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HIGHLIGHTS

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Managing patient expectations in implanting IOLs is crucial...

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In neuro-ophthalmology, there are various infectious diseases to be wary of.

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Inflammation vs infection: ophthalmologists warn us of the importance of differentiating between the two.

Discovering Ophthalmology and the Arts

Take a Foray into Folk Art with Alice Gitter at AAO 2021

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I

t’s fairly safe to assume that without vision, the visual arts wouldn’t be very popular. Our vision and the ability to perceive shapes and colors aren’t required to produce art, but are fundamental for appreciating it.

Cont. on Page 3 >>

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A binary answer never suffices when cultures are at play.

Be part of the conversation for the betterment of global eye care. Start just one conversation today, and make a difference in the world. Great change starts with awareness.


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14 November 2021 | Issue #2

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CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

>> Cont. from Page 1

The American Academy of Ophthalmology (AAO) has also shown its appreciation for art during its annual meetings. Indeed, each year, the Michael F. Marmor Lecture in Ophthalmology and the Arts is delivered by esteemed and well-known figures in the art world — and is a special treat in the sea of scientific lectures. This year marks the 9th edition of the lecture. “This lecture was established by Dr. Marmor to create a moment during our busy Academy where we step back from the science and reflect on some of the other things in life that we enjoy,” said Dr. Paul Sternberg, who moderated the session. “We all chose ophthalmology because we’re visual people, so I think that the arts and ophthalmology is something that is dear to so many of us.” The man for whom the lecture is named is Dr. Michael Marmor, professor of ophthalmology at Stanford University. He was unable to join AAO 2021 in-person, but he did make a virtual appearance to introduce this year’s honored speaker. “It’s been my honor to sponsor these lectures to provide a respite from the clinical intensity of the AAO meeting with an excursion into the arts,” said Dr. Marmor, who shared his regret that he was unable to attend in-person.

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This year, Alice Yelen Gitter received this particular honor as both an art scholar and for her work as senior curator of collections research at the New Orleans Museum of Art. Her presentation, titled Self-Taught American Art: From Obscurity to Recognition, took place in-person (it’s also available on demand) on Day 2 of the American Academy of Ophthalmology’s (AAO 2021) annual meeting.

“It’s been my honor to sponsor these lectures to provide a respite from the clinical intensity of the AAO meeting with an excursion into the arts.”

attended art school: Whose art is more valuable? We certainly don’t have the background or cache to weigh in on that matter, however, Mrs. Gitter does. During her talk, she shared the artwork and background behind some of the 20th century’s most prolific folk artists. The self-taught American artists that Mrs. Gitter highlights share certain characteristics: “They were born between the 1850 and the end of World War II; many were raised in the American south where strong religious overtones dominated the culture and often inspired the production of artworks,” she explained. Some were descendants of slaves or slaves themselves, some were homeless, and often, they used whatever materials they could salvage to create their art.

— Dr. Michael Marmor “Both ophthalmology and art deal with the human being’s ability to see: Medicine measures the physical aspects, art deals with insight and the mind’s eye,” began Mrs. Gitter. “I hope this presentation will encourage each of you to continue to explore the many, many ways of seeing.”

Self-taught art versus the mainstream In the art world, it seems that everything is up for debate and discussion — and simple questions like “why is this art?” or “why is this good art?” become more complex as you try to answer them. Another provocative topic is that of artists who are self-taught versus those who’ve

“They were born between the 1850 and the end of World War II; many were raised in the American south where strong religious overtones dominated the culture and often inspired the production of artworks.” — Alice Yelen Gitter

Mrs. Gitter shared that throughout the 20th century, self-taught art has moved from relative obscurity into the public eye. “Today, some of these self-taught

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14 November 2021 | Issue #2

American artists are becoming widely recognized for the contributions that their raw, unfiltered vision, their unbridled imagination and their natural creativity, has made to the history of American art.”

