Severe Ocular Inflammation Following Ranibizumab or Aflibercept Injections for Age-Related Macular Degeneration: A Retrospective Claims Database Analysis

Purpose: Intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents including ranibizumab and aflibercept are used to treat patients with ocular disorders such as neovascular age-related macular degeneration (nAMD); however, the injections are associated with rare instances of severe ocular inflammation. This study compared severe ocular inflammation rates in patients treated with ranibizumab versus aflibercept.

Methods: United States physician-level claims data covering an 18-month period for each therapy were analyzed. The primary analysis compared severe ocular inflammation event rates per 1000 injections. Sensitivity and subgroup analyses evaluated the impact of factors including intraocular surgery, intravitreal antibiotic administration, and previous intravitreal injections.

Results: The analysis included 432,794 injection claims (ranibizumab n = 253,647, aflibercept n = 179,147); significantly, more unique severe ocular inflammation events occurred in patients receiving aflibercept than ranibizumab (1.06/1000 injections, 95% confidence interval [CI], 0.91–1.21, vs. 0.64/1000 injections, 95% CI 0.54–0.74; p < 0.0001). Comparable results were observed for analyses of patients who had undergone glaucoma or cataract surgeries, had antibiotic-associated endophthalmitis, had non-antibiotic-associated endophthalmitis, and were non-treatment-naive. In contrast, no significant differences in severe ocular inflammation claims were recorded in treatment-naive patients who had no record of anti-VEGF treatment in the 6 months preceding the index claim. No significant change occurred in the rate of severe ocular inflammation claims over time following ranibizumab treatment.

Conclusions: Severe ocular inflammation was more frequent following intravitreal injection with aflibercept than with ranibizumab during routine clinical use in patients with nAMD. This highlights the importance of real-world, post-approval, observational monitoring of novel medicines, and may aid clinical decision-making, including choice of anti-VEGF agent.     

Self-Reported Sleep Duration in Patients with Neovascular Age-Related Macular Degeneration

Purpose: To examine the relationship between self-reported sleep duration and neovascular age-related macular degeneration (nAMD).

Methods: This case-control study comprised 165 subjects (57 patients with nAMD and 108 controls). Controls were matched to cases by age and sex. Participants completed a questionnaire that included questions about sleep duration and quality. Four categories of sleep duration were established; <6 hours, 6–7 hours, 7–8 hours and >8 hours. Association of sleep duration and nAMD was assessed by logistic regression analysis. Multiple logistic regression models were performed to control for possible confounders.

Results: We found a significant association between short sleep duration and nAMD (for <6 hours, odds ratio, OR, 3.29, 95% confidence interval, CI, 1.32–8.27; for 6–7 hours, OR 2.25, 95% CI 0.80–6.32; and for >8 hours, OR 1.39, 95% CI 0.53–3.73) compared with the reference category of 7–8 hours. This association remained significant after adjustment for confounders (<6 hours, OR 3.09, 95% CI 1.20–7.97). In addition, a borderline significant association was observed between self-reported very bad sleep quality and nAMD (OR 2.84, 95% CI 1.02–7.88). The highest rate of sleep medication use was found in the nAMD group (p < 0.001).

Conclusion: Our findings provide evidence to support an association between short sleep duration and nAMD. Considering strategies to improve sleep in these patients may prevent the negative effects of sleep deficiency.     

Stroke Due to Cerebral Vasculitis in a Patient with Relentless Placoid Chorioretinitis

Purpose: To report the first case of stroke in a patient with relentless placoid chorioretinitis.

Methods: Observational case report.

Results: A 20-year-old female with newly diagnosed relentless placoid chorioretinitis was urgently evaluated for unilateral paresthesias. She was found to have acute bilateral pontine strokes and cerebral vasculitis on magnetic resonance imaging of the brain and cerebral angiography.

Conclusions: We report the first case of stroke due to cerebral vasculitis in a patient with relentless placoid chorioretinitis. This case emphasizes the need for timely evaluation of neurological symptoms in patients with this ocular diagnosis.     

Effect of Eyelid Margin Cleaning on Conjunctival and Eyelid Bacterial Flora Before Intraocular Surgery

Purpose: To compare the bacterial cultures of the lower eyelid margins and lower fornices between ocular irrigations with and without eyelid margin cleaning before intraocular surgery.

Methods: A prospective study was carried out that included 102 eyes from 51 patients undergoing intraocular surgery between December 2016 and April 2017. In each patient, the surgical eye (control group) only received ocular irrigation and the opposite eye (study group) received ocular irrigation with eyelid margin cleaning. Normal saline solution was used in all procedures. In each group, samples from the lower eyelid margins and lower fornices were cultured before and after cleaning. Povidone iodine and antibiotic eye drops were instilled after specimen collection.

