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The Harvard Pediatric Retina Lab
Led by Nimesh Patel, MD, a division of Mass Eye and Ear,
a Harvard Medical School teaching hospital
Our Work
We are dedicated to advancing care for retinal diseases through a blend of clinical insight, imaging technology, and data-driven research. The team focuses on three main areas: retinopathy of prematurity (ROP), sickle cell disease (SCD), and adult retinal disorders. We seek to better understand disease progression and tailor care to individual patients, emphasizing early detection and holistic care. With a vision to address disparities in eye health while improving patient outcomes and healthcare sustainability, we leverage innovative tools including AI, large datasets, and novel imaging modalities to serve patients at all stages of life.
You can learn more about the lab’s work and Dr. Patel’s publications through his PubMed and Harvard Catalyst profiles.
Retinopathy of Prematurity
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Sickle Cell Disease
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Adult Retina
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Publications
Here you’ll find our peer reviewed papers updated regularly.
Full-Thickness Macular Hole in a Pediatric Patient With Normal Vision
Abstract
A 17-year-old boy presented with a full-thickness macular hole, with 20/20 vision with eccentric fixation in the left eye. Examination of the left eye showed a large macular hole with a base diameter measuring 1,680 μm and temporal macular and mid-peripheral retinal atrophy on ultra-high-definition optical coherence tomography (OCT) scans. Microperimetry showed eccentric fixation with good nasal sensitivity. A 12 x 12-mm extended-field swept-source OCT angiogram showed flow loss in the temporal macula, with slight reduction noted in the choriocapillaris. Given excellent visual acuity, good tolerance by the patient, and large atrophic hole, the decision was made for observation rather than surgery.
A 17-year-old boy presented with a full-thickness macular hole, with 20/20 vision with eccentric fixation in the left eye. Examination of the left eye showed a large macular hole with a base diameter measuring 1,680 μm and temporal macular and mid-peripheral retinal atrophy on ultra-high-definition optical coherence tomography (OCT) scans. Microperimetry showed eccentric fixation with good nasal sensitivity. A 12 x 12-mm extended-field swept-source OCT angiogram showed flow loss in the temporal macula, with slight reduction noted in the choriocapillaris. Given excellent visual acuity, good tolerance by the patient, and large atrophic hole, the decision was made for observation rather than surgery.
Nondiabetic Vitreous Hemorrhage: A Review of Management Strategy and Outcomes
Abstract
Vitreous hemorrhage involves blood leakage into or around the vitreous cavity, which presents complex management decisions. Treatment options for nondiabetic vitreous hemorrhage (NDVH) traditionally include observation or early vitrectomy. Traditional guidelines have long emphasized an initial period of cautious observation. This systematic review shows that a significant portion (∼62% to 75%) of NDVH patients present a retinal tear and/or detachment upon initial presentation. B-scan ultrasonography, the primary diagnostic tool, exhibits variable sensitivities and may miss approximately half (46.4%) of underlying tears or detachments. Only 25% of observed NDVH cases clear spontaneously, while the remaining will ultimately require vitrectomy due to nonclearance (45%) or sight-threatening complications (30%). Patients under observation experience visual deficits as hemorrhage clears slowly, challenging the efficacy of traditional guidelines favoring observation. While there is no clear guideline concerning the management of NDVH, our findings suggest that early vitrectomy for severe NDVH may be the safest and most appropriate approach, provided the patient accepts procedural risks like cataract development.
Vitreous hemorrhage involves blood leakage into or around the vitreous cavity, which presents complex management decisions. Treatment options for nondiabetic vitreous hemorrhage (NDVH) traditionally include observation or early vitrectomy. Traditional guidelines have long emphasized an initial period of cautious observation. This systematic review shows that a significant portion (∼62% to 75%) of NDVH patients present a retinal tear and/or detachment upon initial presentation. B-scan ultrasonography, the primary diagnostic tool, exhibits variable sensitivities and may miss approximately half (46.4%) of underlying tears or detachments. Only 25% of observed NDVH cases clear spontaneously, while the remaining will ultimately require vitrectomy due to nonclearance (45%) or sight-threatening complications (30%). Patients under observation experience visual deficits as hemorrhage clears slowly, challenging the efficacy of traditional guidelines favoring observation. While there is no clear guideline concerning the management of NDVH, our findings suggest that early vitrectomy for severe NDVH may be the safest and most appropriate approach, provided the patient accepts procedural risks like cataract development.
HYPERACUTE CUTIBACTERIUM ACNES ENDOPHTHALMITIS AFTER CATARACT SURGERY
Purpose:
Postoperative endophthalmitis is a relatively uncommon, but potentially visually devastating, complication associated with cataract surgery. Specific microbial causes of endophthalmitis are characteristically associated with particular disease time courses. Although Cutibacterium acnes is typically associated with an indolent course of inflammation, we report a case of C. acnes endophthalmitis with onset on postoperative day (POD) 1 and a positive culture from POD 2.
Methods:
This is a case report.
Results:
A 56-year-old man underwent cataract extraction and posterior chamber intraocular lens placement in his left eye. On POD 1, he presented with severe discomfort, reduced visual acuity, and significant inflammation. On POD 2, his anterior chamber was tapped and injected with broad-spectrum antibiotics and steroids. The inflammation ultimately resolved, and his visual acuity improved to 20/20.
Conclusion:
C. acnes is a rare cause of hyperacute-onset postoperative endophthalmitis. Maintaining a high clinical suspicion and initiating prompt treatment can help to optimize long-term visual outcomes.
Postoperative endophthalmitis is a relatively uncommon, but potentially visually devastating, complication associated with cataract surgery. Specific microbial causes of endophthalmitis are characteristically associated with particular disease time courses. Although Cutibacterium acnes is typically associated with an indolent course of inflammation, we report a case of C. acnes endophthalmitis with onset on postoperative day (POD) 1 and a positive culture from POD 2.
Methods:
This is a case report.
Results:
A 56-year-old man underwent cataract extraction and posterior chamber intraocular lens placement in his left eye. On POD 1, he presented with severe discomfort, reduced visual acuity, and significant inflammation. On POD 2, his anterior chamber was tapped and injected with broad-spectrum antibiotics and steroids. The inflammation ultimately resolved, and his visual acuity improved to 20/20.
Conclusion:
C. acnes is a rare cause of hyperacute-onset postoperative endophthalmitis. Maintaining a high clinical suspicion and initiating prompt treatment can help to optimize long-term visual outcomes.
Atypical Presentation of Vitreous Inflammation in a Patient With Hypertensive Retinopathy
Purpose: To describe an atypical presentation of vitreous inflammation in a patient with malignant hypertension.
Methods: A case was evaluated.
Results: A patient presenting with a hypertensive emergency was found to have decreased vision in the setting of severe optic nerve head edema, extensive hard exudates, cotton-wool spots, and Elschnig spots in both eyes secondary to malignant hypertension as well as vitreous cells bilaterally. He was admitted to the pediatric intensive care unit for intravenous medications and observation.
Conclusions: This case adds to the growing body of evidence suggesting that hypertensive urgency may be accompanied by inflammation.
Methods: A case was evaluated.
Results: A patient presenting with a hypertensive emergency was found to have decreased vision in the setting of severe optic nerve head edema, extensive hard exudates, cotton-wool spots, and Elschnig spots in both eyes secondary to malignant hypertension as well as vitreous cells bilaterally. He was admitted to the pediatric intensive care unit for intravenous medications and observation.
Conclusions: This case adds to the growing body of evidence suggesting that hypertensive urgency may be accompanied by inflammation.
