Purpose

To report a unique case of Valsalva retinopathy associated with ear popping behavior.

Observations

A 57-year-old woman with a history of well-controlled hypertension presented with episodes of seeing "spots" in her left eye for many years. Her most recent episode failed to resolve spontaneously. Fundus examination revealed scattered retinal hemorrhages in the left eye, and optical coherence tomography demonstrated sub-internal limiting membrane location of these hemorrhages. Fluorescein angiography did not reveal any vascular abnormalities. Based on these findings and an in-depth review of systems, a diagnosis of Valsalva retinopathy was made associated with patient's ear popping habit.

Conclusions and importance

Habitual ear popping can be a potential etiology of symptomatic Valsalva retinopathy. This under-appreciated association may be clinically relevant for patients with a history of suspected Eustachian tube narrowing or dysfunction.

This study sought to assess the association between axial length (AL) and diabetic retinopathy (DR) in a diverse cohort of patients and to investigate the impact of sex on this relationship. An urban safety net hospital database was used for this cross-sectional observational study. Diabetic patients who underwent fundus photography and AL measurement between March 2017 and June 2020 were included. The fundus photographs were graded following the Early Treatment of Diabetic Retinopathy Study criteria. The study enrolled 1843 patients with diabetes (mean age: 56.9 ± 12.1 years; AL: 23.56 ± 1.12 mm), including 931 men and 912 women. Male sex was a risk factor for diabetic retinopathy (P = 0.001; odds ratio [OR] 1.5, 95% confidence interval [CI] 1.18-1.98). A higher DR prevalence was associated with shorter AL both in men (P = 0.003; OR 0.77; 95% CI 0.66-0.91) and women (P = 0.02; OR 0.83; 95% CI 0.71-0.97) after adjusting for systemic risk factors using multivariable logistic regression. There was no significant impact of sex on the relationship between AL and DR (P = 0.56). In the subset of patients with asymmetric DR, the percentage of patients whose shorter eye had a higher stage of DR was not significantly different between men and women (P = 0.20). Male sex is a risk factor for DR in a diverse safety-net hospital population. Longer AL is associated with a lower risk of DR, and this relationship is not affected by sex.

Purpose

To investigate whether men have higher inflammatory protein biomarker concentrations in their aqueous humor (AH) compared with women in groups of patients with varying levels of diabetic disease.

Methods

This cross-sectional study included AH specimens from 59 adult patients comprised of three groups: no diabetes mellitus (DM), DM without diabetic retinopathy (DR), and DM with proliferative diabetic retinopathy (PDR). Protein biomarker concentration values were quantified using a commercial proximity extension assay-based technique.

Results

Intersex comparisons of concentration values for each protein biomarker revealed no discoveries in patients with no DM or with PDR. In contrast, 24 discoveries were detected in patients with DM without DR. The mean concentration value for all 24 protein biomarkers was higher in men compared with women. Of these 24 proteins, 12 demonstrated a significant association with sex on multivariate linear regression analysis. The β coefficient results demonstrated a positive association between male sex and concentration value for all 12 of these proteins.

Conclusions

Higher AH concentration levels of several potential biomarkers, including chemokines, proteases, proteins involved in programmed cell death, and a T-cell surface protein, were detected in men with DM with no DR. These findings suggest that men may have a more inflammatory disease phenotype compared with women in this group of patients.

Translational relevance

The findings of this study help explain differences in epidemiologic patterns of diabetic retinopathy development between men and women.

Purpose

The purpose of this study was to examine whether racial and ethnic differences in retinal microvasculature are detectable with quantitative measures derived from optical coherence tomography angiography (OCTA).

Methods

OCTA scans and fundus photography were obtained in 447 eyes from 271 patients with and without diabetes between April and October 2018. Fundus photos were graded by the hospital reading center for diabetic retinopathy (DR) severity. Eight OCTA parameters relating to the foveal avascular zone (FAZ), superficial vascular perfusion, and deep vascular perfusion were analyzed for significant differences between race and ethnicity groups, self-reported by patients and organized according to National Center for Health Statistics groupings. Multiple regression was then used to adjust estimates for possible confounding by age, gender, hypertension, and last hemoglobin A1c level.

