To describe the presentation of both new-onset and reactivation of thyroid eye disease (TED) following COVID-19 vaccination. Single-institution retrospective case series of patients presenting with symptoms and signs of new or reactivated TED coinciding with recent COVID-19 vaccination. Data collected included patient age, gender, presenting symptoms, ocular history, clinical signs, and interval duration between vaccination and onset of ocular symptoms. Three female patients were identified. All patients were over 18 years of age (range 45–66 years). Patients received either the Moderna or Pfizer COVID-19 vaccine and presented with symptoms of TED within 24 h to 21 days of receiving their first or second dose. None of the patients had previous infections with severe acute respiratory syndrome coronavirus 2. Two patients had a history of inactive TED with stable thyroid function tests: One of these patients had stable disease for at least 15 years and the other had stable disease for 5 years. The third patient had no previous history of thyroid dysfunction or TED and presented with low levels of thyroid-stimulating hormone. All three cases presented with proptosis. In two of three cases, periorbital edema, eyelid retraction, and diplopia were present. None were current smokers. One had prior facial hyaluronic acid filler injections. Symptoms in all cases were improving at 4 to 8 months. While the possibility of unrelated TED flaring concurrently with COVID-19 vaccination exists, questions remain on the effects of the COVID-19 vaccine in patients with autoimmune ophthalmic diseases. Physicians should be aware of this potential association and counsel patients appropriately.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Thyroid eye disease (TED) is the most common extrathyroidal manifestation of autoimmune Graves' hyperthyroidism. TED is a debilitating and potentially blinding disease with unclear pathogenesis. Autoreactive inflammatory reactions targeting orbital fibroblasts (OFs) lead to the expansion of orbital adipose tissues and extraocular muscle swelling within the fixed bony orbit. There are many recent advances in the understating of molecular pathogenesis of TED. The production of autoantibodies to cross-linked thyroid-stimulating hormone receptor and insulin-like growth factor-1 receptor (IGF-1R) activates OFs to produce significant cytokines and chemokines and hyaluronan production and to induce adipocyte differentiation. In moderately severe active TED patients, multicenter clinical trials showed that inhibition of IGF-1R with teprotumumab was unprecedentedly effective with minimal side effects. The emergence of novel biologics resulted in a paradigm shift in the treatment of TED. We here review the literature on advances of pathogenesis of TED and promising therapeutic targets and drugs.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Purpose: To report the intraocular pressure (IOP) and visual outcomes in patients operated for phacomorphic glaucoma in a developing country Methods: Patients undergone surgery for phacomorphic glaucoma between January 2015 and February 2018 with a minimum follow-up of 6 months were reviewed. Multinomial logistic regression was used to predict final visual acuity with different preoperative variables. A Kaplan-Meier analysis was done to calculate survival probabilities at different time points. Results: Presenting IOP of study eye was 38.3±13.4 mmHg with 97.91% (n=94/96) patients on AGMs (mean: 2.7±1.08). Mean duration of complaints was 7.7±6.3 days. The most common postoperative complication was severe anterior chamber inflammation with or without fibrin membrane (in 29.16% eyes). The mean follow-up period was 14.5±9.2 months. At the last visit, the CDVA was 20/30 or better in 54/96 (56.25%) eyes, the mean IOP was 13.6±2.6 mmHg and 30 (31.25%) eyes required additional AGM with the mean number being 1.5±0.6. Two eyes required trabeculectomies for IOP control. The mean survival time of complete and qualified success was 28.5±1.9 and 41.2±0.05 months respectively. The probability of complete and qualified success at month 42 was 11% and 98%. Duration of complains and VCDR were found to be associated with final visual acuity. Conclusions: There was a positive correlation between shorter duration of symptoms with post-operative visual gain, but the glaucomatous damage showed a plateau effect at the IOP of around 35 mmHg. It is not the level of IOP, rather its duration which determines the degree of visual loss.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