Multimodal Imaging Characteristics and Correlation to Outcomes in Patients With Central Retinal Arte
Purpose
To characterize a large modern cohort of patients with central retinal artery occlusion (CRAO) by describing presenting features and outcomes relating to manually segmented optical coherence tomography (OCT) features, angiographic reperfusion, and visual recovery.
Design
Retrospective clinical cohort study.
Methods
Patients with CRAO (ICD-10: H34.1) initially presenting to a tertiary referral center between January 2017 and December 2021 were included. Demographics, eye exam findings, fundus photographs, OCT, and fluorescein angiography were analyzed. Main outcome measures included total and inner retinal thickness on macular OCT, reperfusion, visual outcomes, and development of neovascularization.
Results
A total of 145 eyes of 144 patients with mean age at of 69.4 ± 13.6 years were included. The mean time to presentation was 1.6 ± 4.2 days, with 19% examined within 4.5 hours and 26% within 6 hours of vision loss. 19% had cilioretinal artery (CLRA) sparing. Mean initial visual acuity (VA) was 1.68 ± 1.10 Logarithm of the Minimum Angle of Resolution (LogMAR) (CLRA sparing) compared to 2.53 ± 0.58 LogMAR (non-CLRA sparing), P < .001. 32% had elevated inflammatory makers. Out of 47 eyes with final fluorescein angiography, one-third showed some reperfusion. Final vision was 1.40 ± 1.16 LogMAR (CLRA sparing) compared to 2.46 ± 0.81 (non-CLRA sparing), P < .001. A third of patients improved in VA in both groups, 27% of patients gained more than 2 lines of vision in the CLRA-sparing group and 36% in the non-CLRA-sparing group. 17% improved to better than 20/200 in CLRA-sparing and 4% in non-CLRA sparing. Overall, 11% developed neovascularization all in non-CLRA sparing. In a multiple linear regression, VA at presentation was associated with regaining vision of 2 lines or more (OR = 2.603, P = .007). OCT showed progressive thinning over time, reaching lowest measurements at 6 months, and stabilizing thereafter.
Conclusions
In this modern cohort of acute CRAO patients, presentation to a tertiary facility within 12 hours of symptoms was seen in almost half of the patients. Final VA improved in almost a third of the patients, however, vision better than the legal blindness limit was rare (∼5%). Interestingly, a third of patients had some mild elevation of systemic inflammatory markers. Better VA at presentation was associated with visual gain, while baseline OCT values had poor correlation with final outcome.
To characterize a large modern cohort of patients with central retinal artery occlusion (CRAO) by describing presenting features and outcomes relating to manually segmented optical coherence tomography (OCT) features, angiographic reperfusion, and visual recovery.
Design
Retrospective clinical cohort study.
Methods
Patients with CRAO (ICD-10: H34.1) initially presenting to a tertiary referral center between January 2017 and December 2021 were included. Demographics, eye exam findings, fundus photographs, OCT, and fluorescein angiography were analyzed. Main outcome measures included total and inner retinal thickness on macular OCT, reperfusion, visual outcomes, and development of neovascularization.
Results
A total of 145 eyes of 144 patients with mean age at of 69.4 ± 13.6 years were included. The mean time to presentation was 1.6 ± 4.2 days, with 19% examined within 4.5 hours and 26% within 6 hours of vision loss. 19% had cilioretinal artery (CLRA) sparing. Mean initial visual acuity (VA) was 1.68 ± 1.10 Logarithm of the Minimum Angle of Resolution (LogMAR) (CLRA sparing) compared to 2.53 ± 0.58 LogMAR (non-CLRA sparing), P < .001. 32% had elevated inflammatory makers. Out of 47 eyes with final fluorescein angiography, one-third showed some reperfusion. Final vision was 1.40 ± 1.16 LogMAR (CLRA sparing) compared to 2.46 ± 0.81 (non-CLRA sparing), P < .001. A third of patients improved in VA in both groups, 27% of patients gained more than 2 lines of vision in the CLRA-sparing group and 36% in the non-CLRA-sparing group. 17% improved to better than 20/200 in CLRA-sparing and 4% in non-CLRA sparing. Overall, 11% developed neovascularization all in non-CLRA sparing. In a multiple linear regression, VA at presentation was associated with regaining vision of 2 lines or more (OR = 2.603, P = .007). OCT showed progressive thinning over time, reaching lowest measurements at 6 months, and stabilizing thereafter.
Conclusions
In this modern cohort of acute CRAO patients, presentation to a tertiary facility within 12 hours of symptoms was seen in almost half of the patients. Final VA improved in almost a third of the patients, however, vision better than the legal blindness limit was rare (∼5%). Interestingly, a third of patients had some mild elevation of systemic inflammatory markers. Better VA at presentation was associated with visual gain, while baseline OCT values had poor correlation with final outcome.
Clinical and imaging characteristics associated with foveal neovascularization in proliferative diab
Purpose
To assess the prevalence of foveal neovascularization (FNV) and its associated clinical features in proliferative diabetic retinopathy (PDR) eyes.
Methods
Cross-sectional observational study. Participants underwent ultra-widefield photography, optical coherence tomography (OCT), and swept-source OCT angiography (SS-OCTA). FNV was defined as a hyperreflective lesion breaching the internal limiting membrane and displaying flow signal on OCTA, within 1-mm of foveal avascular zone. Vascular metrics were obtained from the ARI Network portal. Ischemic index (ISI) and inner choroid flow deficit percentage were calculated using FIJI from 12 × 12 and 6 × 6-mm scans, respectively. Logistic regression models were used to compare eyes with and without FNV.
Results
We included 249 eyes of 164 patients (age: 58 [50–65] years). FNV was identified in 20 eyes (8%). Univariate logistic regression revealed significant associations between FNV and younger age (p = 0.03), higher maximal HbA1c (p = 0.04), worse visual acuity (VA) (p = 0.01), presence of disorganization of retinal inner layers (DRIL) (p = 0.01), no macular posterior vitreous detachment (PVD) (p = 0.03), neovascularization elsewhere (NVE) and at the disc (NVD) (p = 0.01 and p = 0.001), and greater ISI (p = 0.04). In multivariable analysis, a significant association remained between FNV and worse VA (p = 0.04), NVD (p < 0.001), DRIL (p < 0.001), and absence of macular PVD (p = 0.01). No associations were found with SS-OCTA vascular metrics.
Conclusions
This study provides a comprehensive characterization of FNV in PDR. FNV was identified in 8% of our cohort, being more prevalent in younger patients with severe PDR, as evidenced by NVD and DRIL presence. The absence of macular PVD may explain its association with younger age.
To assess the prevalence of foveal neovascularization (FNV) and its associated clinical features in proliferative diabetic retinopathy (PDR) eyes.
Methods
Cross-sectional observational study. Participants underwent ultra-widefield photography, optical coherence tomography (OCT), and swept-source OCT angiography (SS-OCTA). FNV was defined as a hyperreflective lesion breaching the internal limiting membrane and displaying flow signal on OCTA, within 1-mm of foveal avascular zone. Vascular metrics were obtained from the ARI Network portal. Ischemic index (ISI) and inner choroid flow deficit percentage were calculated using FIJI from 12 × 12 and 6 × 6-mm scans, respectively. Logistic regression models were used to compare eyes with and without FNV.