“Today, some of these self-taught American artists are becoming widely recognized for the contributions that their raw, unfiltered vision, their unbridled imagination and their natural creativity, has made to the history of American art.” — Alice Yelen Gitter From prehistoric times, wherever there was life, creativity has existed. “People have long told their stories with resourceful artistic tools, and ingenious visual surprise,” she continued. According to Mrs. Gitter, self-taught artists are not aware of art historical tradition like formally trained artists are; they generally have minimal formal education and usually no art instruction; and they initially work outside the art mainstream and don’t seek acceptance into that world, nor do they depend on it for their livelihood. Further, they generally don’t consider themselves “artists,” they don’t know other artists, nor do they visit museums. “These artists are unencumbered by centuries-old ideas of what art ‘is’ or what art ‘should be,’” said Mrs. Gitter.

The artists Below are the self-taught artists that Mrs. Gitter shared during her presentation. Purvis Young (1943-2010) walked and biked through his shambling neighborhood in Miami; this became the source for his inspiration and imagery. He also used discarded materials in his art. In describing one of his artworks, Mrs. Gitter said that his large brush strokes often represent “long arms of the people of the city raising their arms to heaven, asking for help.”

Hawkins Bolden (1914-2005) was from Tennessee and used found materials to create his art. “Hawkins Bolden was declared legally blind at age 7,” shared Mrs. Gitter. “As an avid gardener, he earned his living cultivating lawns and cleaning alleys in his Memphis neighborhood from which he scavenged discarded materials that he used for assemblages.”

first African American to have a solo exhibition at the Museum of Modern Art (in 1937).

Charlie Lucas (1951-) is a car mechanic who collects materials from his job to create sculptures. Mrs. Gitter shared one of his quotes: “I don’t just collect junk. I look for pieces with character in them and they show themselves to me.”

Bill Traylor (1853-1949) painted his daily life with “extraordinary design and composition.” Traylor was born a slave outside of Selma, Alabama where he lived and worked until 1927, when he moved to Montgomery,” said Mrs. Gitter. “It was in 1939, when he was 85, that Traylor began to paint continuously.”

“These artists are unencumbered by centuries-old ideas of what art ‘is’ or what art ‘should be’.” —Alice Yelen Gitter Sister Gertrude Morgan (1900-1980) was a missionary and artist — and like all self-taught artists, she had an innate drive to create. “She incorporated biblical chapters and verse, often from Revelations … and she illustrated each verse with her own imagery,” said Mrs. Gitter. William Edmondson (1874-1951) began creating art in 1932 when God “called him to carve limestone” that he collected from demolished curbs and buildings. “First, He told me to make tombstones. Then he told me to cut figures,” Edmondson was quoted as saying. He also has the unique honor of being the

J.B. Murray (1908-1988) used color and lines to create his abstract paintings. “Murray said he was instructed by the Lord to spread his word through ‘spirit script,’ a direct communication with God,” shared Mrs. Gitter.

Sam Doyle (1906-1985) used his work to depict his own rich cultural heritage. He depicted both local figures, like the first Black midwife on St. Helena’s Island, as well as famous African Americans, like the great boxer Joe Light. William Hawkins’ (1895-1990) inspiration came from commercially printed images and photographs that he retrieved from piles of trash from his daily rounds of Columbus, Ohio dumpsters, shared Mrs. Gitter. “I don’t copy what I see. I make it better,” Hawkins is quoted as saying. Clementine Hunter (1887-1988) created paintings that documented plantation life in Louisiana, where she lived and worked from age 12 to 101. A quote from Hunter said that painting is harder than picking cotton, as it sweats your mind. “The concept is that artists are artists,” Mrs. Gitter said in conclusion. “And artists, basically, are people that are driven by the same things.”


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

How to Manage Expectations When Implanting IOLs by Andrew Sweeney

with an IOL exchange or refractive enhancement.

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This session of the AAO 2021 annual meeting remains available on demand for you to watch at your own convenience. It’s full of practical advice that you will likely find to be considerably beneficial to your practice. So, check it out when you can!