In eyes with previous corneal refractive surgery, difficulties in accurately determining corneal refractive power and in predicting the effective lens position create challenges in intraocular lens (IOL) power calculations. There are three categories of methods proposed based on the use of historical data acquired prior to the corneal refractive surgery. The American Society of Cataract and Refractive Surgery postrefractive IOL calculator incorporates many commonly used methods. Accuracy of refractive prediction errors within ± 0.5 D is achieved in 0% to 85% of eyes with previous myopic LASIK/photorefractive keratectomy (PRK), 38.1% to 71.9% of eyes with prior hyperopic LASIK/PRK, and 29% to 87.5% of eyes with previous radial keratotomy. IOLs with negative spherical aberration (SA) may reduce the positive corneal SA induced by myopic correction, and IOLs with zero SA best match corneal SA in eyes with prior hyperopic correction. Toric, extended-depth-of-focus, and multifocal IOLs may provide excellent outcomes in selected cases that meet certain corneal topographic criteria. Further advances are needed to improve the accuracy of IOL power calculation in eyes with previous corneal refractive surgery.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

PURPOSE: Excellent vision is essential to performing well in sports. Sports vision includes visual, perceptual, cognitive, and oculomotor tasks that enable athletes to process and respond to what is seen. We aimed to examined how sports vision parameters – dynamic visual acuity (DVA), eye movement (EM), peripheral vision (PV), and momentary vision (MV) – varied with age and sex and assessed how static visual acuity (SVA) affect sports vision performance. MATERIALS AND METHODS: Sports vision was assessed at 45 cm distance at best-corrected SVA in 310 nonathletic participants (age, 6–60 years). Among these 310 participants, 108 university students underwent their sports vision test at 45 cm and 2.5 m distance, with and without glasses. The 4 sports vision parameters were measured by Athlevision software package installed to a laptop. Two-way analysis of variance (ANOVA) was used to compare sports vision performance in relation to age group and sex. Repeated-measures ANOVA with 1 within-factor (4 conditions) were used to analyze how sports vision varied among the near/far distance with/without glasses conditions. RESULTS: DVA increased during childhood, peaked during the 20s or 30s, and gradually decreased during middle age (P < 0.0001). DVA was significantly better in males than in females (P = 0.0001). The other 3 sport vision parameters – EM, PV, and MV – exhibited similar age trends (P < 0.001) but did not differ between two sexes. The university students with mild myopia had similar DVA, EM, and PV at both near and far distances, with and without correction; but moderate or severe myopic students with uncorrected vision had worse DVA, EM, and PV at 2.5 m than at 45 cm. CONCLUSION: Low SVA in uncorrected myopia significantly interferes the performance in sport vision tests applied in this study, especially in far distance. Improve static vision, such as myopic correction, may significantly improve sports vision, which is important in athletic performance and safety.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Intraocular lens (IOL) exchange may be required after multifocal IOL implantation due to dissatisfaction. Late IOL exchange is more challenging when it is done with capsulotomy. We presented a retrospective case series study enrolling four consecutive eyes reviewing late IOL exchange due to decreased vision and dysphotopsia. High residual hyperopia, astigmatism, and IOL tilt occurred in 3 eyes, respectively. The mean time to the IOL exchange was 15.8 ± 10.63 months. After separation of the adhesions by visco-dissection assisted with a 27-gaze needle and sinskey hook, IOL was explanted. One-piece IOL was implanted in the bag in two eyes without posterior capsulotomy, whereas three-piece IOL was implanted in the sulcus after viscoelastic tamponade in the other 2 eyes with capsulotomy. No complication occurred and dysphotopsia disappeared. The mean logarithm of the minimum angle of resolution best-corrected visual acuity significantly improved from 0.33 ± 0.12 preoperatively to 0.11 ± 0.13 postoperatively. In conclusion, late IOL exchange could be safely performed with proper technique and achieve good results.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Eyelid retraction related to thyroid eye disease (TED) is a challenging condition. It is one of the main clinical signs and a major diagnostic criterion in TED. This condition may threaten vision due to exposure keratopathy, in addition to its esthetic alterations, which may lead to psychosocial implications and affect the patient's quality of life. Although it is more commonly observed in the upper eyelid, it may be present on both the upper and lower lids. Numerous surgical and nonsurgical treatment modalities have been described and will be reviewed in this article. Management should be based on an individual patient assessment, taking into consideration the disease stage, severity, and clinician experience.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