Results
We included 249 eyes of 164 patients (age: 58 [50–65] years). FNV was identified in 20 eyes (8%). Univariate logistic regression revealed significant associations between FNV and younger age (p = 0.03), higher maximal HbA1c (p = 0.04), worse visual acuity (VA) (p = 0.01), presence of disorganization of retinal inner layers (DRIL) (p = 0.01), no macular posterior vitreous detachment (PVD) (p = 0.03), neovascularization elsewhere (NVE) and at the disc (NVD) (p = 0.01 and p = 0.001), and greater ISI (p = 0.04). In multivariable analysis, a significant association remained between FNV and worse VA (p = 0.04), NVD (p < 0.001), DRIL (p < 0.001), and absence of macular PVD (p = 0.01). No associations were found with SS-OCTA vascular metrics.
Conclusions
This study provides a comprehensive characterization of FNV in PDR. FNV was identified in 8% of our cohort, being more prevalent in younger patients with severe PDR, as evidenced by NVD and DRIL presence. The absence of macular PVD may explain its association with younger age.
Choriocapillaris Loss in a Pediatric Patient With Congenital Cytomegalovirus Seen on Optical Coheren
Purpose: To describe choriocapillaris loss on optical coherence tomography angiography (OCTA) imaging in a pediatric patient with congenital cytomegalovirus (CMV). Methods: A case was evaluated. Results: A 7-year-old female patient was referred for retinal evaluation of maculopathy in the right eye. She was diagnosed with congenital CMV at 14 months of age, at which time treatment was not deemed necessary. At 7 years of age, the patient was asymptomatic with 20/20 Snellen visual acuity. Funduscopy and colored fundus photographs showed macular scarring. Ancillary testing was performed, with retinal pigment epithelium alterations and disruption of the outer retinal layers seen on OCT and choriocapillaris loss in the area of the macular scar seen on OCTA. Conclusions: For patients with congenital CMV, OCTA imaging can show significant changes in choriocapillaris function. These changes do not necessarily correlate with visual function parameters. OCTA may be useful as an additional screening or surveillance modality for patients with congenital CMV or CMV retinitis.
Operative Times in Scleral Buckle Surgery: Influencing Factors and Cost Analysis
Purpose: To determine the various factors affecting the duration of scleral buckle surgery, the percentage of profitable scleral buckle cases, and the operational break-even point. Methods: This single-center retrospective consecutive series comprised patients diagnosed with primary rhegmatogenous retinal detachment (RD) repaired with scleral buckling between 2019 and 2021. The primary outcome was operative time. Factors associated with longer surgery time were identified using regression analysis. A time-driven activity-based cost analysis was performed. Results: Following are the mean values: duration of 108 primary RD scleral buckle repairs, 106 ± 35 minutes (range, 52-231; median, 98); number of breaks, 2.15 ± 1.5 (range, 0-10); extent of the RD, 4.3 ± 2.0 clock hours (range, 0-9); duration of follow-up with a retina physician, 489 ± 355 days (range, 0-1316). Twenty eyes (19%) required subsequent RD repair. A regression analysis showed the following main risk factors for prolonged duration of RD repair via scleral buckling: number of breaks (β = 5.98; P = .005), use of radial elements (β = 52.09; P = .001), and gas injection (β = 31.27; P < .001). The median cost per case was $7674.64, which was $2713.64 (55%) more than the maximum Medicare reimbursement of $4961.00. The break-even time was 54.43 minutes. Conclusions: Independent risk factors for a prolonged duration of primary scleral buckle surgery include multiple breaks, use of radial elements, and gas injection. These additive steps could justify a separate complex Current Procedural Terminology code. The large majority of cases were not profitable, with losses proportional to operative time. This study demonstrates the clear need for greater reimbursements and economic incentives for scleral buckle surgery.
Update on Management of Retinopathy of Prematurity: A Review
Abstract
Retinopathy of prematurity (ROP) remains a significant health care concern in neonatal care as advances in neonatal intensive practices have improved the survival rates of premature infants. The management and screening of ROP have evolved significantly, with notable trends and advancements aimed at improving outcomes. The use of intravitreal antivascular endothelial growth factor injections has emerged as a prominent initial treatment for ROP in addition to laser photocoagulation. Screening practices have also seen enhancements, with a shift toward efficiency and tele-screening to optimize ROP management. This review aims to discuss available treatment and screening methods and explore new potential therapeutic tools for ROP.
Retinopathy of prematurity (ROP) remains a significant health care concern in neonatal care as advances in neonatal intensive practices have improved the survival rates of premature infants. The management and screening of ROP have evolved significantly, with notable trends and advancements aimed at improving outcomes. The use of intravitreal antivascular endothelial growth factor injections has emerged as a prominent initial treatment for ROP in addition to laser photocoagulation. Screening practices have also seen enhancements, with a shift toward efficiency and tele-screening to optimize ROP management. This review aims to discuss available treatment and screening methods and explore new potential therapeutic tools for ROP.
Cost-effectiveness Analysis of Digital Therapeutics for Amblyopia
Purpose
To evaluate the cost-utility of Luminopia (Luminopia, Inc) and CureSight (NovaSight, Ltd) as therapy for amblyopia compared with current common amblyopic treatments such as glasses, atropine drops, and patching.
Design
Cost analysis based on data from published randomized control trials (RCTs).
Subjects
Data from Luminopia, CureSight, and atropine RCTs.
Methods
A cost-utility analysis was performed using patient preference-based time trade-off utility values from previous literature. Costs for eye examinations were calculated using reimbursement data; device costs for duration of treatment were provided by sales representatives of Luminopia and CureSight. All treatments were inclusive of the cost of eyeglasses. Visual acuity (VA) and stereoacuity outcomes were extrapolated from the RCTs for atropine, Luminopia, and CureSight. A quality-adjusted life-year (QALY) was calculated by multiplying utility gain, a value correlated with VA gain, by length of time of benefit.
Main Outcome Measures
Cost, cost per QALY, and cost per stereoacuity gain.
Results
The cost to treat amblyopia with glasses alone for 12 weeks was $514. The cost of treating with patching for 12 weeks was $540 and with atropine for 16 weeks was $652, whereas the cost of treating with Luminopia or CureSight for 12 weeks was $1951 and $1564 or $1814, respectively. Treatment with glasses alone or patching for 12 weeks resulted in a cost per QALY gained of $427 and $101, respectively. Atropine treatment for 16 weeks resulted in a cost per QALY gained of $151. The cost per QALY for 12-week Luminopia treatment was $618 versus $368 or $427 for 12-week CureSight treatment and $314 or $354 for 16-week CureSight treatment (P < 0.05). Cost per stereoacuity gain for 12-week treatment duration was $6421/log arcsec (glasses), $1801/log arcsec (patching), and $3007/log arcsec or $3488/log arcsec (CureSight).
Conclusions
Treatment of amblyopia with Luminopia or CureSight is cost-effective in comparison with established willingness-to-pay thresholds and can provide a viable treatment option, especially for those who are unable to tolerate patching or atropine penalization. Cost-effectiveness values based on VA gain of Luminopia and CureSight were comparable.
To evaluate the cost-utility of Luminopia (Luminopia, Inc) and CureSight (NovaSight, Ltd) as therapy for amblyopia compared with current common amblyopic treatments such as glasses, atropine drops, and patching.
Design
Cost analysis based on data from published randomized control trials (RCTs).
Subjects
Data from Luminopia, CureSight, and atropine RCTs.