When asked what the best piece of advice he could give to the session’s audience, Dr. Ayres said that there were three key factors to consider when dealing with an nd unhappy patient. These were to listen oe t s to them and address their concerns; make sure that there’s no residual refractive error; and to make sure the ocular surface is treated. He emphasized that this should address most problems, but that the last resort can be going wa

This was another of the 30-minute long sessions involving two clinicians who fielded questions from the audience, something we view as one of the standout features of AAO 2021. Held by Drs. Cathleen M. McCabe, medical

director and CMO of Eye Health America (Bradenton, Florida), and Brandon Ayres at Wills Eye Hospital (Philadelphia, Pennsylvania), the session covered a wide range of issues. These included the doctors’ opinions on implanting a multifocal lens in the non-dominant eye in a patient with perfect uncorrected distance vision; negative dysphotopsia in a toric multifocal lens; and when exactly one should check an IOL for rotation post-procedure; among other topics.

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Of course, we are not a gambling publication, we’re all about ophthalmology, so let’s not get too off track — but managing patient expectations is an absolutely crucial skill. This certainly applies to surgeons implanting multifocal IOLs, given the wide range of issues they may encounter during treatment, as well as the wide variety of patients and their particular needs. How to Manage the Unhappy Multifocal Patient, held on the second day of the American Academy of Ophthalmology’s (AAO 2021) annual meeting, was a rapid-fire examination of this important subject.

Dr. McCabe’s advice was simpler, but no less effective. She said that it’s all about “ocular surface, ocular surface, ocular surface.” She went on to add that there was nothing else to think about until one has fully maximized their understanding of the surface and that it could often tell you more about the patient’s refraction. She also added that ensuring that the patient can maintain their ocular surface post-procedure, before implanting an IOL, is absolutely crucial toward securing the best possible outcome for all concerned.

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earning to manage expectations is one of the most important life skills to have: It can help forestall disappointment and create achievable goals. The ability to do so, for example, is why a certain Media MICE employee has devoted himself to a career as a writer — and has not instead spent all of his money on lottery tickets. Sure, you could become fabulously rich, but is it reasonable to expect that would be the most likely outcome after spending thousands on gambling?

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14 November 2021 | Issue #2

Diseases Other than COVID-19

! h a z Huz mon

by Sam McCom

D

ay 2 of the American Academy of Ophthalmology’s 2021 annual meeting (AAO 2021) featured a session we didn’t know we’d been missing. Titled, Infectious disease in neuroophthalmology: It’s not just COVID-19, the session took a deep dive into diseases that, as the title suggested, aren’t the one we’ve heard enough about for three lifetimes. It was as refreshing as an ice bath after a jog in the summer heat, and tasted like a breath of freedom. We’ll never be free of diseases, of course, but isn’t it nice to at least be able to talk about more than just one? There was, of course, one session that covered COVID-19 — which the organizers mercifully put at the opening spot to get it out of the way, with full apologies offered by the presenter, SARS-CoV2 can be associated with systemic and neurological autoimmune disorders. What we don’t know is whether the overall incidence of viral-associated autoimmune disorders will increase, and the effects of widespread vaccination, if any. This information was shared with us by Dr. Vivek Patel, from the Gavin Herbert Eye institute at the University of California at Irvine. But really, we don’t want to dwell on COVID-19, because there’s much more to discuss.

Why should ophthalmologists care about food poisoning? Dr. Paul Philips, from Little Rock, Arkansas, brought up this intriguing

question — that was then followed by a case study. Any ophthalmologists who have had med students ask “Why should I care about diarrhea? I want to be an ophthalmologist,” will now have an answer ready. Dr. Philips’ case involved a 55-year-old man, who had developed binocular, horizontal diplopia four days prior to referral. He said he did not have any decreased vision or eye pain, presented no other neurologic symptoms, and an MRI/MRA brain scan showed nothing remarkable. He had no hypertension, diabetes, or history of cancer, was not on any medication, and had a history of moderate alcohol consumption.