Results

Significant differences in FAZ area were found between white and non-white patients. After adjustment, the differences between white and all non-white groups were statistically significant (p<0.05) among patients with mild to moderate DR. In those without diabetes, the Hispanic and Asian groups had significantly larger FAZ areas (p<0.005) than NH white patients. In those with mild to moderate non-proliferative diabetic retinopathy (NPDR), NH Black, Hispanic, and Asian patients also had significantly larger FAZ areas than NH white patients (p<0.005).

Conclusion

Significant differences in FAZ area exist among different racial and ethnic groups. These results highlight the importance of considering and further studying race and ethnicity in OCTA analyses of the retinal microvasculature.

Purpose: To improve awareness of delayed onset uveitis in patients with a history of intraocular tattoo ink injection.Results: A 47-year-old man underwent a scleral tattoo procedure during which there was inadvertent intraocular injection of tattoo ink into his right eye. He subsequently developed endophthalmitis, retinal detachment, and retinal necrosis. He was treated with intravitreal and oral antibiotics and underwent vitreoretinal surgical intervention. A vitreous specimen was obtained and demonstrated significantly elevated levels of several heavy metals. One month later, he developed an acute granulomatous anterior uveitis in the same eye that was managed with a combination of topical and perioperative intravitreal, intravenous, and oral corticosteroids.Conclusion: This case highlights the importance of monitoring patients with a history of intraocular tattoo ink injection for delayed onset uveitis in addition to retinal toxicity.

In this study, we examined the impact of diabetes mellitus (DM) disease duration on optical coherence tomography angiography (OCTA) parameters in diabetic patients without diabetic retinopathy (DR). A total of 1118 eyes from 1118 DM patients without DR were divided into three groups by DM duration: 0−5 years (short cohort; n = 571), 6−10 years (medium cohort; n = 306), and >10 years (long cohort; n = 241). Ultra-widefield fundus photography and nine OCTA parameters derived from the superficial retinal capillary plexus were analyzed. Perfusion density (PD) and vessel length density (VD) were significantly decreased within the 1 mm patch in patient OCTAs from the medium cohort compared to the short cohort. Conversely, PD and VD were significantly decreased within the 6 mm patch and inner ring among the long cohort compared to the short and medium cohorts. These findings remained consistent after controlled analysis. Patients in the medium cohort had the largest FAZ area, while patients in the long cohort had the smallest FAZ area, with a statistically significant difference between the two groups. Superficial PD and VD significantly decreased among the medium and long cohorts compared to the short cohort, confirming that subclinical, progressive macular vasculature change is associated with longer DM duration. However, while FAZ area significantly increased in the medium cohort, the long cohort exhibited decreased FAZ area, suggesting the latter may possess protective factors that decrease overall risk of DR development.

Purpose

To investigate any associations between cigarette smoking and retinal microvascular changes in diabetic patients without visible retinopathy.

Design

Retrospective, cross-sectional study.

Participants

1099 eyes from 1099 diabetic patients with no clinical evidence of diabetic retinopathy (DR) were included in this study.

Methods

Diabetic patients underwent optical coherence tomography angiography (OCTA) scanning at Zuckerberg San Francisco General Hospital and Trauma Center between April 2018 and September 2019. Patient demographic and clinical information was collected. Standard bivariate statistics and multivariate linear regression were performed.

Main outcome measures

OCTA parameters included metrics related to the foveal avascular zone (FAZ; area, perimeter, circularity), perfusion density (PD; full, center, inner), and vessel length density (VLD; full, center, inner).

Results

The study population included 750 non-smokers and 349 smokers. FAZ perimeter was the only OCTA parameter that was significantly different between the two groups on uncontrolled analysis (P = 0.033). Multivariate regression analyses revealed significant associations between lower VLD full (β = -0.31, P = 0.048), lower VLD inner (β = -0.35, P = 0.046) and a history of smoking. No significant associations between cigarette smoking and either FAZ or PD were detected.