Methods
A cost-utility analysis was performed using patient preference-based time trade-off utility values from previous literature. Costs for eye examinations were calculated using reimbursement data; device costs for duration of treatment were provided by sales representatives of Luminopia and CureSight. All treatments were inclusive of the cost of eyeglasses. Visual acuity (VA) and stereoacuity outcomes were extrapolated from the RCTs for atropine, Luminopia, and CureSight. A quality-adjusted life-year (QALY) was calculated by multiplying utility gain, a value correlated with VA gain, by length of time of benefit.
Main Outcome Measures
Cost, cost per QALY, and cost per stereoacuity gain.
Results
The cost to treat amblyopia with glasses alone for 12 weeks was $514. The cost of treating with patching for 12 weeks was $540 and with atropine for 16 weeks was $652, whereas the cost of treating with Luminopia or CureSight for 12 weeks was $1951 and $1564 or $1814, respectively. Treatment with glasses alone or patching for 12 weeks resulted in a cost per QALY gained of $427 and $101, respectively. Atropine treatment for 16 weeks resulted in a cost per QALY gained of $151. The cost per QALY for 12-week Luminopia treatment was $618 versus $368 or $427 for 12-week CureSight treatment and $314 or $354 for 16-week CureSight treatment (P < 0.05). Cost per stereoacuity gain for 12-week treatment duration was $6421/log arcsec (glasses), $1801/log arcsec (patching), and $3007/log arcsec or $3488/log arcsec (CureSight).
Conclusions
Treatment of amblyopia with Luminopia or CureSight is cost-effective in comparison with established willingness-to-pay thresholds and can provide a viable treatment option, especially for those who are unable to tolerate patching or atropine penalization. Cost-effectiveness values based on VA gain of Luminopia and CureSight were comparable.
Evaluating the Utility of Initial Examinations in Retinopathy of Prematurity
Purpose
To assess the utility of the first or second examinations for retinopathy of prematurity (ROP) in a medium-risk cohort of infants and to propose an optimization to the current ROP screening guidelines.
Design
Retrospective consecutive study.
Participants
Infants screened for ROP between January 2017 and August 2023 at 3 different tertiary-level care neonatal intensive care units.
Methods
Analysis of patients who did not meet criteria for microprematurity or nanoprematurity (those born at ≥ 27 weeks and weighing ≥ 800 g).
Main Outcome Measures
The primary outcomes included the rates of ROP and treatment-warranted ROP (TW-ROP), the presence of TW-ROP at the first or second inpatient examinations, the number of inpatient examinations performed before the first ROP diagnosis, and the overall number of inpatient examinations performed.
Results
A total of 2004 neonates were screened for ROP, among whom 1125 (56.1%) met the inclusion criteria. Of those, 237 neonates (21.1%) had ROP. Eleven infants (1.0%) required treatment for active disease. The median postmenstrual age (PMA) at first ROP diagnosis was 35.3 weeks (interquartile range [IQR], 33.7–37 weeks; range, 30.3–46.7 weeks). The median PMA at stage 3 diagnosis was 39.3 weeks (IQR, 38.3–41.2 weeks; range, 35.1–44.4 weeks). The median PMA at first treatment was 39.6 weeks (IQR, 35.8–43.3 weeks; range, 35.3–49.6 weeks). The median number of inpatient examinations was 2.0 (IQR, 1–4 examinations) for traditional screening, 1.0 examination (IQR, 1–3 examinations) after eliminating the first ROP inpatient examination, and 1.0 examination (IQR, 1–2 examinations) after eliminating the first and second ROP examinations (P < 0.001). No patients met type 1 ROP treatment criteria at either the first or second inpatient examination (100% sensitivity for TW-ROP). In this cohort, starting examinations at 34 weeks’ PMA could save 30.6% of inpatient examinations.
Conclusions
In infants not meeting criteria for microprematurity or nanoprematurity, no type 1 ROP was diagnosed at either of the first 2 inpatient examinations. We propose an amendment algorithm (FIRST-ROP) in which ROP examinations start at 34 weeks’ PMA for neonates born at ≥27 weeks gestational age and ≥800 grams.
To assess the utility of the first or second examinations for retinopathy of prematurity (ROP) in a medium-risk cohort of infants and to propose an optimization to the current ROP screening guidelines.
Design
Retrospective consecutive study.
Participants
Infants screened for ROP between January 2017 and August 2023 at 3 different tertiary-level care neonatal intensive care units.
Methods
Analysis of patients who did not meet criteria for microprematurity or nanoprematurity (those born at ≥ 27 weeks and weighing ≥ 800 g).
Main Outcome Measures
The primary outcomes included the rates of ROP and treatment-warranted ROP (TW-ROP), the presence of TW-ROP at the first or second inpatient examinations, the number of inpatient examinations performed before the first ROP diagnosis, and the overall number of inpatient examinations performed.
Results
A total of 2004 neonates were screened for ROP, among whom 1125 (56.1%) met the inclusion criteria. Of those, 237 neonates (21.1%) had ROP. Eleven infants (1.0%) required treatment for active disease. The median postmenstrual age (PMA) at first ROP diagnosis was 35.3 weeks (interquartile range [IQR], 33.7–37 weeks; range, 30.3–46.7 weeks). The median PMA at stage 3 diagnosis was 39.3 weeks (IQR, 38.3–41.2 weeks; range, 35.1–44.4 weeks). The median PMA at first treatment was 39.6 weeks (IQR, 35.8–43.3 weeks; range, 35.3–49.6 weeks). The median number of inpatient examinations was 2.0 (IQR, 1–4 examinations) for traditional screening, 1.0 examination (IQR, 1–3 examinations) after eliminating the first ROP inpatient examination, and 1.0 examination (IQR, 1–2 examinations) after eliminating the first and second ROP examinations (P < 0.001). No patients met type 1 ROP treatment criteria at either the first or second inpatient examination (100% sensitivity for TW-ROP). In this cohort, starting examinations at 34 weeks’ PMA could save 30.6% of inpatient examinations.
Conclusions
In infants not meeting criteria for microprematurity or nanoprematurity, no type 1 ROP was diagnosed at either of the first 2 inpatient examinations. We propose an amendment algorithm (FIRST-ROP) in which ROP examinations start at 34 weeks’ PMA for neonates born at ≥27 weeks gestational age and ≥800 grams.
INTRAVITREAL SUSTAINED RELEASE STEROID IMPLANTS ARE SAFE AND EFFECTIVE IN PATIENTS WITH GLAUCOMA DRA
Purpose:
To describe effects of sustained-release steroid delivery devices on intraocular pressure (IOP) in eyes with glaucoma drainage devices.
Methods:
Retrospective case series of eyes with steroid implants (dexamethasone or fluocinolone acetonide) and prior glaucoma drainage devices (Ahmed, Baerveldt) without uveitis. Outcomes included IOP, IOP rise, central foveal thickness, and IOP medications.
Results:
We included 14 eyes (14 patients, 38% men, 94% pseudophakic). Mean age at steroid implantation was 64 ± 12 years. Baerveldt (64%) was more common than Ahmed (36%). Tubes were in the anterior chamber (57.1%), sulcus (28.6%), and pars plana (14.3%). Ozurdex (93%) was more common than Yutiq (7%). Mean IOP was 13.5 ± 3.4 mmHg preimplant, 11.8 ± 3.7 mmHg at month 1, 13.3 ± 3.6 mmHg at month 3 (P = 0.35), and 11.3 ± 3.8 mmHg at 1 year (P = 0.032). Mean antihypertensive medication was unchanged at month 3 (P = 1.0) and −0.36 medication at last follow-up (P = 0.35). Mean central foveal thickness change was −204 ± 158 µm (P = 0.001). There were no cases of endophthalmitis.