Upon examination, the patient showed bilateral 50% abduction, elevation, and depression deficits, 40 prism diopter esotropia, and his pupils traced constriction to light and accommodation. But he did mention to Dr. Philips he’d had an episode of diarrhea one week before the diplopia, leading to the above medical student comment. So, why should ophthalmologists care about diarrhea? There are four reasons, Dr. Philips said: • Vitamin deficiency, which can lead to conditional ike Wenicke’s encephalopathy, due to a lack of B vitamins


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

• Toxins like botulism • Autoimmune-molecular mimicry like Miller-Fisher syndrome

ask why an ophthalmologist should care about diarrhea? Give them the bullet list above. It’s almost like our body is all connected.

• A direct invasion, like Whipple’s disease

That sneaky ocular syphilis

Drawing the link was a bit tricky, but Dr. Philips could at least rule out thyroid eye disease and myasthenia gravis, as they would not involve the pupils, and myasthenia gravis, which would be unlikely to be so isolated. The patient also displayed decreased reflexes in some muscles, notably in the arms. A cerebrospinal fluid (CSF) analysis showed elevated protein levels — and serology showed elevated anti-GQ1b Ab levels, confirming a diagnosis of MillerFisher syndrome (MFS). For the unaware, MFS is a rare, acquired nerve disease considered to be a subset of GuillainBarré syndrome. “Through a mechanism of molecular mimicry, the bacteria trigger an antibody response that targets the GQ1b antibody … affecting the neuromuscular junction.” Essentially, Miller-Fisher syndrome develops central nervous system problems that result in ocular motility problems. Elevated anti-GQ1b Ab antibody levels are positive in 85-95% of patients with MFS. Most patients with MFS recover spontaneously and completely within 3 months, and recovery starts at 12-15 days. Treatment is primarily observational.

We’ve covered ocular syphilis more than a few times in this publication, largely because of the morbid fascination that goes along with it. It’s such a weird disease and can imitate many others, as doctors well know. That includes ocular manifestations. Well, pardon the spoiler, but you may have an idea of how this story goes. Dr. Nancy Newman, from Atlanta, presented a fascinating case that’s going to have us scratching our heads and peeking out from behind our hands for a while. In Dr. Newman’s case, a 55-year-old man presented with bilateral disc edema. He was obese, with a BMI of 35, had diabetes milletus, hypetension, and dry eye. He has not had COVID and remains unvaccinated. Four to five months prior, he flew to New Orleans for the first time since the pandemic and, as he put it, “had a really good time.” Two months ago, he had developed headaches and blurred vision that slowly worsened, and wasn’t helped by normal reading glasses. He was also hospitalized for a respiratory infection and at that point his diabetes was diagnosed. It was then he went to an optometrist, who noticed the edema and elevated blood pressure. There were no anterior chamber flares, however.

So, what do you tell someone when they

An MRI showed a flattening of his pituitary and a hypoplastic transverse sinus. So, Dr. Newman asked, is this idiopathic intracranial hypertension (IIH) and, more importantly, did he really need a lumbar puncture? A lumbar puncture is valuable in cases of questionable IIH, to obtain CSF analysis, and to start treatment, as a lumbar puncture decreases ICP. Dr. Newman noted that if it were a female in question, the lumbar puncture would be an easy call. But the lumbar puncture was done, and CSF noted 6 nucleated cells — above the normal of 5 or less — as well as elevated protein levels. Dr. Newman wasn’t convinced he had IIH, as retinal evaluation showed no signs of active inflammation. So, an inflammatory and infectious workup was obtained. So, like … what gives? The result? The patient was both HIV positive and had developed ocular and neurosyphilis in the setting of newly diagnosed HIV. Syphilis can affect all parts of the eye in nasty ways. That’s well known. As syphilis is the great imitator, it can look just like IIH. But diagnosing syphilis is difficult: the CSF VDRL is 100% specific for neurosyphilis but only 30-70% sensitive, and false negative rates for CSF RPR are even higher. As an important note, neurosyphilis occurs two times more frequently in coinfected HIV patients. That HIV infection can alter the presentation of neurosyphilis and ocular syphilis. In the U.S., testing for HIV is recommended for all syphilis patients. Dr. Newman’s takeaways? Always perform a lumbar puncture in cases of presumed IIH; syphilis is still the great imitator, especially when coexistent with HIV; bilateral disc edema makes ocular syphilis neurosyphilis, and requires a lumbar puncture for CSF; the CSF profile of syphilitic meningitis may be subtle; and always check serum markers even if CSF is negative. We’ll let the reader draw any connections between the “really good time” the man had in New Orleans and his condition — Dr. Newman didn’t elaborate, but we can read between the lines. That said, we encourage everyone to have some good clean fun in New Orleans while you’re there.