PURPOSE: This study aims to objectively measure the effect of slow tempo music on various markers for anxiety. MATERIALS AND METHODS: This is a repeated measure randomized control trial of patients with age-related cataracts undergoing cataract extraction through phacoemulsification under local anesthesia. Patients were randomized into two groups: music group where a standardized piano music was played and control group. Salivary alpha-amylase (sAA) levels were measured at the beginning and at the end of surgery. Blood pressure and heart rate were also measured at 5 min before surgery and at four other standardized points during and after surgery. Visual Analog Scale for anxiety was also gauged: preoperatively, perioperatively, and 15 min postoperatively. RESULTS: Ninety-two patients were randomized equally to the music group and control group. Paired sample t-test showed a reduction in the level of sAA during surgery in the music group (P = 0.019). The odds ratio for a drop in sAA with music was 4.407 (P = 0.001). Lower systolic blood pressure was observed in the music group: at delivery of local anesthesia (P = 0.047), at first incision (P = 0.023), and during sculpting (P = 0.15). Similarly, diastolic blood pressure was lower at first incision (P = 0.019) in the music group. The visual analog scale for anxiety during surgery was found to be lower in the music group (P = 0.046). CONCLUSION: A slow tempo music during cataract surgery was shown to significantly reduce several indicators for anxiety at various points during cataract surgery.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

PURPOSE: Exophthalmometry value has great clinical significance in the presence of many orbital diseases which can cause proptosis, including thyroid-associated orbitopathy, tumors, inflammation, head and orbital trauma, and craniofacial abnormalities. Measurements of exophthalmometry and ocular biometry vary between races and countries. This study aimed to present the normative values of exophthalmometry in adult Malays of Kelantan and the relationship between ocular biometry (axial length, corneal curvature, anterior chamber depth, and white-to-white) with the obtained exophthalmometry values. MATERIALS AND METHODS: This was a hospital-based, cross-sectional study in the Ophthalmology Clinic of Universiti Sains Malaysia, Kubang Kerian, Kelantan, where 267 individuals above 20 years old participated between August 2018 and May 2020. Participants were examined with Hertel exophthalmometer and intraocular lens Master by the same investigator. Data were analyzed using the Statistical Package of the Social Science software (version 24.0). Multiple linear regression was used to assess any significant correlation between exophthalmometric value and each biometric variable. RESULTS: In the data collected, the mean exophthalmometric value for the right eye was 13.93 ± 2.221 mm and the left eye was 13.93 ± 2.232 mm. Overall, male had a higher exophthalmometric value than the female with a statistically significant P = 0.001. Axial length was uniquely significant for the amount of variance in the exophthalmometric value with P < 0.001, while corneal curvature, anterior chamber depth, and white-to-white showed no statistical significance. CONCLUSION: Our study had established the normal exophthalmometric value for Malay adults in Kelantan for future clinical reference. The axial length had shown to have a significant positive correlation with exophthalmometric values.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

