Faculty Bibliography

PURPOSE/OBJECTIVE:To report outcomes of pediatric patients with combined hamartoma of the retina and the retina pigment epithelium (CHRRPE) followed up conservatively or after pars plana vitrectomy (PPV). METHODS:This retrospective multicenter study included sixty-two eyes of 59 pediatric patients with CHRRPE from 13 different international centers with an average age of 7.7±4.7 (0.3-17) years at the time of the diagnosis, and having undergone PPV or followed conservatively. At baseline and each visit, visual acuity values, optical coherence tomography (OCT) for features and central foveal thickness (CFT), and tumor location were noted. Lesions were called as zone 1, if it involves the macular and peripapillary area, and the others were called as zone 2 lesions. RESULTS:Twenty-one eyes of 20 patients in the intervention group and 41 eyes of 39 patients in the conservative group were followed for a mean of 36.2±40.4 (6-182) months. BCVA improved in 11 (68.8%) of 16 eyes in the intervention group and 4 (12.9%) of 31 eyes in the conservative group (p<0.001). The mean CFT decreased from 602.0±164.9 μm to 451.2±184.3 μm in the intervention group, while it increased from 709.5±344.2 μm to 791.0±452.1 μm in zone 1 eyes of the conservative group. Posterior location of tumor, irregular configuration of the foveal contour and ellipsoid zone defect in OCT, subretinal exudate and prominent vascular tortuosity were associated with poor visual acuity. CONCLUSIONS:Vitreoretinal surgery is safe and effective in improving vision and reducing retinal distortion in zone 1 CHRRPE in children.

PURPOSE/OBJECTIVE:To report a case of paracentral acute middle maculopathy (PAMM) in an otherwise healthy young, multiparous woman in her second trimester of pregnancy. METHODS:Case report RESULTS:: A 38-year-old woman in her twentieth week of pregnancy presented with a four-day history of an acute paracentral scotoma in her left eye. Fundoscopic examination of the left eye was significant for a white-gray lesion inferonasal to the fovea which corresponded with spectral domain-optical coherence tomography (SD-OCT) hyperreflectivity at the outer plexiform layer-inner nuclear layer junction and optical coherence tomography angiography (OCTA) non-perfusion. A diagnosis of paracentral acute middle maculopathy was made. The patient was sent for a hypercoagulability work-up that revealed elevated factor VIII activity, which has been associated with increased risk of complications during pregnancy. CONCLUSION/CONCLUSIONS:PAMM in pregnancy may be secondary to an underlying hypercoaguable condition. We recommend systemic evaluation and referral to a high-risk pregnancy specialist if PAMM is diagnosed during pregnancy. Additionally, OCTA in PAMM may demonstrate reperfusion of the affected vessels.

Purpose/UNASSIGNED:Ocular trauma with intraocular foreign body (IOFB) can have devastating visual consequences. Management and antimicrobial strategies remain variable due to the infrequency and heterogeneity of presentation. Our goal was to identify risk factors for endophthalmitis and poor visual outcomes in cases of IOFB and investigate management strategies. Patients and Methods/UNASSIGNED:A retrospective chart review was conducted in 88 eyes of 88 patients suffering traumatic injury with IOFB at the University of Michigan between January 2000 and December 2019. Medical records were reviewed to characterize the injuries and IOFBs as well as how clinical presentation and treatment modalities were associated with outcomes. Results/UNASSIGNED:Delayed presentation (P=0.016) and organic IOFB (P=0.044) were associated with development of endophthalmitis. Retinal detachment (P=0.012), wound length greater than 5 mm (P=0.041), and poor presenting visual acuity (P=0.003) correlated with poor final visual outcome. Antibiotic prophylaxis was given to all patients, though agents and routes of delivery varied. Endophthalmitis developed in 4.9% of the eyes after initial management, with primary and secondary removal of posterior segment IOFBs associated with similar rates of endophthalmitis (P=1.000). Conclusion/UNASSIGNED:Poor presenting visual acuity and severity of injury, as measured by large wound and retinal detachment, correlate with poor visual outcome. Prompt globe closure and antimicrobial prophylaxis are critical for infection prevention. In cases where IOFB removal and globe closure cannot be performed concurrently, primary globe closure with aggressive antibiotic prophylaxis offers a reasonable alternative to prevent endophthalmitis.