Conclusion:
Intravitreal steroid implants were safe and effective for the treatment of postsurgical CME in patients with pre-existing glaucoma drainage devices. There was no increase in IOP and no increase in antihypertensive drops.
To describe effects of sustained-release steroid delivery devices on intraocular pressure (IOP) in eyes with glaucoma drainage devices.
Methods:
Retrospective case series of eyes with steroid implants (dexamethasone or fluocinolone acetonide) and prior glaucoma drainage devices (Ahmed, Baerveldt) without uveitis. Outcomes included IOP, IOP rise, central foveal thickness, and IOP medications.
Results:
We included 14 eyes (14 patients, 38% men, 94% pseudophakic). Mean age at steroid implantation was 64 ± 12 years. Baerveldt (64%) was more common than Ahmed (36%). Tubes were in the anterior chamber (57.1%), sulcus (28.6%), and pars plana (14.3%). Ozurdex (93%) was more common than Yutiq (7%). Mean IOP was 13.5 ± 3.4 mmHg preimplant, 11.8 ± 3.7 mmHg at month 1, 13.3 ± 3.6 mmHg at month 3 (P = 0.35), and 11.3 ± 3.8 mmHg at 1 year (P = 0.032). Mean antihypertensive medication was unchanged at month 3 (P = 1.0) and −0.36 medication at last follow-up (P = 0.35). Mean central foveal thickness change was −204 ± 158 µm (P = 0.001). There were no cases of endophthalmitis.
Conclusion:
Intravitreal steroid implants were safe and effective for the treatment of postsurgical CME in patients with pre-existing glaucoma drainage devices. There was no increase in IOP and no increase in antihypertensive drops.
The U.S.A. eligible retinopathy of prematurity screening population 2003-2022: WONDER-ROP Study
Purpose: To delineate the trends of the United States population eligible for retinopathy of prematurity (ROP) screening as defined by the Joint Statement Screening Guidelines of the American Academies of Pediatrics and Ophthalmology from the Centers for Disease Control using the Wide-ranging Online Data for Epidemiologic Research (WONDER) Database.
Design: National, retrospective study.
Subjects: Infants with ROP in the United States between 2003 and 2022.
Methods: Data collected from WONDER database over the 20-year period 2003-2022.
Main outcome measured: The parameters of state, infant birth weight (BW), and last menstrual period estimated gestational age (EGA). Four categories of qualification for ROP Screening eligibility were created: BW, EGA, combined BW and EGA (double eligible infants), and Unique Eligible Infants (UEI).
Results: The number of eligible for ROP screening in the U.S peaked at 56,106 in 2007 and has steadily declined to 41,083 in 2022, averaging 47,088 per year throughout the study period. During the first ten-year period, there was an average of 50,895 eligible infants per year vs 43,281 infants per year during the second ten-year period. This was a statistically significant trend. BW slightly surpassed EGA as a driver for screening eligibility every year. Both the numbers of eligible micropremature (24-26 weeks GA and/or BW 600-800 g) infants and numbers of eligible nanopremature (<24 weeks GA and/or BW <600 g) infants mirrored the trendline overall eligibility trends. At the state level, Texas surpassed California in 2012 in terms of the highest number of eligible infants, and Florida surpassed New York in 2011 as the state with the third most eligible infants. These changes persisted until the end of the study period. State level changes were driven by EGA. For micropremature infants, California and New York demonstrated a decline in eligibility driven by both BW and EGA.
Conclusion: Consistent with a drop in overall births, the numbers of eligible infants for ROP screening at birth have been decreasing since its peak in 2007, with stabilization in the 2020's. Nationally, BW drives eligibility. Both micro- and nano-premature infants have decreased in a manner that corresponds to overall eligibility with nano-premature infants having a slight relative decrease. This data adds important context to studies on infant survivability and ROP screening epidemiology.
Design: National, retrospective study.
Subjects: Infants with ROP in the United States between 2003 and 2022.
Methods: Data collected from WONDER database over the 20-year period 2003-2022.
Main outcome measured: The parameters of state, infant birth weight (BW), and last menstrual period estimated gestational age (EGA). Four categories of qualification for ROP Screening eligibility were created: BW, EGA, combined BW and EGA (double eligible infants), and Unique Eligible Infants (UEI).
Results: The number of eligible for ROP screening in the U.S peaked at 56,106 in 2007 and has steadily declined to 41,083 in 2022, averaging 47,088 per year throughout the study period. During the first ten-year period, there was an average of 50,895 eligible infants per year vs 43,281 infants per year during the second ten-year period. This was a statistically significant trend. BW slightly surpassed EGA as a driver for screening eligibility every year. Both the numbers of eligible micropremature (24-26 weeks GA and/or BW 600-800 g) infants and numbers of eligible nanopremature (<24 weeks GA and/or BW <600 g) infants mirrored the trendline overall eligibility trends. At the state level, Texas surpassed California in 2012 in terms of the highest number of eligible infants, and Florida surpassed New York in 2011 as the state with the third most eligible infants. These changes persisted until the end of the study period. State level changes were driven by EGA. For micropremature infants, California and New York demonstrated a decline in eligibility driven by both BW and EGA.
Conclusion: Consistent with a drop in overall births, the numbers of eligible infants for ROP screening at birth have been decreasing since its peak in 2007, with stabilization in the 2020's. Nationally, BW drives eligibility. Both micro- and nano-premature infants have decreased in a manner that corresponds to overall eligibility with nano-premature infants having a slight relative decrease. This data adds important context to studies on infant survivability and ROP screening epidemiology.
A Quantitative Normative Database for Expanded Field Swept-source OCT Angiography in the Pediatric P
Background and objective: To report quantitative vascular metrics of healthy control eyes of children, using expanded field swept-source optical coherence tomography angiography (SS-OCTA), as a baseline to compare with pathologic findings.
Patients and methods: A cross-sectional observational study of healthy eyes of children (age 6 to 18) who were imaged on the PLEX Elite 9000 instrument at 100-kHz scanning rate using 3 × 3-mm, 6 × 6-mm, and 12 × 12-mm protocols centered on the fovea (2019 to 2023). Scans were uploaded to the ARI Network (Zeiss Portal v5.4) and processed with the macular density algorithm (v.0.7.3.3) to calculate vessel density (VD) and vessel skeletonized density (VSD) in the superficial capillary plexus (SCP), deep capillary plexus, and whole retina (WR) and foveal avascular zone (FAZ) metrics.
Results: Forty-eight eyes of 39 children (72% male) were included. Median age was 14 years (interquartile range 10 to 16). Male sex was associated with lower VD and VSD compared to female sex (P < 0.05). Older age was associated with higher VD and VSD (6 × 6-mm) (P < 0.05) and lower FAZ circularity (P = 0.017). Non-Hispanic White children had a lower VD and VSD of the SCP in the inner superior ring (3 × 3-mm), a higher VD and VSD of the SCP and WR in the central ring (6 × 6-mm), and a lower FAZ area (6 × 6-mm) (P < 0.05).
Conclusions: This study presents a database for expanded field vascular metrics in pediatric subjects across various angiogram sizes. The VD increases throughout childhood and the FAZ circularity diminishes. Future studies using SS-OCTA will need to account for influencing factors such as sex, age, race, and ethnicity.
