Faculty Bibliography

INTRODUCTION/BACKGROUND:Angioinvasive fungal sinusitis (AIFS) is a rapidly progressive, highly morbid infection. It can be challenging to obtain an early diagnosis, but intervention in the acute period is crucial for prognosis. Previous literature has identified numerous radiographic features with high sensitivity and specificity for AIFS, even in early disease. Bedside nasal endoscopy can substantiate the diagnosis but can also yield false negative results. Initially, these patients may present to the ophthalmologist. Thus, to avoid visual and potentially life-threatening complications, subtle clinical signs in conjunction with suspicious radiographic features must be promptly recognized by the ophthalmologist and escalated appropriately. We review, for the benefit of the ophthalmic community, the salient radiographic features of AIFS and integrate them into a decision-making algorithm for diagnostic workup and management. METHODS:A literature search was conducted using a comprehensive keyword search in the Pubmed and Embase databases. English studies from 1988 to 2022 describing the radiographic features of AIFS queried. Literature on the newly described entity, COVID-19 COVID-19-associated mucormycosis was included. The authors collected the most frequently reported indicators of AIFS. RESULTS:The authors review 4 radiographic findings that are frequently associated with AIFS, including in the early stages of disease: 1) loss of contrast enhancement in the nasal turbinate and maxilla (i.e., "black turbinate and maxillary sign"), (2) periantral involvement seen as changes in density, fat stranding or obliteration of the anterior, retromaxillary, or retroantral fat planes on CT, (3) Tissue invasion without bony erosion, (4) Hypointense T2W sinonasal secretions on MRI in the setting of acute sinusitis. The authors additionally propose an algorithm that suggests surgical exploration for patients with clinical concern for AIFS and these radiographic features, even if bedside nasal endoscopy is inconsistent with AIFS. CONCLUSION/CONCLUSIONS:The radiographic signs highlighted herein should heighten suspicion for AIFS in the appropriate clinical setting, prompting urgent surgical exploration regardless of nasal endoscopy findings.

PURPOSE/OBJECTIVE:We developed human cornea organoids (HCOs) from induced pluripotent stem cells (iPSCs) where single-cell RNA-sequence (scRNA-seq) analysis suggested similarity with developing rather than mature human corneas. We performed immunohistology to determine the presence of corneal glycosaminoglycans as an assessment of maturity. We undertook a detailed comparison of the HCO scRNA-seq data with a recent scRNA-seq study of human fetal corneas at different stages to gauge the HCO's maturity. METHODS:We generated HCOs from a second iPSC line, NCRM-1, to assess the reproducibility of HCO development. We stained sections from both HCO lines with Alcian blue and picrosirius red to determine deposition of sulfated glycosaminoglycans and fibrillar collagens. We immunolocalized glycosaminoglycan biosynthetic enzymes and proteoglycan core proteins. The scRNA-seq data from IMR90.4 HCOs were compared to that of fetal corneas using MetaNeighbor analysis to assess the similarity of HCOs to different stages of human corneal development. RESULTS:The MetaNeighbor analysis suggests closer alignment of the IMR90.4 HCOs with 17-18 post-conception week fetal human corneas. HCOs from both iPSC lines deposit sulfated glycosaminoglycans and fibrillar collagens. Immunohistology showed chondroitin/dermatan sulfate (CS/DS) and keratan sulfate in the presumptive stromal and some epithelial layers. The NCRM-1-derived HCOs show increased CS/DS staining compared to the IMR90.4 derived HCOs. CONCLUSIONS:Both HCO lines show similar developmental patterns and timeline. The NCRM-1 HCO line may have more glycosaminoglycan deposition. Overall, the glycosaminoglycan deposition pattern is consistent with an immature tissue. Optimizations based on our current findings may yield more mature stromal cells and cornea-typical proteoglycans.

PURPOSE/UNASSIGNED:The objective of this study was to evaluate the relationship between research activity and National Institutes of Health (NIH) funding status of the United States (US) academic ophthalmologists. METHODS/UNASSIGNED:and w-RCR quantified research productivity, while m-RCR measured research impact. RESULTS/UNASSIGNED: < .001) than non-funded peers. A similar trend was observed among non-tenured faculty members. CONCLUSION/UNASSIGNED:and RCR, which suggests that NIH funding may be a critical factor in enhancing scholarly contributions of ophthalmologists.  These findings underscore the importance of continued investment in NIH funding to foster high-impact research within the field of ophthalmology.

