abnormalities (27/50) followed by keratitis (22/50). Four patients had moderate risk for keratoconus in one eye and eight patients were suspected to have keratoconus. However, SCORAD severity index was not associated with age, sex, or the number or presence of ophthalmic abnormalities. This is the first study in Saudi Arabia to evaluate the prevalence of ocular manifestations in children with AD. The results indicate that the majority of children with AD have ocular abnormalities that mainly include lid abnormalities. Based on these findings, larger scale studies are needed to affirm whether regular screening for ophthalmic abnormalities would be beneficial for children with AD in terms of early intervention and prevention of sight-threatening complications.

Anti-IgLON-5 Associated Neurological Disease Presenting with Bilateral Optic Neuritis, Orthostatic Intolerance, Sleep-Related Movements in Setting of Testicular Mass: Expanding Clinical Phenotypes in the Disease. (P5-5.028)

<h3>Objective:</h3> We report a novel presentation of IgLON5-associated neurological disease with possible paraneoplastic phenomena, expanding the clinical phenotypic spectrum of this disorder. <h3>Background:</h3> Anti-IgLON5-associated neurological disease is characterized by neuroinflammatory and neurodegenerative features. Autopsies from advanced cases reveal phospho-tau accumulation in the hypothalamus and brainstem. Clinical features include sleep and movement disorders, bulbar symptoms, dysautonomia and motor neuron disease-like phenotypes. Overlap with progressive supranuclear palsy (PSP-like) is also seen. <h3>Design/Methods:</h3> A fifty-one-year-old man in general good health presented with deficits in visual fields, visual acuity and color vision. Funduscopic examination demonstrated bilateral optic disc edema confirmed by magnetic resonance imaging. Slit-lamp exam demonstrated granular-appearing optic discs and hemorrhagic telangiectasias. Treatment with high-dose steroids with taper was initiated. Early cessation of steroids caused symptom recurrence. New onset disabling orthostatic intolerance, daytime somnolence, sleep apnea, and twitching while sleeping were noted. <h3>Results:</h3> Repeat brain imaging demonstrated partial resolution of optic disc edema. Cerebrospinal fluid evaluation demonstrated normal opening pressure and glucose, 4 nucleated cells, elevated protein (82 mg/dl), and negative neuroinfectious work-up. Cytology showed rare lymphocytes and monocytes. IgLON5 antibodies were identified (1:8 titer). Whole-body PET scan demonstrated FDG-avid lesions in a testicle, with ultrasound demonstrating hypoechogenicity suggestive of infection/trauma vs burned-out tumor, representing a potential paraneoplastic etiology. His treatment regimen was escalated to monthly intravenous Cyclophosphamide infusions over 6 months. <h3>Conclusions:</h3> This patient presented with recurrent bilateral optic neuritis, evolving to develop sleep apnea, daytime hypersomnolence, and involuntary nocturnal movements. IgLON5 antibodies were detected in cerebrospinal fluid. Symptomatic response to immunosuppressive therapy, with symptom relapse on pausing immunosuppression was noted. While oculomotor abnormalities are reported in the disorder, this is a novel presentation of CNII involvement in a patient with IgLON5 antibodies. As understanding of IgLON-5 disease evolves, a low threshold for diagnostic suspicion is emphasized, as treatment may prevent irreversible neuronal damage and subsequent neurodegeneration. <b>Disclosure:</b> Dr. Varma-Doyle has nothing to disclose. Dr. Chwalisz has nothing to disclose. Dr. Linnoila has received research support from NIH/NINDS. Dr. Linnoila has received personal compensation in the range of $10,000-$49,999 for serving as a expert respondent on autoimmune encephalitis with U.S. government/DHHS/vaccine injury compensation program.

Performance of a Silicone Hydrogel Daily Disposable Contact Lens among Wearers with Lens-related Dryness

Background: Addressing contact lens dryness continues to be a development goal of contact lens (CL) manufacturers. Objective: The objective of this study is to evaluate the clinical performance of kalifilcon A, a daily disposable silicone hydrogel (SiHy) CL, in subjects that experience dryness with their habitual planned-replacement SiHy CLs relative to a non-dry subgroup. Methods: A cohort of adapted planned-replacement SiHy CL wearers wore kalifilcon A lenses for at least 8 hours daily over two weeks. After one week of lens wear, subjects completed a survey regarding their lens wearing experience with respect to comfort and vision. Subsequently, subjects visited the clinics for the 2-week visit, during which the investigators completed a slit lamp exam and questionnaire regarding lens performance. Results: The evaluation included 180 subjects experiencing CL dryness with their habitual SiHy lenses and 213 subjects that did not. Both subgroups largely agreed with all comfort and vision attribute statements, and the dryness subgroup expressed higher levels of agreement with most comfort-related statements. Among habitual rewetting drop users, 73.9% in the dryness subgroup and 73.1% in the non-dry subgroup used drops less frequently while wearing kalifilcon A lenses. Investigators found no &gt; Grade 2 slit-lamp findings, nor differences between subgroups. Neither subgroup showed a change in ratings between visits, except for a significantly higher proportion of improvers in the non-dry subgroup for upper lid tarsal conjunctival abnormalities. Conclusion: The kalifilcon A lens performed well among habitual planned-replacement SiHy CLs wearers. Its unique chemistry can provide a more satisfying wear experience for SiHy lens wearers experiencing CL dryness.