The purpose of this study was to describe the single-triangle technique for congenital ptosis repair with a frontalis sling in blepharophimosis patients. The single-triangle technique was used in 40 eyes of 20 patients of blepharophimosis syndrome. The center point of the lid is marked. The desired base length is calculated depending on the available horizontal fissure width. Two marks are inked 2 mm above the lid margin, equidistant from the central mark. A single brow mark is placed in such a way that it is directly above the center point of the lid. These are now joined to complete the triangle. In blepharophimosis patients, the mean preoperative margin reflex distance (MRD1) was 1.0 ± 1.1 mm which increased to 4.1 ± 1.6 mm after surgery. The MRD1 increased by 3.1 ± 1.7 mm. Cosmetic outcome was graded with a score of 0, 1, or 2 to indicate poor, good, and excellent results, respectively. Out of the 40 eyes that were operated, 33 eyes had a score of 2, 5 eyes had a score of 1, and 2 eyes were scored 0. The single-triangle technique has several advantages over both the Fox pentagon technique and modified Crawford technique in severe blepharophimosis patients. It is not only a much simpler procedure to perform but also has a better control over the curvature of the lid without any central focal notching, thus providing better cosmesis and esthetic results.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Unilateral proptosis secondary to ectopic lacrimal gland tissue is rare. The most common site of ectopic lacrimal gland tissue is at the bulbar conjunctiva and limbal area. Although uncommon, intraorbital ectopic lacrimal gland tissue may mimic other ominous symptoms of intraorbital neoplasm in childhood. We present a rare case of intraconal ectopic lacrimal gland tissue in a 14-year-old girl with intermittent proptosis since childhood associated with subconjunctival hemorrhage and excruciating pain. She underwent lateral orbitotomy with orbital mass excision that resulted in good outcomes and no recurrence was seen at 6 months after the surgery.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

PURPOSES: To investigate the legibility of a standardized logarithmic print size of traditional Chinese (TC) characters and compare it with Early Treatment Diabetic Retinopathy Study (ETDRS) near chart. MATERIALS AND METHODS: A total of 1243 commonly used TC characters were chosen and divided into three groups according to its stroke complexity: Group A with 2–9 strokes, Group B with 10–17 strokes, and Group C with 18–25 strokes. For each group of characters, near charts were created using randomly chosen characters arranged in decreasing logarithmic size. In a well-illuminated room, healthy controls were fully corrected to test both ETDRS near chart and our set of TC near charts. The smallest legible font sizes (SLFS) in TC near charts were recorded and analyzed. RESULTS: Forty-two healthy eyes (21 participants) (age 29 ± 8.9 years old) were included. The mean near best-corrected visual acuity (nBCVA) in ETDRS chart was 0.06 ± 0.05 logMAR. We found that the mean SLFS in TC charts (0.33 ± 0.09 logMAR) was significantly larger than the nBCVA in ETDRS chart (P < 0.001). The SLFS of Group B and the SLFS of Group C was significantly larger than that of Group A (P < 0.001). CONCLUSION: According to our results, to recognize TC characters, normal-sight readers need a 0.22–0.30 logMAR (1.7–2.0 fold) enlargement of the acuity size measured by ETDRS near chart. The low-stroke TC charts may provide a new method to assess the postsurgical outcomes for comparable functional visual acuity in reading TC characters.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Human tears contain more than 1500 proteins that could be diagnostically relevant. To date, numerous candidates on a biomarker of protein origin were identified for ocular and systemic diseases. However, the suitable sampling method is still the subject of discussion. To address the need for a description of sampling methods properties for possible clinical analyses, we studied a total protein concentration and electrophoretic pattern of tear fluid collected by capillary tubes, Schirmer strips, cellulose microsponges, and flushing. The total protein concentration was 4.339 μg/μL ± 1.905 μg/μL, 0.967 μg/μL ± 0.117 μg/μL, 0.022 μg/μL ± 0.016 μg/μL, and 0.008 μg/μL ± 0.006 μg/μ for the capillary tubes, Schirmer strips, flushing, and cellulose microsponges, respectively. Sodium dodecyl sulfate polyacrylamide electrophoresis showed the different patterns of tear proteins obtained by the above-mentioned sampling methods. These differences could originate from the use of a bigger amount of extraction reagent that was not used in the case of capillary tubes, and retention of the proteins by strips and sponges. Taken together, capillary tubes, Schirmer strips, cellulose microsponges, and flushing represent sensitive and convenient sampling methods for tear fluid collection. For the isolation of proteins from strips and sponges, and for the flushing, less than 100 μL of a reagent should be used to ensure the sufficient concentration of the biomarkers in a trace amount.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