Results: The most common bacterial isolate of all groups was Staphylococcus spp. There were no statistically significant differences of positive cultures between the control and study groups in either lower eyelid margins (Odds ratio [OR], 2.19; 95% CI, 0.84–5.72) nor lower fornices (OR, 0.93; 95% CI, 0.43–2.00). In addition, there were no statistically significant differences of positive cultures between before and after eyelid cleanings from both lower eyelid margins (OR, 2.74; 95% CI, 0.53–14.24) and lower fornices (OR, 0.73; 95% CI, 0.21–2.57).

Conclusions: Eyelid margin cleaning with normal saline solution immediately before intraocular surgery did not help to decrease microbial loading on the ocular surfaces. The rate of bacterial contamination, however, was not increased which could be due to not performing eyelid compression.     

Epidemiology of Ocular Toxoplasmosis in Three Community Surveys in the Central Region of Ghana,West Africa

Purpose: To conduct the first ever population-based survey on ocular toxoplasmosis in the Central Region of Ghana.

Methods: A cross-sectional population-based study was conducted in three randomly selected communities in the Central Region, Ghana. Visual acuity (VA) measurement, dilated fundus examination by indirect ophthalmoscopy and serology testing were performed on all participants. Ocular toxoplasmosis was diagnosed based on characteristic retinal lesions and supported by positive serologic testing using commercial enzyme-linked immunosorbent assay (ELISA) kits.

Results: A total of 390 subjects aged 10–100 years (mean age 47 years) were examined; 118 (30.3%) were male and 272 (69.7%) female. Ten subjects (6 females and 4 males) had toxoplasmic ocular lesions (prevalence 2.6%). Of these, two had bilateral lesions and eight had unilateral lesions. Subjects with toxoplasmic ocular lesions were older than those without lesions (p = 0.028). The development of ocular toxoplasmosis was not associated with rural dwelling, sex, keeping cats, or consumption of meat.

Conclusion: The prevalence of ocular toxoplasmosis in our Ghanaian study population was lower than findings from Southern Brazil, where there is a similar prevalence of infection in the general population.     

Vision-related Quality of Life in Patients with Non-infectious Uveitis: A Cross-sectional Study

Purpose: To analyze the influence of socio-demographic, comorbidity, and clinical-related variables in the vision-related quality of life (VR-QoL) of non-infectious uveitis patients.

Methods: Cross-sectional study includes 156 consecutive non-infectious uveitis patients from a tertiary uveitis clinic from Madrid (Spain). The main outcome was the log-transformed composite score of the Visual Functioning Questionnaire 25. Bivariate and multivariate ordinary least-squares regression models were performed and results expressed using effect sizes with 95% confidence intervals (95% CI).

Results: In the multivariate analysis, one unit increase in the logarithm of the minimum angle of resolution scale [i.e., worse best corrected visual acuity (BCVA)] was associated with a seven times worse VR-QoL (a 0.14-fold change [95% CI: 0.07–0.27]). Patients with ocular comorbidities had a 64% worse VR-QoL (a 0.61-fold change [95% CI: 0.49–0.77]).

Conclusions: Lower BCVA and the presence of ocular comorbidities had a significant, independent, and deleterious effect in the VR-QoL of non-infectious uveitis patients.     

Prevalence of Pseudoexfoliation Syndrome and Associated Factors in South Koreans: The Korean National Health and Nutrition Examination Survey

Purpose: To investigate the prevalence of pseudoexfoliation syndrome (PXS) and factors associated with PXS in South Koreans by analyzing data from the Korean National Health and Nutrition Examination Survey (KNHANES).

Methods: Using the KNHANES database of 2009–2012, 13,223 participants aged 50 years or older were included. Participants underwent standardized interviews and systemic and ocular examinations. Systemic factors analyzed included age, sex, daily length of sun exposure, presence of Raynaud phenomenon or migraine, hypertension, diabetes mellitus, body mass index, serum lipid profile, duration and frequency of smoking, and alcohol consumption. Evaluated ocular factors were refractive error, presence of cataract and glaucoma, intraocular pressure, and peripheral anterior chamber depth. Logistic regression analysis was performed to identify factors associated with the presence of PXS.