PURPOSE/UNASSIGNED:To determine the characteristics of normal tension glaucoma referrals at a tertiary care center and risk factors associated with unilateral versus bilateral disease. PATIENTS AND METHODS/UNASSIGNED:Medical records were reviewed of patients who were referred to a single glaucoma provider at a tertiary care center and were given a presumptive diagnosis of normal tension glaucoma (NTG) between the years 2018 and 2021. Data collected included demographics, medical and family history, ophthalmic history, ophthalmic examination findings, neuro-ophthalmology referrals, and magnetic resonance imaging (MRI) results. RESULTS/UNASSIGNED:A total of 98 patients were included in this study. The majority of patients (82%) had bilateral disease at initial presentation. Most patients (65%) had a history of systemic disease, including hypertension (32%), cardiovascular disease (19%), diabetes (12%), obstructive sleep apnea (10%), or orthostatic hypotension (4%). Conditions associated with vascular dysregulation were identified in 24% of patients. Sixty six percent of patients had a family history of glaucoma, while nearly half (49%) were myopic. Of patients with unilateral disease, 39% had workup or consideration of other neuro-ophthalmic diagnoses compared to 13% of patients with bilateral disease (P = 0.01). CONCLUSION/UNASSIGNED:Patients referred for NTG commonly present with disc changes in both eyes. Clinicians should assess for the presence of systemic diseases associated with vascular dysregulation, myopia, and a family history of glaucoma. Patients with unilateral disease consistent with NTG may benefit from additional workup including neuroimaging or a neuro-ophthalmic evaluation.

The XEN®45 Glaucoma Treatment System (gel stent; Allergan, an AbbVie company, Irvine, CA, USA) is a minimally invasive bleb-forming surgical device that was originally approved to lower intraocular pressure by diverting the aqueous humor from the anterior chamber to the subconjunctival space (like trabeculectomy) following ab-interno placement. Since approval of the gel stent in multiple countries, the implantation technique has evolved considerably, being performed ab interno or ab externo with open or closed conjunctiva, based on patients' needs and/or surgeons' preferences. Additional technical variations that can facilitate gel stent placement and/or improve outcomes have also emerged. This article aims to increase awareness of these developments to facilitate informed decision-making and improve surgical success and outcomes for patients.

PURPOSE/UNASSIGNED:We evaluated the efficacy of varenicline solution nasal spray (VNS) in treating dry eye disease (DED) associated with moderate to severe Sjogren's disease and analyzed tear film cytokine levels of patients with DED and Sjogren's disease before and after VNS use. METHODS/UNASSIGNED:This was a pilot study involving a single-center, single-arm investigator-initiated trial. Patients with moderate to severe Sjogren's disease were given VNS 0.03 mg twice daily for 28 days. Patients were assessed on day 0 before VNS use, day 14 and day 28. Clinical exam findings, symptomatology as measured by the eye dryness score, and tear cytokines were assessed at baseline and day 28. RESULTS/UNASSIGNED:Thirty-nine subjects were included. Between day 0 and day 28, there was a statistically significant improvement in the eye dryness score (p = 0.01), corneal staining (p < 0.001), and conjunctival staining (p = 0.04). There was a statistically significant increase in tear secretion by unanesthetized Schirmer's in subjects with a baseline Schirmer's ≤5 mm (n = 35 eyes, p = 0.02) and a non-statistically significant increase in tear secretion in subjects with a baseline Schirmer's of 6-10 mm (n = 16 eyes, p = 0.79). There was a statistically significant decrease in tear film cytokine concentration of IFNγ (p = 0.0003), IL-12p70 (p < 0.0001), IL-17a (p = 0.004), IL-1β (p = 0.007), IL-2 (p < 0.0001), IL-4 (p = 0.01), and TNF-α (p = 0.02), and no significant change in IL-6 (p = 0.56) and IL-10 (p = 0.18). CONCLUSION/UNASSIGNED:Our findings add to existing evidence that VNS improves subjective dry eye symptoms, corneal and conjunctival staining, and tear secretion in a subset of tear-deficient patients, while providing new evidence that VNS reduces concentration of pro-inflammatory cytokines in the tear film. CLINICAL TRIAL REGISTRATION NUMBER/UNASSIGNED:NCT05700422.