Patients and methods: A cross-sectional observational study of healthy eyes of children (age 6 to 18) who were imaged on the PLEX Elite 9000 instrument at 100-kHz scanning rate using 3 × 3-mm, 6 × 6-mm, and 12 × 12-mm protocols centered on the fovea (2019 to 2023). Scans were uploaded to the ARI Network (Zeiss Portal v5.4) and processed with the macular density algorithm (v.0.7.3.3) to calculate vessel density (VD) and vessel skeletonized density (VSD) in the superficial capillary plexus (SCP), deep capillary plexus, and whole retina (WR) and foveal avascular zone (FAZ) metrics.
Results: Forty-eight eyes of 39 children (72% male) were included. Median age was 14 years (interquartile range 10 to 16). Male sex was associated with lower VD and VSD compared to female sex (P < 0.05). Older age was associated with higher VD and VSD (6 × 6-mm) (P < 0.05) and lower FAZ circularity (P = 0.017). Non-Hispanic White children had a lower VD and VSD of the SCP in the inner superior ring (3 × 3-mm), a higher VD and VSD of the SCP and WR in the central ring (6 × 6-mm), and a lower FAZ area (6 × 6-mm) (P < 0.05).
Conclusions: This study presents a database for expanded field vascular metrics in pediatric subjects across various angiogram sizes. The VD increases throughout childhood and the FAZ circularity diminishes. Future studies using SS-OCTA will need to account for influencing factors such as sex, age, race, and ethnicity.
Exudative retinal detachment in a pediatric patient with Rubinstein-Taybi syndrome
Purpose:
To highlight findings of retinal exudation with exudative retinal detachment in a patient with Rubinstein-Taybi syndrome (RSTS) due to CREBBP mutation, successfully treated with laser, with the goal of adding to the known phenotypic spectrum of ophthalmic manifestations of RSTS.
Methods:
A case report of a pediatric patient evaluated with multimodal imaging including fundus photography and fluorescein angiography.
Results:
A 15-year-old female with RSTS caused by a frameshift mutation in CREBBP was referred for retinal examination under anesthesia. In additional to typical features of RSTS, including developmental delay, microcephaly, and broad thumbs and toes, she had an ocular history of bilateral nasolacrimal duct obstructions and intermittent exotropia. Dilated fundus examination revealed left iris coloboma, bilateral optic nerve colobomas, and exudation of the left temporal retina with associated exudative retinal detachment and inferotemporal hemorrhage. Fluorescein angiography demonstrated leakage and avascularity of both eyes, with diffuse leakage and nonperfusion noted in the left eye. The avascular areas of the right eye were treated prophylactically with laser as well as sub-Tenon’s triamcinolone. The left retinal exudation initially improved with several rounds of laser treatment, however vitreoretinal membranes eventually developed, resulting in a focal tractional detachment requiring vitrectomy and lensectomy.
Conclusion:
Patients with RSTS have a wide spectrum of ophthalmic manifestations. Our patient demonstrated marked peripheral retinal avascularity and vascular leakage, ultimately resulting in a novel finding of sub-retinal exudation. Laser to the avascular retina led to initial regression of the exudation, however the patient ultimately developed a focal tractional detachment requiring surgery.
To highlight findings of retinal exudation with exudative retinal detachment in a patient with Rubinstein-Taybi syndrome (RSTS) due to CREBBP mutation, successfully treated with laser, with the goal of adding to the known phenotypic spectrum of ophthalmic manifestations of RSTS.
Methods:
A case report of a pediatric patient evaluated with multimodal imaging including fundus photography and fluorescein angiography.
Results:
A 15-year-old female with RSTS caused by a frameshift mutation in CREBBP was referred for retinal examination under anesthesia. In additional to typical features of RSTS, including developmental delay, microcephaly, and broad thumbs and toes, she had an ocular history of bilateral nasolacrimal duct obstructions and intermittent exotropia. Dilated fundus examination revealed left iris coloboma, bilateral optic nerve colobomas, and exudation of the left temporal retina with associated exudative retinal detachment and inferotemporal hemorrhage. Fluorescein angiography demonstrated leakage and avascularity of both eyes, with diffuse leakage and nonperfusion noted in the left eye. The avascular areas of the right eye were treated prophylactically with laser as well as sub-Tenon’s triamcinolone. The left retinal exudation initially improved with several rounds of laser treatment, however vitreoretinal membranes eventually developed, resulting in a focal tractional detachment requiring vitrectomy and lensectomy.
Conclusion:
Patients with RSTS have a wide spectrum of ophthalmic manifestations. Our patient demonstrated marked peripheral retinal avascularity and vascular leakage, ultimately resulting in a novel finding of sub-retinal exudation. Laser to the avascular retina led to initial regression of the exudation, however the patient ultimately developed a focal tractional detachment requiring surgery.
Dropless Vitreoretinal Surgery: A Review and Pooled Analysis
Abstract
The aim of this review is to provide an overview of the literature on dropless vitreoretinal surgery. A comprehensive search was conducted using the PubMed database from August 2004 to August 2024 using the following keywords: “dropless” and “vitrectomy” or “retinal surgery” or “detachment surgery”. Relevant studies included randomized controlled trials (RCTs) and observational studies. Data on protocols, patient characteristics, clinical and visual outcomes and adverse events were collected. Seven studies met the inclusion criteria. Protocols included a range of alternative antimicrobial and anti-inflammatory prophylaxis including intravitreal, intracameral, subconjunctival or sub-Tenon's injection of single-use, compounded medication. The current literature demonstrated no increased rates of endophthalmitis and no increase in intraocular pressure during the post-operative period. In summary, this review pools the current dropless protocols and outcomes for vitreoretinal surgery. There is moderate certainty suggesting non-inferiority, yet there is a need for higher quality supporting evidence and prospective RCTs.
The aim of this review is to provide an overview of the literature on dropless vitreoretinal surgery. A comprehensive search was conducted using the PubMed database from August 2004 to August 2024 using the following keywords: “dropless” and “vitrectomy” or “retinal surgery” or “detachment surgery”. Relevant studies included randomized controlled trials (RCTs) and observational studies. Data on protocols, patient characteristics, clinical and visual outcomes and adverse events were collected. Seven studies met the inclusion criteria. Protocols included a range of alternative antimicrobial and anti-inflammatory prophylaxis including intravitreal, intracameral, subconjunctival or sub-Tenon's injection of single-use, compounded medication. The current literature demonstrated no increased rates of endophthalmitis and no increase in intraocular pressure during the post-operative period. In summary, this review pools the current dropless protocols and outcomes for vitreoretinal surgery. There is moderate certainty suggesting non-inferiority, yet there is a need for higher quality supporting evidence and prospective RCTs.
United States versus Non-United States Retreatment Rates after Intravitreal Anti-VEGF Injections for
Retinal Imaging Biomarkers and Correlation to Systemic Disease Activity in Pediatric Sickle Cell Dis
Purpose: To correlate retinal imaging findings with systemic disease activity in children with sickle cell disease (SCD).
Design: A retrospective consecutive series.
Subjects: Children with SCD aged ≤18 years who had an ophthalmic examination at Boston Children's Hospital between January 1998 and August 2022 were included.
Main outcome measures: Systemic findings included the number of hospitalizations, number of strokes, treatment with hydroxyurea, hemoglobin (Hgb), and fetal Hgb levels, and time-averaged mean velocity (TAMV) in the right middle cerebral artery (RMCA) and left middle cerebral artery (LMCA) on transcranial Doppler (TCD).
Methods: Total retinal thickness was measured on macular OCT (Spectralis OCT2, Heidelberg Engineering). Vessel density (VD) of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) and superficial foveal avascular zone area were measured on 6 × 6-mm OCT angiography (OCTA) scans.