Results: PXS was found in 16 participants (0.12%). When compared with the non-PXS group, eyes with PXS showed a higher prevalence of cataract (p = 0.020). In logistic regression analysis, age (odds ratio, OR, 1.04, 95% confidence interval, CI, 0.99–1.09; p = 0.016) and the presence of cataract (OR 8.17, 95% CI 1.06–62.84; p = 0.044) were associated with the presence of PXS. Sun exposure for ≥5 hours/day was marginally associated with the presence of PXS (OR 2.76, 95% CI 0.96–7.95; p = 0.060).

Conclusion: The prevalence of PXS per 1000 persons was 1.10 in South Koreans aged ≥50 years. Participants with PXS had a higher prevalence of cataract, were older, and were more likely to be exposed to the sun for ≥5 hours/day than participants without PXS.     

High Resolution Chest Computerized Tomography in the Diagnosis of Ocular Sarcoidosis in a High TB Endemic Population

Purpose: To review the role of high resolution chest computed tomography (HRCT) in ocular sarcoidosis in a high TB endemic population.

Methods: This was a retrospective study.

Results: Out of 140 cases, 54 had ocular sarcoidosis, while 86 cases had ocular tuberculosis. Abnormal HRCT findings was noted in 52 cases (96.3%) of ocular sarcoidosis compared with 55 cases (64.7%) of ocular tuberculosis (p = 0.001). Mediastinal lymphadenopathy was the most common finding in both groups (p = 0.544). Hilar lymphadenopathy and fissural nodules were significantly seen in ocular sarcoidosis (p = 0.001). Necrosis was seen in three cases of ocular sarcoidosis. In nearly half of the cases, it was not possible to differentiate between sarcoidosis and tuberculosis on HRCT.

Conclusions: HRCT is a useful diagnostic tool in ocular sarcoidosis. Bilateral hilar lymphadenopathy and fissural nodules are significant findings in ocular sarcoidosis. A confident diagnosis of ocular sarcoidosis is made by the amalgamation of results of clinical, radiologic, and other laboratory investigations.     

Chikungunya Virus Infection Manifesting as Intermediate Uveitis

Purpose: To describe a case of intermediate uveitis caused by chikungunya virus infection in the Western Hemisphere.

Methods: Case report of a patient diagnosed with chikungunya infection presenting with blurry vision and floaters.

Results: Exam revealed a unilateral intermediate uveitis, with an extensive work-up positive for chikungunya virus immunoglobulin M and G titers. The patient responded to oral corticosteroids with signs and symptoms resolving over the course of 3 months’ treatment.

Conclusions: While anterior uveitis and retinitis are the most common ocular manifestations of chikungunya infection, we report here a case of chikungunya infection presenting as an intermediate uveitis, responding well to oral corticosteroids. This case demonstrates the varied presentation of chikungunya-related uveitis and highlights its consideration in the differential diagnoses of those who have had preceding systemic viral symptoms and uveitis.     

Ocular Inflammatory Disorders in Autoimmune Lymphoproliferative Syndrome (ALPS)

Purpose: To describe inflammatory ocular findings in patients with autoimmune lymphoproliferative syndrome (ALPS).

Methods: A retrospective review of medical records for ALPS patients seen at the National Eye Institute between 2003 and 2013.

Results: A total of 29 ALPS patients previously referred for ocular or visual symptoms or with a history of prolonged corticosteroid use, were identified. Mean age was 20 years (range: 4–66 years). The majority were male (n = 21, 72.4%) and Caucasian (n = 24, 82.8%). Ten (34.5%) had abnormal ocular findings, the most common of which was an ocular inflammatory disorder (n = 4, 13.8%). Uveitis was seen in two patients with ALPS-FAS and one with ALPS-U, all of whom required long-term systemic immunosuppression. One patient with ALPS-FAS had a history of optic neuritis.

Conclusions: ALPS can have intraocular inflammatory manifestations that require routine follow-up to ensure appropriate and timely treatment of intraocular disease. Long-term immunosuppression may be needed for patients with ALPS-associated uveitis.     

The TNF-α-308G/A Polymorphism is Not Associated with Ocular Chlamydia trachomatis Infection in Han Chinese Children

Objective: To investigate the association between the TNF-α-308G/A polymorphism and ocular chlamydia trachomatis (C. Trachomatis) infection among Han Chinese children.

Methods: 248 patients and 162 matched healthy controls were recruited. The diagnosis of ocular C. Trachomatis infection was given after clinical observation and latex immunochromatography tests. The TNF-α-308G/A polymorphism was genotyped by sequencing.

Results: No association was found between the TNF-α-308G/A polymorphism and ocular C. Trachomatis infection.

Conclusions: The TNF-α-308A polymorphism is unlikely to play a major role in the risk for ocular C. Trachomatis in the Chinese population.     