PURPOSE/UNASSIGNED:Low vision services are beneficial for many patients with visual impairment. To facilitate referrals from Montefiore Medical Center in the Bronx to specialists at Lighthouse Guild (LHG), a New York City-based non-profit offering low vision services, an integrated referral system and best practice advisory (BPA), a pop-up tool used to guide clinicians toward recommended actions based on patient data, were implemented within the electronic medical record (EMR; Epic Systems). This was later expanded to nearby medical centers. The primary objectives of this retrospective study are to describe these EMR modifications and analyze how they impacted referrals to LHG low vision services. The secondary objective is to understand barriers to evaluation through an analysis of scheduling rates on an index year (2023). PATIENTS AND METHODS/UNASSIGNED:We analyzed referrals to LHG from Montefiore's Department of Ophthalmology along with other local institutions between 2015 (baseline year) to 2023. Patient demographic data were extracted from Montefiore Epic. Referral volumes were obtained from LHG and trended over time to determine the impact of sequential workflow modifications and regional expansions. Descriptive statistics and a chi-square analysis were performed to compare patients successfully scheduled for LHG services in 2023 with those who were referred but not scheduled. RESULTS/UNASSIGNED:Referrals to LHG increased by 220% from 2016-2017 (N=45 to 144). A flag indicating a patient's visual status resulted in a 65% year-to-year increase in 2019 (N=207 to 341). The BPA and expansion to nearby institutions increased total referrals by 90% (N=573 to 1,090). Older individuals referred to LHG were less likely to schedule appointments than younger individuals (67 vs 60 years old) (p=0.0090). CONCLUSION/UNASSIGNED:An EMR-based system designed to alert clinicians of visual deficits and enable real-time referrals dramatically improved access to low vision services. Further integration of services and coordination of care should focus on vulnerable patients such as the elderly.

INTRODUCTION/UNASSIGNED:A standardized multidisciplinary treatment protocol for NVG was developed in 2020 at the University of Chicago and has been termed Salvaging the Conventional Outflow Pathway in Neovascular Glaucoma (SCOPING). We describe 9 eyes with anterior segment neovascularization and at least partially open angles that underwent the SCOPING protocol to suppress the underlying neovascular drive, control intraocular pressure, and medically or surgically salvage the angle whenever possible. METHODS/UNASSIGNED:Nine eyes from 8 patients with first-time anterior segment neovascularization, at least partially open angles, and normal or elevated IOP were treated with 6 serial monthly intravitreal bevacizumab injections interspersed with pan-retinal photocoagulation. RESULTS/UNASSIGNED:Five eyes with completely open angles without any peripheral anterior synechiae and each achieved and/or maintained physiologic IOP without requiring surgery. The other 4 eyes presented with partially open angles. Three out of these 4 eyes required subsequent IOP-lowering surgery. None of the 9 eyes developed recurrence of anterior segment neovascularization during the treatment protocol. DISCUSSION/UNASSIGNED:This protocol may be utilized to salvage the conventional outflow pathway for patients with partially or completely open angles. The etiology and diagnosis of neovascular glaucoma have been established. Current treatment strategies include reduction of neovascular drive including panretinal photocoagulation, intravitreal injections, intraocular pressure lowering medications, and filtration surgery. However, a protocol has not been developed to treat neovascular glaucoma (NVG). Our SCOPING protocol may be helpful for glaucoma specialists in treating patients with neovascular glaucoma.

PURPOSE/UNASSIGNED:To determine the efficacy and safety of repetitive transorbital alternating current stimulation (rtACS) treatment by assessing vision-related quality of life and visual function outcome in subjects treated with rtACS versus sham-control. STUDY DESIGN/UNASSIGNED:Double masked, randomized, sham-controlled clinical trial (NCT03188042). SUBJECTS/UNASSIGNED:Sixteen subjects with moderate-to-advanced glaucoma (visual field [VF] mean deviation [MD] ≤-6.00 decibels) randomized into sham (9 subjects) or rtACS intervention (7 subjects) groups. METHODS/UNASSIGNED:Subjects underwent 10 rtACS sessions over 2 weeks. All subjects had comprehensive ocular examination at baseline, 1-week, and 4-weeks posttreatment. MAIN OUTCOME MEASURES/UNASSIGNED:Visual acuity (VA), contrast sensitivity (CS), VF MD, number of threshold sensitivity points that changed or were unchanged, and vision-related quality of life (VR-QoL) questionnaire scores. RESULTS/UNASSIGNED: = 0.04). No significant changes were detected with VA, CS, and VF analyses for either group. No serious adverse events were noted in either study group. CONCLUSIONS/UNASSIGNED:Repetitive transorbital alternating current stimulation therapy showed a significant beneficial effect on several domains of VR-QoL. Further studies will determine its utility in glaucoma. FINANCIAL DISCLOSURES/UNASSIGNED:Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.