We get to talk about something else for a change!

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14 November 2021 | Issue #2

Best Poster Highlights from AAO 2021 Annual Meeting

by Hazlin Hassan and Tan Sher Lynn

Posters abound at this year’s AAO annual meeting. According to the virtual platform, there are a total of 492 posters on everything ophthalmology. Out of 492, 93 are about the retina and vitreous, and we highlight here some of the best poster awardees in the said category…

PO036: Incidence of CRAO and CRVO during the Covid-19 Pandemic The purpose of this study by Dr. Ahmad Al Moujahed and colleagues was to examine the incidence of central retinal artery occlusion (CRAO) and central retinal vein occlusion (CRVO) during the COVID-19 pandemic. Multiple reports have documented cases of CRAO and CRVO in patients with COVID-19 and suggested a possible link between the virus and these visionthreatening conditions. In this retrospective study of a database of more than 400,000 patients from over 65 private retinal clinics across the United States, the overall number of new patients dropped dramatically during the first few months of the pandemic (67% less than pre-COVID). The number of newly diagnosed patients with CRAO or CRVO also dropped (20% and 30% less than pre-COVID). Therefore, the relative number of these new conditions compared to all new diagnoses increased, which may have led to the impression that more patients were presenting with CRAO or CRVO. “As most states reopened after June

2020 and the number of patients seen in retina clinics increased (90% compared to pre-COVID), the proportion of newly diagnosed patients with CRAO or CRVO returned to similar trends as seen pre-COVID, with no increase,” the investigators said. In conclusion, CRAO and CRVO cases did not increase during the pandemic. Further studies are needed to investigate if there is an association between COVID-19 and retinal vascular occlusions.

PO038: Change to Plaquenil Screening Criteria Improves Detection Changes to hydroxychloroquine (plaquenil) screening criteria improve the detection of early changes and improve patient safety, said Dr. Suri

N. Appa and colleagues from the Southern California Permanente Medical Group. In the study, 3,675 patients were screened for plaquenil toxicity. “With the use of the new criteria, the number of patients screening positive and referred for retina physician evaluation increased to from 11% to 19%,” they said. In addition, the percentage of patients with confirmed earlier toxicity increased from 13% to 17%.


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Hydroxychloroquine is used to treat various rheumatologic and dermatologic conditions. It has also been used off-label to treat COVID-19, although data to support its efficacy is mixed. However, hydroxychloroquine can adversely impact the cornea, ciliary body, and retina. The early signs of hydroxychloroquine toxicity are macular edema and/or bilateral granular depigmentation of the RPE in the macula. A standardized approach to screen for plaquenil toxicity was created at Kaiser Permanente Southern California in 2015. This program is based on optical coherence tomography (OCT) imaging and provides patient flexibility for scheduling. The images are reviewed at a reading center. In 2018, some patients were seen to be progressing to significant ellipsoid layer loss, despite showing near normal images one year prior. New criteria were created and implemented to improve earlier detection. OCT images from patients are taken and uploaded to a central server for reading center evaluation. The percentage referred for toxicity doubled by adding new criteria for cases of suspected toxicity. “The new OCT criteria improves the detection of early changes and improves patient safety,” the investigators said. By increasing testing sensitivity, the number of MD-confirmed patients with toxicity increased three-fold, they added. “More rigorous testing improved efficiency in preventing vision loss in hydroxychloroquine-treated patients,” they concluded.