Prevalence of Childhood Blindness and Ocular Morbidity in a Rural Pediatric Population in Southern India: The Pavagada Pediatric Eye Disease Study-1

Purpose: To determine the prevalence of childhood blindness and ocular morbidity in a rural pediatric population in South India.

Methods: A population-based, cross-sectional survey of children was conducted in three phases in Pavagada and Madhugiri taluks (subdivisions) of Tumkur district in the state of Karnataka, India. In the first phase, trained fieldworkers screened 23,100 children. In the second phase, children with eye diseases were referred to the peripheral hospital to be examined by a general ophthalmologist. In the third phase, children with major eye diseases were examined by a pediatric ophthalmologist.

Results: The prevalence of ocular morbidity was 2.66% (95% confidence interval, CI, 2.46–2.87%). The most commonly observed ocular morbidity was Bitot spots (1%) followed by refractive error (0.6%). In total, 18 children were blind and the prevalence of childhood blindness (best-corrected visual acuity <3/60) was 0.08% (95% CI 0.04–0.11%); 8 (44.44%) had retinal blindness, 5 (27.76%) had lens-related blindness, 2 (11.11%) had bilateral microphthalmos, 1 (5.56%) was blind due to anterior staphyloma in the right eye and anophthalmos in the left eye, 1 (5.56%) had bilateral uveal coloboma and 1 (5.56%) had cortical visual impairment.

Conclusions: Nearly half of the blindness in the population was due to unavoidable causes (retinal). In addition to providing eye care services, an appropriate service delivery model would include the provision of rehabilitative and low vision services and implementation of genetic studies to understand the causes and increase awareness of inherited eye diseases.     

Gender-related effects of vision impairment characteristics on depression in Korea

Purpose: To investigate the gender-specific associations between perceived vision impairment and symptoms of depression.

Methods: We used the data from the 2012 Korean Longitudinal Study of Aging database of 7448 individuals aged 45 years and older. Questionnaires assessing depression symptoms and perceived visual impairment at near, distance, and in general were administered. Logistic regression analyses were used to evaluate if visual impairment could lead to depression, adjusting for the potential confounders of age, socioeconomic status (household income, education level, marital status, and employment status), and health behaviors (alcohol consumption, smoking, and physical activity level) after gender stratification.

Results: Perceived general and near vision impairment were significantly associated with symptoms of depression in males (odds ratio [OR] = 2.78 and 2.54; 95% confidence interval [CI], 1.91–4.04 and 1.78–3.63). Perceived general and distance vision impairment were significantly associated with symptoms of depression in females (OR = 2.16 and 2.08; 95% CI, 1.67–2.79 and 1.61–2.69). General sight with near vision impairment in males and general sight with distance vision impairment in females could be stronger predictors of depression than other vision impairment combinations (area under the receiver operating characteristic curve [AUROC], 0.6461; p = 0.0425 in males; AUROC, 0.6270; p = 0.0318 in females).

Conclusion Gender differences were found in the characteristics of visual impairment on symptoms of depression. Ophthalmologists should be aware that near vision impairment in males and distance vision impairment in females have an adjunctive effect that might contribute to symptoms of depression.     

Ocular findings in a patient with Cockayne syndrome with two mutations in the ERCC6 gene

Background: Cockayne syndrome is a rare, autosomal recessive, multisystem disorder that causes a senile appearance. Ophthalmic abnormalities are frequently present. Here, we report a wide range of ocular findings in a child with Cockayne syndrome.

Materials and methods: The systemic and ocular findings were reviewed. A mutation analysis was performed in the patient and her parents.

Results: The patient underwent a complete ocular examination. Both eyes had low visual acuity, corneal epithelial degeneration, punctate opacities of the lens, and retina disorders. The systemic findings included growth deficiency and a senile appearance. Gene analysis showed mutations in exons 4 and 18 of the ERCC6 gene.

Conclusion: Multiple ocular abnormalities were observed in a patient with Cockayne syndrome. A detailed ophthalmic evaluation of children with Cockayne syndrome is advised.     

Boston Type I Keratoprosthesis Implantation Following Autologous Submandibular Gland Transplantation for End Stage Ocular Surface Disorders

Purpose: To describe the results of Boston keratoprosthesis implantation in a patient with Stevens–Johnson syndrome following autologous submandibular gland transplantation.

Design: Observational case report.

Methods: We report the case of a man diagnosed with Stevens–Johnson syndrome. Autologous submandibular gland transplantation was performed in the right eye in 2008 to ameliorate tear film deficiency. Due to the improvement in the microenvironment of the ocular surface, Boston keratoprosthesis implantation was performed in the right eye in 2011.