Results: Six hundred six eyes from 303 pediatric SCD patients (53% males) were included. OCT and OCTA images were acquired on 104 (17.2%) and 60 (9.9%) eyes at presentation and on 159 (26.2%) and 100 (16.5%) eyes at the final visit, respectively. When adjusting for race and age, retinal thinning on OCT was associated with a higher frequency of hospitalizations, a higher frequency of strokes, and treatment with hydroxyurea. Retinal thickness in the inferior and temporal macula was positively correlated with TAMV in RMCA and in LMCA. Foveal retinal thickness was positively correlated with Hgb level. Similarly, reduced VD in the SCP and DCP in the inferior temporal macula correlated with a higher number of hospitalizations and strokes. A higher VD of the DCP in the inferior-temporal macula positively correlated with TAMV in RMCA (ρ = 0.328, P = 0.3) and in LMCA (ρ = 0.342, P = 0.029). A higher Hgb level correlated with a higher prevalence (ρ = 0.237, P = 0.037) and severity (ρ = 0.299, P = 0.008) of peripheral retinopathy in HbSC, while it correlated with lower prevalence (ρ = -0.183, P = 0.004) and severity (ρ = -0.185, P = 0.004) of peripheral retinopathy in HbSS genotypes. Visual acuity did not correlate with TCD velocity, Hgb level, or number of hospitalizations in HbSS or HbSC genotypes.
Conclusions: OCT and OCTA findings are correlated with the severity of systemic disease in children with SCD. Imaging parameters were better correlated with key outcomes such as stroke and hospitalizations than visual acuity. The results suggest that quantitative measures on retinal imaging could be used as biomarkers to predict systemic disease risk and activity.
Design: A retrospective consecutive series.
Subjects: Children with SCD aged ≤18 years who had an ophthalmic examination at Boston Children's Hospital between January 1998 and August 2022 were included.
Main outcome measures: Systemic findings included the number of hospitalizations, number of strokes, treatment with hydroxyurea, hemoglobin (Hgb), and fetal Hgb levels, and time-averaged mean velocity (TAMV) in the right middle cerebral artery (RMCA) and left middle cerebral artery (LMCA) on transcranial Doppler (TCD).
Methods: Total retinal thickness was measured on macular OCT (Spectralis OCT2, Heidelberg Engineering). Vessel density (VD) of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) and superficial foveal avascular zone area were measured on 6 × 6-mm OCT angiography (OCTA) scans.
Results: Six hundred six eyes from 303 pediatric SCD patients (53% males) were included. OCT and OCTA images were acquired on 104 (17.2%) and 60 (9.9%) eyes at presentation and on 159 (26.2%) and 100 (16.5%) eyes at the final visit, respectively. When adjusting for race and age, retinal thinning on OCT was associated with a higher frequency of hospitalizations, a higher frequency of strokes, and treatment with hydroxyurea. Retinal thickness in the inferior and temporal macula was positively correlated with TAMV in RMCA and in LMCA. Foveal retinal thickness was positively correlated with Hgb level. Similarly, reduced VD in the SCP and DCP in the inferior temporal macula correlated with a higher number of hospitalizations and strokes. A higher VD of the DCP in the inferior-temporal macula positively correlated with TAMV in RMCA (ρ = 0.328, P = 0.3) and in LMCA (ρ = 0.342, P = 0.029). A higher Hgb level correlated with a higher prevalence (ρ = 0.237, P = 0.037) and severity (ρ = 0.299, P = 0.008) of peripheral retinopathy in HbSC, while it correlated with lower prevalence (ρ = -0.183, P = 0.004) and severity (ρ = -0.185, P = 0.004) of peripheral retinopathy in HbSS genotypes. Visual acuity did not correlate with TCD velocity, Hgb level, or number of hospitalizations in HbSS or HbSC genotypes.
Conclusions: OCT and OCTA findings are correlated with the severity of systemic disease in children with SCD. Imaging parameters were better correlated with key outcomes such as stroke and hospitalizations than visual acuity. The results suggest that quantitative measures on retinal imaging could be used as biomarkers to predict systemic disease risk and activity.
Delayed Dx of Intraocular Foreign Body: Clinical Characteristics, Outcomes, Complications
Title: Clinical Characteristics, Outcomes, and Complications Associated With Delayed Diagnosis of Intraocular Foreign Body.
Purpose: To describe the clinical characteristics, outcomes, and complications in cases of intraocular foreign bodies (IOFBs) when the diagnosis is missed or delayed.
Methods: This nonconsecutive case series was a retrospective multicenter study of adult patients with a delayed diagnosis of IOFB, defined as initially presenting elsewhere with a missed diagnosis or a delay of more than 24 hours to seek care.
Results: Eighteen eyes were included. The mean (±SD) presenting logMAR visual acuity (VA) was 0.45 ± 0.70 (Snellen equivalent, 20/56). The most common presenting symptom was decreased vision (11 patients [61%]). The general emergency department setting accounted for most initial evaluations (11 patients [61%]); however, 6 patients (33%) were seen in an outpatient setting by an optometrist, ophthalmologist, or both. The most common anatomic locations of the IOFBs were in the iris/anterior chamber (4 [22%]) or lens (4 [22%]) followed by the pars plana/ciliary body (3 [17%]), vitreous (3 [17%]), or retina (3 [17%]). Complications at presentation included endophthalmitis (1 [6%]), retinal detachment (1 [6%]), and retinal tears (4 [22%]). Five patients (28%) had siderosis at presentation. The mean final logMAR VA was 0.13 ± 0.32 (Snellen equivalent, 20/26). At the last follow-up, 15 eyes (83%) had a VA of 20/30 or better. The median follow-up was 139 days (IQR, 86-557).
Conclusions: Eyes with a delayed diagnosis of IOFBs often present with good vision and self-sealing wounds. Missed IOFBs can be associated with siderosis, RD, and endophthalmitis. Visual outcomes may be salvaged with prompt treatment.
Purpose: To describe the clinical characteristics, outcomes, and complications in cases of intraocular foreign bodies (IOFBs) when the diagnosis is missed or delayed.
Methods: This nonconsecutive case series was a retrospective multicenter study of adult patients with a delayed diagnosis of IOFB, defined as initially presenting elsewhere with a missed diagnosis or a delay of more than 24 hours to seek care.
Results: Eighteen eyes were included. The mean (±SD) presenting logMAR visual acuity (VA) was 0.45 ± 0.70 (Snellen equivalent, 20/56). The most common presenting symptom was decreased vision (11 patients [61%]). The general emergency department setting accounted for most initial evaluations (11 patients [61%]); however, 6 patients (33%) were seen in an outpatient setting by an optometrist, ophthalmologist, or both. The most common anatomic locations of the IOFBs were in the iris/anterior chamber (4 [22%]) or lens (4 [22%]) followed by the pars plana/ciliary body (3 [17%]), vitreous (3 [17%]), or retina (3 [17%]). Complications at presentation included endophthalmitis (1 [6%]), retinal detachment (1 [6%]), and retinal tears (4 [22%]). Five patients (28%) had siderosis at presentation. The mean final logMAR VA was 0.13 ± 0.32 (Snellen equivalent, 20/26). At the last follow-up, 15 eyes (83%) had a VA of 20/30 or better. The median follow-up was 139 days (IQR, 86-557).
Conclusions: Eyes with a delayed diagnosis of IOFBs often present with good vision and self-sealing wounds. Missed IOFBs can be associated with siderosis, RD, and endophthalmitis. Visual outcomes may be salvaged with prompt treatment.