Correlation between the Serum Concentration of Vitamin A and Disease Severity in Patients Carrying p.G90D in RHO, the Most Frequent Gene Associated with Dominant Retinitis Pigmentosa: Implications for Therapy with Vitamin A.

The pathogenic variant p.G90D in RHO is believed to be responsible for a spectrum of phenotypes, including congenital stationary blindness (for the purpose of this study termed night blindness without degeneration; NBWD), Sector RP, Pericentral RP, and Classic RP. We present a correlation between the serum concentration of vitamin A and disease severity in patients with this variant. This prospective study involved 30 patients from 7 families (17 male; median age 46 years, range 8−73). Full ophthalmological examination including visual acuity, Goldmann perimetry, slit-lamp exam, optical coherence tomography, fundus autofluorescence, and electrophysiology was performed to determine the presenting phenotype. The serum concentration of vitamin A was determined from a fasting blood sample taken on the day of the exam, where it was found that 23.3% (7/30) of patients had NBWD, 13.3% (4/30) had Sector RP, 3.3% (1/30) had Pericentral RP, and 60% (18/30) had Classic RP. Multiple logistic regression revealed a significantly higher probability of having a milder phenotype (NBWD or Sector RP) in association with younger age (p < 0.05) and a higher concentration of vitamin A (p < 0.05). We hypothesize that vitamin A in its 11-cis-retinal form plays a role in stabilizing the constitutively active p.G90D rhodopsin and its supplementation could be a potential treatment strategy for p.G90D RHO patients.

Effect of Autologous Platelet-Rich Plasma Drops in the Treatment of Ocular Surface Disease.

Platelet rich plasma (PRP) is an autologous preparation that concentrates platelets in a small volume of plasma. The purpose of this study was to determine if PRP eye drops improved the symptoms and signs of ocular surface disease. A retrospective case series was conducted of patients who were prescribed PRP eye drops. Subjects were excluded if they did not have follow-up, underwent intraocular surgery prior to follow-up, received nerve growth factor treatments, or did not have a baseline examination with photography. Symptoms were assessed using the Ocular Surface Disease Index (OSDI). Patients also underwent a slit lamp exam, ocular surface staining with fluorescein and lissamine green, and Schirmer testing. The charts of 47 patients treated with PRP drops for ocular surface disease were reviewed. Sixty-four eyes of 32 patients were included in the study who had photographs of lissamine green staining taken at baseline and at follow-up. Thirteen patients (28%) had ocular graft-versus-host disease, 16 patients (34%) had Sjögren's syndrome, and 4 patients (8.5%) had rheumatoid arthritis. There was a statistically significant decrease in OSDI score from baseline to follow-up (39.5 vs 30.8 points, p = 0.02). Among the 64 eyes included, 9 (14%) had an improvement in conjunctival lissamine green staining, while 6 (9%) had an increase in staining at follow-up. Among the 20 eyes with Schirmer testing, there was a borderline significant increase in score from baseline to follow-up (5.9 vs 9.7, p = 0.06). Among the 44 eyes that had corneal fluorescein staining (CFS) reported, 8 (18.2%) had decreased staining and 2 (4.5%) had increased staining at follow-up. Treatment with PRP drops was associated with a significant improvement in symptoms in patients with ocular surface disease. Future larger prospective studies are needed to further evaluate the efficacy of PRP drops for treating ocular surface disease.

Exfoliation Syndrome and Exfoliation Glaucoma in the Navajo Nation.

(1) Background: Exfoliation syndrome (XFS) is a common cause of secondary open angle glaucoma. In 1971, Faulkner et al. estimated the prevalence of XFS among 50 Navajo Nation residents as 38%. Given that XFS can cause irreversible blindness secondary to glaucoma (XFG), this study aims to identify the current prevalence of XFS among Navajo Nation residents within the Four Corners region of the U.S. (2) Methods: A retrospective chart review was conducted from 2016 to 2021 for patients aged 18 and older. All patients with XFS or XFG diagnosed by slit lamp exam were identified through chart review. (3) Results: Of the 1152 patient charts available for review, eight patients (11 eyes) were diagnosed with XFS with three patients (4 eyes) demonstrating concomitant XFG. Within this XFS population, 50% of the patients identified as male, with a mean age of 73 years. The overall prevalence of XFS was 0.7% and the overall prevalence of XFG was found to be 0.26%. The rate of XFG among patients with XFS was 37.5%. (4) Conclusion: Compared to Faulkner’s study of Navajo Nation residents in 1971, our findings show a considerably lower prevalence of XFS at 0.7%. We present the largest study to date of XFS among this population.