Conclusions

Our results suggest that smoking is likely associated with deleterious changes in the retinal microvasculature of patients with a history of diabetes and no visible DR. Based on these findings, diabetic patients with a history of smoking may benefit from higher prioritization in terms of ophthalmic screening.

Purpose

To compare quantitative changes in macular parameters in diabetic patients detected by two optical coherence tomography angiography (OCTA) instruments.

Methods

80 phakic eyes were classified as no diabetes, diabetes without diabetic retinopathy (DR), mild non-proliferative diabetic retinopathy (NPDR), and severe NPDR or proliferative DR (PDR). OCTA was performed using devices from two manufacturers (Zeiss and Heidelberg). Superficial and deeper vascular skeleton density (SVSD, DVSD), superficial and deeper vessel area density (SVAD, DVAD), choriocapillaris flow voids (CCFV), and choroidal flow voids (CFV) were calculated. Inter-device comparisons were performed using the size comparison index (SCI) and the discrepancy index (DI).

Results

The two devices were inconsistent in SVSD, DVSD, DVAD, CCFV and CFV parameters (all P < 0.05). In addition, the SCI was positive for DVAD (all P < 0.001) and negative for SVSD, DVSD, CCFV and CFV in all groups (all P <0.001), except for DVSD in severe NPDR or PDR. The discrepancy index was not significantly different among groups for SVD, SPD, DVD, DPD and CFV (all P> 0.05). The mean DI of CCFV was statistically different between the four groups (P < 0.001).

Conclusions

The two instruments were largely inconsistent in the measurement of macular parameters relevant to DR. The choice of imaging device can impact OCTA analytics and should be taken into account when drawing conclusions about DR-related changes.

Purpose

To study the feasibility and efficacy of a new remote wet lab for microsurgical education using a corneal suturing task.

Setting

Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.

Design

Prospective randomized controlled study.

Methods

Ten ophthalmology residents were stratified by postgraduate year and randomized to perform a corneal suturing task consisting of placing the 4 cardinal sutures for a penetrating keratoplasty in porcine eyes with or without remote ophthalmology attending feedback. Subsequently, both groups repeated the same task without remote feedback to test whether initial remote feedback affected subsequent performance. Finally, the group without feedback was crossed over to repeat the same corneal suturing task with remote feedback. The effectiveness of the remote wet lab was assessed subjectively by survey and objectively by grading each suture pass.

Results

Resident-reported comfort with corneal suturing improved significantly after the remote wet lab for all residents. Residents and attendings rated the remote wet lab as equally or more effective compared with previous in-person wet labs and overall effective in corneal suturing. Attendings rated the remote wet lab as effective in multiple domains of microsurgical education using a modified microsurgical global rating scale. Objective corneal suturing performance was similar for both groups.

Conclusions

The remote wet lab was feasible and effective for training ophthalmology residents in corneal suturing. This represents a new social distancing compliant platform for microsurgical education during the COVID-19 pandemic.

Background

Eosinophilic meningitis is uncommon and often attributed to infectious causes.

Case presentation

We describe a case of a 72-year-old man who presented with subacute onset eosinophilic meningitis, vasculitis, and intracranial hypertension with progressive and severe neurologic symptoms. Brain MRI demonstrated multifocal strokes and co-localized right temporo-parieto-occipital vasogenic edema, cortical superficial siderosis, and diffuse leptomeningeal enhancement. He ultimately underwent brain biopsy with immunohistochemical stains for amyloid-β and Congo red that were extensively positive in the blood vessel walls and in numerous diffuse and neuritic parenchymal confirming a diagnosis of amyloid-β related angiitis. He was treated with immunosuppression with clinical stabilization.

Conclusions

Amyloid-β related angiitis is an underrecognized cause of eosinophilic meningitis that can present fulminantly and is typically responsive to immunosuppression. The presence of eosinophils may provide additional clues to the underlying pathophysiology of amyloid-β related angiitis.