Introduction/UNASSIGNED:Prognosis of uveal melanoma (UM) is assessed using clinical staging or molecular testing. Two modalities often used for prognostication are the American Joint Committee on Cancer (AJCC) staging and a tumor gene expression profile (GEP), the outcomes of which are often discordant. This article discusses a total risk score created to combine the discordant information from both sources. Methods/UNASSIGNED:A retrospective case series was conducted of all patients presenting with UM over 6 years to 2 referral centers. Each tumor was classified using the AJCC and the GEP. A total risk score was calculated for each patient using results from both AJCC and GEP. Kaplan-Meier analysis of metastasis-free survival was used to compare groups. Results/UNASSIGNED:A total of 294 patients were included in the study. Kaplan-Meier estimates showed significant curve separation between individual AJCC and GEP risk groups. The combined total risk score provided an accurate estimate of prognosis that incorporated results from both AJCC and GEP. Conclusions/UNASSIGNED:Clinical staging and molecular prognostication of UM can be discordant. There is important information provided by each system that is not provided by the other. The total risk score provides a simple method to combine information from both AJCC stage and the GEP class in order to provide patients and care teams with a more complete understanding of metastatic risk.

PURPOSE/UNASSIGNED:To describe a rare case of intraocular lymphoma that metastasized from cutaneous mycosis fungoides and transformed to large cell T cell lymphoma resulting in vitreoretinal pathology. METHODS/UNASSIGNED:Retrospective case report. RESULTS/UNASSIGNED:A 57-year-old male presented with 3 months of blurred vision in the right eye. He reported only a medical history of psoriasis. Examination revealed keratic precipitates and dense vitritis in the right eye. He was taken for a diagnostic vitrectomy. Histopathology showed that atypical lymphoid cells and flow cytometry were consistent with transformed large cell T-cell lymphoma. During follow-up, pre- and inner retinal lesions were noted throughout the posterior pole. Histopathology of the psoriatic lesions was consistent with mycosis fungoides. He was initiated on systemic and intravitreal methotrexate with improvement in vision. CONCLUSIONS/UNASSIGNED:Ocular involvement in metastatic transformed T-cell lymphoma is extremely rare but can be present with vitritis and retinal deposits. Our patient responded well to intravitreal methotrexate therapy.

Purpose : To evaluate the diagnostic yield and clinical impact of the SPARK/Invitae gene panel in patients with known or suspected inherited degenerative retinal disease, in comparison with traditional clinical assessments. Methods : Patients of the authors' clinical practices obtained genetic screening at no charge via the SPARK/Invitae ID your IRD genetic testing panel, which ranged from 248 genes to 293 genes. Over 16 months, tests were submitted for 87 patients and results were available for 70 patients. Clinical diagnoses prior to submitting the gene panel . By continuing to use our website, you are agreeing to included retinitis pigmentosa; Stargardt disease; Best vitelliform dystrophy; Leber our privacy policy. congenital amaurosis; choroideremia; achromatopsia; cone-rod dystrophy; congenital stationary night blindness; occult macular dystrophy; and familial dominant drusen in addition to patients with normal clinical findings and unclear diagnoses. Results : Of 70 patients, SPARK/Invitae considered the results ''Positive or Potentially Positive'' in 24 cases (34.3%), Carrier in 16 cases (22.9%) and ''Uncertain'' in 30 cases (42.9%). Uncertain results comprised patients with only Variants of Uncertain Significance. Patients categorized as a Carrier by SPARK/Invitae but who demonstrated pathogenic genetic changes correlating to the clinical diagnosis were considered to be in agreement with the clinical impression. The genetic diagnosis agreed with the clinical diagnosis in 30/70 (42.9%) total patients. Test results were consistent with the clinical impression in 13/26 (50.0%) retinitis pigmentosa cases, 6/8 (75.0%) Stargardt patients, 3/7 (42.9%) cone-rod dystrophy cases, and 2/4 (50.0%) Best vitelliform dystrophy patients. Gene testing helped elucidate diagnoses in two patients with unclear clinical impressions: one panel showed autosomal recessive achromatopsia and the other showed a carrier state for autosomal recessive retinitis pigmentosa. Of four patients with normal clinical exams, none had diagnostic results: all showed Uncertain findings. Conclusions : The SPARK/Invitae gene panel provided a genetic diagnosis consistent with the clinical impression in about 40 percent of patients. Retinitis pigmentosa and Stargardt disease were the most common clinical diagnoses and the diagnoses most often confirmed by testing. Genetic screening also assisted in clarifying unknown diagnoses for two patients