Results: He maintained a VA of 20/100 for 12 months. At the last follow-up visit (54 months), his VA had declined to finger count level due to de novo glaucoma, which was treated with glaucoma drainage device implantation, cyclophotocoagulation and topical anti-glaucoma medications.

Conclusions: The procedures described provide patients with end-stage ocular surface disease an option to lessen the severity of keratoconjunctivitis sicca and to regain their VA.     

A Hemophagocytic Lymphohistiocytosis Patient that Presented with Unilateral Panuveitis

Purpose: To describe a case of hemophagocytic lymphohistiocytosis (HLH) with ocular changes prior to the systemic changes.

Methods: A 53-year-old man presented with the chief complaint of decreased vision in his right eye. The patient was examined by ocular examination, slit lamp examination, optical coherence tomography, laboratory examination, abdominal ultrasound, and bone marrow biopsy.

Results: Ocular examination revealed uveitis OD and optical coherence tomography revealed macular edema OD. Laboratory examination demonstrated cytopenia in two cell lines, hypofibrinogenemia, and elevated serum ferritin. Abdominal ultrasound findings indicated hepatosplenomegaly. The bone marrow biopsy specimen demonstrated histiocytes and significant hemophagocytosis, leading to a diagnosis of HLH.

Conclusion: Ophthalmic manifestation can be the first sign of HLH and progress to fatal systemic changes.     

Prevalence of Dry Eye in Uyghur and Han Ethnic Groups in Western China

Purpose: To describe and compare the prevalence and characteristics of dry eye among Han and Uyghur persons living in Kashi, the most inland city of China.

Methods: A total of 1015 residents of Kashi participated in this 2013 cross-sectional study. To evaluate clinical characteristics, each subject completed (1) a dry-eye questionnaire detailing symptoms of dry eye, (2) Schirmer’s I-test (SIT), (3) tear-film break-up time (BUT) test, and fluorescein staining of the cornea. Dry eye was defined as the existence of dry eye symptoms and at least two positive clinical signs. Data were analyzed using SPSS software. The prevalence and risk factors of dry eye were evaluated using a multivariate model.

Results: Overall, 282 (27.8%) of the 1015 participants were diagnosed with dry eye (95% confidence interval (CI): range, 25.5–30.1). The prevalence of dry eye among Han persons (37.9 %) (95% CI: range, 35.8–40.0) was higher than that among Uyghurs (21.8%) (95% CI: 19.6–24.0) (p < 0.05). The prevalence of dry eye was 25.6% (95% CI: range, 23.3–27.8) among men and 28.7% (95% CI: 26.5–30.9) among women (p > 0.05). Risk factors for dry eye included ethnicity, age, occupation, arthritis, and dry mouth.

Conclusions: Our study revealed a higher prevalence of dry eye among Han than Uyghur persons in Kashi. Dry eye was significantly associated with environment and ethnicity.     

Risk Factors for Developing Myopia among Schoolchildren in Yerevan and Gegharkunik Province,Armenia

Purpose: Myopia is a complex condition leading to visual impairment and blindness. This study assessed the prevalence of and risk factors for myopia among schoolchildren in urban and rural areas of Armenia.

Methods: A cross-sectional interviewer-administered survey together with eye screenings was conducted among schoolchildren in the capital Yerevan and in Gegharkunik Province. The study used multi-stage random sampling to obtain the sample of 1260 schoolchildren. Study questionnaires were developed based on the Sydney Myopia Study questionnaire. Continuous reading was defined as the average number of hours spent reading or on near work without a break. Children underwent measurements of visual acuity using a Golovin-Sivtsev eye chart, cycloplegic retinoscopy, and dilated fundus examination.

Results: The mean age of the children was 13 years, and myopia was present in 18.1%. The prevalence of myopia was higher among Yerevan children (23.3%) than those living in Gegharkunik Province (12.5%). In the adjusted model, myopia was significantly associated with age (odds ratio, OR, 1.11, 95% confidence interval, CI, 1.04–1.18), region (OR 2.40, 95% CI 1.62–3.57), school achievement (OR 1.62, 95% CI 1.05–2.51), parental myopia (OR 2.89, 95% CI 1.79–4.69), and continuous reading (OR 1.99, 95% CI 1.31–3.02), but not near work (OR 0.97, 95% CI 0.89–1.05).

Conclusion: The study found that a positive family history of myopia and environmental factors had independent associations with myopia. The number of near work hours did not play a major role in the development of myopia, but length of time of focused continuous reading did.