Timing of Retinopathy of Prematurity Diagnosis and Treatment in Micro-Premature and Nano-Premature I
Objective: We aimed to determine the timing of retinopathy of prematurity (ROP) diagnosis and treatment in a cohort of infants meeting criteria for micro and/or nano-prematurity with the goal of informing screening protocols in this high-risk group.
Design: Retrospective consecutive study.
Participants: We included all screened infants who met the criteria for micro-prematurity (24-26 weeks GA and/or BW 600-799 grams) or nano-prematurity (<24 weeks GA and/or BW <600 grams).
Methods: Data collected from 2013 to 2023 included GA at birth, BW, postmenstrual age (PMA) at ROP diagnosis, PMA at type 1 ROP diagnosis, and number of inpatient examinations.
Main outcomes measures: Rates of ROP and treatment-warranted ROP, timing to first ROP diagnosis and treatment-warranted ROP, and the number of examinations.
Results: 3239 infants were screened during this time period for ROP, and 650 infants met inclusion criteria. The median GA at birth and BW were 25.3 weeks and 682.5 grams, respectively. 456 infants (70.2%) were micro-premature and 194 (29.8%) were nano-premature. ROP was detected in 524 patients (80.6%). The median PMA at first ROP diagnosis was 33.7 weeks. The median interval from birth to first ROP diagnosis was 8.4 weeks. The median exam number at first ROP diagnosis was the second exam. The median number of inpatient examinations was 9. Of ROP patients, 180 (34.4%) had ROP diagnosis at their first examination. A total of 126 (19.4% of all infants and 24.0% of those with ROP) infants met type 1 treatment criteria. The median PMA at type 1 ROP diagnosis was 37 weeks . The median interval from birth to type 1 ROP was 12 weeks. The median exam number at type 1 diagnosis was the 5th exam.
Conclusions: In this modern cohort of high-risk extremely premature infants, 9 patients (1.4%) were diagnosed with type 1 ROP on the first or second inpatient exams. These infants had generally good outcomes after treatment, with only two eyes of one patient progressing to stage 4 disease. Our findings support maintaining current screening guidelines for high-risk extremely premature infants, while suggesting opportunities for optimizing screening approaches through risk stratification.
Design: Retrospective consecutive study.
Participants: We included all screened infants who met the criteria for micro-prematurity (24-26 weeks GA and/or BW 600-799 grams) or nano-prematurity (<24 weeks GA and/or BW <600 grams).
Methods: Data collected from 2013 to 2023 included GA at birth, BW, postmenstrual age (PMA) at ROP diagnosis, PMA at type 1 ROP diagnosis, and number of inpatient examinations.
Main outcomes measures: Rates of ROP and treatment-warranted ROP, timing to first ROP diagnosis and treatment-warranted ROP, and the number of examinations.
Results: 3239 infants were screened during this time period for ROP, and 650 infants met inclusion criteria. The median GA at birth and BW were 25.3 weeks and 682.5 grams, respectively. 456 infants (70.2%) were micro-premature and 194 (29.8%) were nano-premature. ROP was detected in 524 patients (80.6%). The median PMA at first ROP diagnosis was 33.7 weeks. The median interval from birth to first ROP diagnosis was 8.4 weeks. The median exam number at first ROP diagnosis was the second exam. The median number of inpatient examinations was 9. Of ROP patients, 180 (34.4%) had ROP diagnosis at their first examination. A total of 126 (19.4% of all infants and 24.0% of those with ROP) infants met type 1 treatment criteria. The median PMA at type 1 ROP diagnosis was 37 weeks . The median interval from birth to type 1 ROP was 12 weeks. The median exam number at type 1 diagnosis was the 5th exam.
Conclusions: In this modern cohort of high-risk extremely premature infants, 9 patients (1.4%) were diagnosed with type 1 ROP on the first or second inpatient exams. These infants had generally good outcomes after treatment, with only two eyes of one patient progressing to stage 4 disease. Our findings support maintaining current screening guidelines for high-risk extremely premature infants, while suggesting opportunities for optimizing screening approaches through risk stratification.
Real-Time Adverse Events in Pediatric Fluorescein Angiography: IV versus Oral
Abstract:
EN FACE DEPTH-RESOLVED OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY MONITORING OF MACULAR OUTER RETINAL
Purpose:
Multifocal choroiditis is a rare inflammatory condition characterized by retinal and choroidal lesions that may present similarly to ocular pathology of various etiologies. Here, we present a case of multifocal choroiditis mimicking syphilitic uveitis with unique en face optical coherence tomography angiography imaging characteristics.
Methods:
This was a case report.
Results:
A 61-year-old woman presented with blurry vision, floaters, and multiple whitish subretinal deposits on en face swept-source optical coherence tomography angiography in the left eye. Fluorescent treponemal antibody test absorption was positive, which led to the initial diagnosis of syphilitic uveitis and subsequent treatment with IV penicillin. During follow-up, optical coherence tomography angiography of the left eye revealed the development of a new choroidal neovascular membrane and new punched-out lesions in the posterior pole. The patient was eventually diagnosed with multifocal choroiditis and treated with aflibercept injections.
Conclusion:
Immune-mediated uveitis can simulate infectious and neoplastic uveitis. En face optical coherence tomography angiography is a unique imaging modality that allowed for the complete characterization and monitoring of the submacular deposits. This expands the clinical spectrum of multifocal choroiditis.
Multifocal choroiditis is a rare inflammatory condition characterized by retinal and choroidal lesions that may present similarly to ocular pathology of various etiologies. Here, we present a case of multifocal choroiditis mimicking syphilitic uveitis with unique en face optical coherence tomography angiography imaging characteristics.
Methods:
This was a case report.
Results:
A 61-year-old woman presented with blurry vision, floaters, and multiple whitish subretinal deposits on en face swept-source optical coherence tomography angiography in the left eye. Fluorescent treponemal antibody test absorption was positive, which led to the initial diagnosis of syphilitic uveitis and subsequent treatment with IV penicillin. During follow-up, optical coherence tomography angiography of the left eye revealed the development of a new choroidal neovascular membrane and new punched-out lesions in the posterior pole. The patient was eventually diagnosed with multifocal choroiditis and treated with aflibercept injections.
Conclusion:
Immune-mediated uveitis can simulate infectious and neoplastic uveitis. En face optical coherence tomography angiography is a unique imaging modality that allowed for the complete characterization and monitoring of the submacular deposits. This expands the clinical spectrum of multifocal choroiditis.
Rhegmatogenous Retinal Detachment following Bleb Needling: A case report
Purpose:
This is a case of a 29-year-old female patient with retinal detachment (RD) following a bleb needling procedure.
Methods:
This is a retrospective case report.
Results:
The patient has a history of high myopia and juvenile open-angle glaucoma treated with trabeculectomy and trabeculectomy revision. Ten days after a bleb needling procedure, she presented with sudden loss of vision due to a rhegmatogenous RD.
Conclusion:
The aim of this case is to report the possibility of retinal detachment following bleb needling in patients with predisposing risk factors.
This is a case of a 29-year-old female patient with retinal detachment (RD) following a bleb needling procedure.
Methods:
This is a retrospective case report.
Results:
The patient has a history of high myopia and juvenile open-angle glaucoma treated with trabeculectomy and trabeculectomy revision. Ten days after a bleb needling procedure, she presented with sudden loss of vision due to a rhegmatogenous RD.
Conclusion:
The aim of this case is to report the possibility of retinal detachment following bleb needling in patients with predisposing risk factors.
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