PO039: Clinical Features, Factors of Tumor Growth, Appearance of Tumor Vascular by SS-OCTA and Outcomes of Intravitreal Injection of VEGF Therapy in Patients With Choroidal Osteoma Choroidal osteoma (CO) frequently leads to progressive visual loss due to

complications of secondary choroidal neovascularization (CNV). Dr. Nan Zhou from China and colleagues analyzed the clinical features of CO and tumorrelated neovascularization using swept source optical coherence tomography angiography (SS-OCTA), and evaluated the outcomes of intravitreal ranibizumab (IVR) injection therapy in patients diagnosed with CO from January 1996 to January 2021. Patients diagnosed with CO were divided into Group 1 which was non-treatment, and Group 2 which received one initial IVR injection followed by pro re nata dosing regimen (1+PRN). Main outcome measures include tumor growth, tumorrelated neovascularization, tumor decalcification and visual acuity. A total of 186 eyes (149 patients) with CO were included, with 112 eyes receiving IVR. The investigators found that SS-OCTA was able to visualize CO vasculature and penetrate tumor decalcification and decalcification lesions. “Tumor growth was seen in both peripheral and deep areas, respectively. These results recognized that CO showed evolution with change in clinical features over many years. The appropriate understanding of the structures of seafan shaped tumor vasculature (SFVNs) in CO, which previously described as choroidal neovascularization (CNV), is important for understanding tumor pathogenesis, diagnosis, treatment and prognosis,” said Dr. Zhou. Dr. Zhou also noted that anti-VEGF therapy can control tumor growth of CO and maintain better visual acuity, as the ten-year Kaplan-Meier analysis revealed tumor growth in 35.6% in Group 1, and 10.8% in Group 2. The authors concluded that anti-VEGF therapies could directly stabilize the tumor, prevent decalcification of tumors, or stimulate tumor decalcification at an early point, particularly in cases where the fovea is threatened by an advancing margin of the osteoma; and that SSOCTA can monitor and evaluate osteoma tumor blood vessels and growth status.

PO051: Retinal Impacts of Bariatric Surgery: A Meta-Analysis of 362,589 Patients Bariatric surgery has shown efficacy in inducing remission of type 2 diabetes and reducing other microvascular complications, but its impact on diabetic retinopathy (DR) is unclear. Dr. Caberry Weiyang Yu from McMaster University, Canada, and colleagues did a systemic review and meta-analysis on the impact of bariatric surgery on DR for obese diabetic patients in comparison to medical treatment. The investigating team searched through studies that compared DR in diabetic patients who had undergone bariatric surgery versus medical management in Medline, Embase, Cochrane Central and Web of Science databases up to March 2020. Primary outcomes included prevalence of all DR and sight-threatening DR after surgery, while secondary outcomes included worsening of DR within and beyond 12 months. Fourteen studies of 362,589 patients were included in this study. Surgical patients had statistically significantly lower postoperative prevalence of all DR (RR 0.17; 95% CI, 0.13-0.22) and sight-threatening DR (RR 0.47; 95% CI 0.27-0.82). Early worsening of DR and progression to sight-threatening DR had occurred more often in those with more severe DR initially. Beyond 12 months, bariatric surgery resulted in significantly fewer patients with worsened DR (RR 0.29; 95% CI, 0.16-0.54). In conclusion, bariatric surgery was associated with fewer cases of all and sight-threatening DR in obese patients with type 2 diabetes mellitus. “Severity of DR at baseline was an important sign of early worsening of DR post-operatively, and early vigilant screening for patients with existing sightthreatening DR who undergo bariatric surgery is needed,” said Dr. Yu.

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14 November 2021 | Issue #2

more indicative of inflammation or infection, and what courses of diagnosis would be most effective to diagnose them in practice.