Use of An Ophthalmology Tutorial to Improve Resident Comfort with the Emergency Eye Exam.

This tutorial should be utilized for emergency medicine (EM) interns and junior residents. Ophthalmology is characteristically a weak area in both medical school and resident education. Medical students are rarely given formal didactic education on the use of the slit lamp or a systematic approach to examining the eye. For EM residents, this leads to inefficient and uncomfortable encounters with patients with eye complaints. We sought to develop a comprehensive emergency ophthalmology tutorial utilizing asynchronous learning followed by a hands-on skill session that would address this need. By the end of this small group didactic, learners will be able to: 1) demonstrate ability to focus on the various components of the slit lamp exam 2) demonstrate understanding of a systematic approach to the eye exam 3) demonstrate appropriate use of the Diaton, iCare, and Tonopen tonometers. This two-hour small group didactic combines hands-on learning sessions to learn the slit lamp exam and tonometry measurement, with a systematic review of the eye exam to help learners better organize their exams and understand the use of necessary tools. The emergency ophthalmology tutorial was initially designed as an education project in which we collected pre- and post-participation surveys regarding resident comfort with various components of the emergency eye exam. After the course residents received a post-course survey to complete. Given the positive feedback we received from our residents regarding the tutorial, we applied for Institutional Review Board (IRB) approval to publish our retrospective survey data. Our IRB waived the need for participant consent. Twelve emergency medicine residents including 11 interns and one post-graduate year (PGY) 2 resident participated in the emergency ophthalmology tutorial as part of our intern boot camp in July of 2021. Twelve PGY-1 residents initially signed up for the course and filled out the pre-participation survey but one of them was not able to attend their scheduled class, so a PGY-2 resident requested to attend.Prior to the course, we used a Likert scale from 1-7, finding that 61.5% (8/13) of participants felt very uncomfortable with performing slit lamp exams, 84.6% (11/13) felt very uncomfortable with using the Diaton tonometer, 76.9% (10/13) felt very uncomfortable with using the iCare tonometer, and 69.3% (9/13) felt uncomfortable or very uncomfortable with using a systematic approach to examining the eye. After the course, 75% (9/12) of participants felt that the course exceeded expectations in ensuring their ability to perform the subcomponents of the slit lamp exam, 75% (9/12) and 83.3% (10/12) of participants felt that the course exceeded expectations in ensuring their ability to use the Diaton and iCare tonometers, respectively, and 91.7% (11/12) felt that the course exceeded expectations in ensuring their ability to perform a systematic eye exam. Participation in a 2-hour emergency ophthalmology tutorial with assigned asynchronous pre-course work improved emergency medicine resident comfort with various components of the eye exam. Emergency ophthalmology, eye exam, slit lamp, tonometry.

S3196 Wilson Disease in a U.S. Navy Pilot: Delayed Diagnosis With Drastic Career Implications

Introduction: Wilson disease is an autosomal recessive genetic disorder of the intracellular copper transport ATP7B leading to impaired copper excretion and subsequent accumulation in the liver, brain and cornea. Index symptoms vary widely and include neurologic and psychiatric abnormalities. The wide array of subtle symptoms often lead to significant delays in diagnosis and thus prognostic implications for patients diagnosed with this rare disease. In the Armed Forces, the diagnosis and clinical sequelae can have drastic career implications especially when neurologic sequelae are resistant to treatment. Case Description/Methods: A 28 year old US Navy pilot male presented to behavioral health clinic with complaint of depressed mood. He was diagnosed with major depressive disorder which was resistant to traditional treatment for over a year. He developed fasciculations of his neck and arms which was associated with initiation of an SSRI. When he had difficulty landing an aircraft due these progressive symptoms, he was deemed incapable of flight. He later required admission for suicidal ideations. He had several concerning incidents occur including driving over a median and through several red lights. Neurology was consulted and examination showed hyperkinetic movements of his extremities with head and voice tremors. Lab work revealed ALT 52 and AST 48 and later, a ceruloplasmin of 6.7. A slit lamp exam was performed revealing Kayser-Fleischer rings. MRI brain showed abnormal T2 signal within the basal ganglia and midbrain consistent with copper deposition. MRI liver was consistent with cirrhosis. A liver biopsy confirmed the diagnosis of Wilson disease with cirrhosis. He was started on trientene and zinc for chelation and his mood markedly improved. However, his neurologic abnormalities have persisted despite ongoing therapy for over 4 years, permanently ending his piloting career. Discussion: Our case highlights the importance of careful clinical consideration in patients presenting with psychiatric complaints. We aim to highlight this patient’s response to therapy, and lack thereof, as the range of patient response can be quite broad. The majority of patient’s have significant or even total resolution of symptoms. Our patient had significant improvement in depression after chelation therapy but his neurologic symptoms did not recover. Regrettably, the patient’s Navy pilot career was brought to an early close given the severity of his symptoms and lack of response and thus, inability to perform as an aviator.