Purpose : To assess risk factors for development of endophthalmitis following open globe injury. Methods : A retrospective chart review of all patients treated for open globe injury at the University of Michigan from January 2000 through July 2017 was conducted. Exclusion criteria included intravitreal injection or intraocular surgery in the 30 days prior to injury or less than 30 days of follow-up. A total of 586 out of 993 eyes were included in the study. The main outcome measure was the rate of endophthalmitis in these eyes. Results : 25/586 eyes (4.3%) presented with endophthalmitis, or developed endophthalmitis following globe closure. Of these, 12/25 eyes (48.0%) presented with endophthalmitis and 13/25 eyes (52.0%) developed endophthalmitis after globe closure. Multivariate logistic regression analysis identified time to globe repair (OR 4.5, CI 1.9-10.7, p = 0.0008), zone I injury (OR 3.6, CI 1.1-11.0, p = 0.0282), and need for additional surgery (OR 5.5, CI 1.5-19.7, p = 0.0092) as factors associated with increased risk of developing endophthalmitis. Subconjunctival antibiotics (OR 0.3, CI 0.1-0.7, p = 0.0036) were associated with decreased risk of developing endophthalmitis. Conclusions : Prompt closure of the globe and use of subconjunctival antibiotics may reduce the risk of endophthalmitis in open globe injuries. Furthermore, a one-time dose of prophylactic antibiotics with same day discharge and delayed IOFB removal with intravitreal injection of antibiotics did not increase the rate of endophthalmitis. Open globe injuries can be visually devastating and understanding what factors predict and protect against endophthalmitis is paramount to achieving the best possible visual outcomes

Purpose : To identify risk factors for endophthalmitis and poor visual outcomes in cases of retained intraocular foreign body (IOFB) and management strategies for these cases. Methods : A retrospective chart review was conducted in 88 eyes of 88 patients suffering traumatic injury with retained IOFB at the University of Michigan between January 2000 and December 2019. Medical records were reviewed to identify the nature of the injury, IOFB composition, and presenting characteristics of each eye as well as the surgical and antimicrobial strategies employed. Details of the injury, IOFBs, and clinical presentation were utilized to identify factors associated with clinical outcomes. Visual outcomes and development of endophthalmitis were additionally evaluated for association with treatment modalities. Results : This cohort developed endophthalmitis at a rate of 11.4% (4.5% presented with endophthalmitis, 7.1% of the remaining eyes developed endophthalmitis after initial intervention). Delayed presentation and organic IOFB were significantly associated with development of endophthalmitis. Retinal detachment, wound length greater than 5 mm, and poor presenting visual acuity were associated with poor final visual outcome. Antibiotic prophylaxis was given to all patients, though agents and routes of delivery varied. Primary and deferred removal of posterior segment IOFBs were associated with similar rates of endophthalmitis. Conclusions : Poor presenting visual acuity and severity of injury as measured by large wound and retinal detachment correlate with poor visual outcome. Prompt globe closure and antimicrobial prophylaxis is critical for infection prevention. Deferred IOFB removal may carry similar risk of endophthalmitis as primary removal

Background/Aims/UNASSIGNED:To determine the rate of endophthalmitis and assess risk factors for development of endophthalmitis following open globe injury (OGI). Methods/UNASSIGNED:A retrospective chart review of all patients treated for OGI at the University of Michigan from January 2000 to July 2017 was conducted. Exclusion criteria included intravitreal injection or intraocular surgery in the 30 days prior to injury or less than 30 days of follow-up. A total of 586 out of 993 open globe injuries were included in the study. The main outcome measure was the rate of endophthalmitis. Results/UNASSIGNED:In this study, 25/586 eyes (4.3%) had endophthalmitis. Of these, 12/25 eyes (48.0%) presented with endophthalmitis and 13/25 eyes (52.0%) developed endophthalmitis after globe closure. Multivariate analysis identified time to globe repair (OR 4.5, CI 1.9-10.7, p = 0.0008), zone I injury (OR 3.6, CI 1.1-11.0, p = 0.0282), and need for additional surgery (OR 5.5, CI 1.5-19.7, p = 0.0092) as factors associated with increased risk of developing endophthalmitis. Subconjunctival antibiotic injection at the time of globe closure (OR 0.3, CI 0.1-0.7, p = 0.0036) was associated with decreased risk of developing endophthalmitis. Conclusion/UNASSIGNED:Prompt globe closure and subconjunctival antibiotics may reduce the risk of endophthalmitis in OGI. Furthermore, our practice of a one-time dose of systemic prophylactic antibiotics, and intravitreal antibiotics if intraocular foreign body (IOFB) removal is delayed, was not found to increase the rate of endophthalmitis.

PURPOSE/OBJECTIVE:This review article is meant to serve as a reference guide and to assist the treating physician in making an appropriate selection and duration of an antimicrobial agent. METHODS:Literature review. RESULTS:Infections of the posterior segment require prompt medical or surgical therapy to reduce the risk of permanent vision loss. While numerous options exist to treat these infections, doses and alternative therapies, especially with contraindications for first-line therapy, are often elusive. Antimicrobial agents to treat posterior segment infections can be administered via various routes, including topical, intravitreal, intravenous, and oral. CONCLUSIONS:Although there are many excellent review articles on the management of endophthalmitis, we take the opportunity in this review to comprehensively summarize the appropriate antimicrobial regimen of both common and rare infectious etiologies of the posterior segment, using evidence from clinical trials and large case series.