New diagnostic methods for infections

by

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The first speaker, Dr. Thuy Doan from the University of California, San Francisco, opened by talking about the topic of Diagnostics for Ocular Infections. When it comes to diagnosing ocular infectious disease, Dr. Doan noted that doctors have typically utilized the same techniques employed in other areas of medicine: targeted pathogen diagnoses. These include stains, cultures, antigen testing, antibody testing, and nucleic acid amplification tests. While these tests are highly effective, they are also very narrow in scope, only providing results relevant to one particular type of infection.

ice

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W

hen a patient’s eyes are inflamed, it is always cause for concern (at the very least). And sometimes, it’s cause for alarm, a sign of something that can be permanently damaging, or even life-threatening. There are numerous things that can cause uveitis or eye inflammation — these include trauma, allergies and conditions external to the eye. But many of the most dangerous causes for inflammation are related to infection. The courses of treatment for ocular infection, as opposed to other forms of inflammation, can vary pretty drastically. And it is not always easy for an ophthalmologist to distinguish one from the other. The diagnosis and treatment of these two different, yet

highly similar, conditions was the topic of Diagnostic and Treatment Challenges of Ocular Infection vs. Inflammation on the second day of the American Academy of Ophthalmology’s (AAO 2021) annual meeting. The presenters began the symposium by discussing some new technologies available to the medical profession in the diagnosis of infections, as well as new developments in treatment options. Following this, the panel reviewed data samples presented from actual cases, taking straw polls on whether the symptoms of the patients were

But recently, a number of studies have shown that we are able to ascertain broader results. In a study Dr. Doan conducted, her lab was able to characterize all pathogens in low biomass samples, such as the ocular surface or conjunctival samples. Other recent studies have also shown broadbased reactions based upon short- and long-term antibiotic resistance, which can help to diagnose a wider spectrum of bacteria, fungi and viruses. Using molecular-level biomarkers, these recent testing developments represent a much more efficient technique for testing. These new testing techniques do not rely on pathogen-focused polymerase chain reaction (PCR) testing, but instead analyze metagenomic data from RNA sequencing. Dr. Doan says that these


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

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cellular reaction analyses could be a valuable diagnostic tool when more traditional testing methods have failed to show results, but where infection is still suspected.

Systemic vs. local treatment for inflammation

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Turning to the treatment of non-infectious uveitis, the next presenter Dr. Phoebe Lin, from Casey Eye Center in Portland, Oregon, addressed the question of how and when systemic therapy is an appropriate treatment measure. As steroids are the most common treatment for inflammation not related to infection, Dr. Lin presented results from a study seeking to find whether locally applied steroids were any more or less effective than systemic (frequently oral) applications.

Dr. Lin concluded that both treatments are very effective, with each having some advantages over the other. Locally administered steroids showed much faster and more complete control of inflammation, but at much higher risk of cataracts, glaucoma and infection. The studies also seemed to indicate that where systemic treatment was effective, it was perhaps a better option in the longer term.

The difficulty of telling infection from inflammation The latter half of the symposium involved unique case studies in uveitis. Presenters described several patients’ background and symptoms and a panel of experts voted, based on the available data, whether they would opt to proceed with treatment for infection, or to address the inflammation as caused by another source. Several of the cases delivered a clear consensus, with the panel all choosing one course of treatment over the other. Somewhat surprisingly, however, the majority of cases involved a split decision, often of exactly 50% to 50%. While of course, these results were based upon a very limited amount of information, it highlights the difficulty presented by telling apart these similar conditions, which require quite different treatment approaches.

XL_EASYRET_MOSAR_PUB_AN_211103

While local application of steroid treatments administered through a transvitreal implant showed a higher degree of control and efficacy in the very short term, that improvement tapered off quite quickly. The differences disappeared after a 4-year period, and subsequent results showed that systemic treatments proved to be somewhat more effective after a period of 7 years. At that time, patients who received systemic treatments showed greater visual improvement in mean visual acuity by 7.2 letters. Additionally, the presence of side effects was considerably higher among patients who had received local applications.

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With such tricky similarities between the causes underlying uveitis, it is encouraging to know that the methods for diagnosing and for treating these conditions are always getting better and more diverse.

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