We report an atypical case of diffuse large B-cell lymphoma (DLBCL) of bilateral lacrimal glands and paranasal sinus following mucosa-associated lymphoid tissue (MALT) lymphoma of the lung. Bilateral DLBCL is rare in the literature, and only few cases of DLBCL in bilateral lacrimal gland are reported. A 71-year-old male presented with bilateral, slowly enlarging, and swelling of both eyelids. Computed tomography scan images showed bilateral symmetric, hyperdense, circumferential masses over lacrimal glands occupying most of the orbital compartment. Neither optic nerve involvement nor adjacent orbital walls erosion was noted. Bilateral excisional biopsy and pathological examination confirmed the diagnosis of DLBCL. Since DLBCL of bilateral lacrimal gland can occur in case of systemic MALT lymphoma, excision and pathological examination is mandatory, and further metastatic workup is essential.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

To report a sequential observational study of changes in the retinal and choroidal blood flow during medical and surgical treatments for a thyroid eye disease (TED) patient, using optical coherence tomography angiography (OCTA) and laser speckle flowgraphy (LSFG). A 28-year-old man with a history of Graves' disease diagnosed 8 months prior was presented in the active phase of TED. His clinical activity score (CAS) was 6, but without diplopia or visual loss. Intraocular pressure measurement was OD 20 mmHg and OS 24 mmHg. Thyrotropin receptor antibody (TRAb) and thyroid-stimulating antibody levels were 18.8 IU/L and 4347%. Magnetic resonance imaging revealed enlargement of both extraocular muscles and fat compartments in both orbits. The patient underwent IV pulsed steroid therapy (1 g/day, 3 days) followed by an oral prednisone for 1 month. His CAS score decreased to 4. Bilateral orbital fat decompression decreased his final CAS score to 1 in both eyes. Intraocular blood flow was measured using laser speckle flowgraphy (LSFG), and OCTA was performed. Retinal blood flow increased slightly, but choroidal blood flow showed a robust increase. Choroidal blood flow measured using both LSFG and OCTA was negatively correlated with the CAS score and TRAb. In our case report, the ocular perfusion, especially choroidal blood flow, may decrease in active TED, which may be reversed by medical and surgical treatment.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Purpose: Tocilizumab (TCZ) through intravenous infusion has been shown to effectively treat active thyroid eye disease (TED) refractory to systemic steroids. TCZ is also available as a self-administered subcutaneous injection, but data demonstrating the efficacy of this formulation are limited. This study investigated the efficacy and safety of subcutaneous TCZ (SC-TCZ) for the treatment of active, moderate-to-severe TED in smokers. Materials and Methods: This retrospective clinical case series evaluated the clinical outcomes and adverse effects of SC-TCZ when taken for a minimum of 4 months by patients with moderate-to-severe TED and a current or recent history of cigarette smoking. Results: Three patients received SC-TCZ every 1-2 weeks (4.6-11.2 mg/kg/month). The average pre-to-posttreatment clinical activity score reduction was 5.4, and proptosis was reduced by an average of 2.0 mm. No serious adverse effects were reported. Conclusion: SC-TCZ may be a useful and effective therapy for treating challenging cases of inflammatory TED and offers a safe alternative to office or hospital-based infusions. Further studies are needed to better understand optimal dosing regimens and relative efficacy compared to monthly TCZ infusions and other immunotherapies.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

PURPOSE: The purpose was to study the effects of removal of the lateral orbital rim in patients with prior three-wall decompression for thyroid eye disease (TED). MATERIALS AND METHODS: This was a single-institution retrospective case series of patients presenting with symptoms and signs of residual symptomatic proptosis that had previously undergone three-wall decompression for TED. Data collected included patient age, gender, presenting symptoms, ocular history, proptosis reduction, and complications. RESULTS: Eleven orbits were identified. The mean preoperative exophthalmometry for the operative eye was 24.0 mm with 2.7 mm of relative proptosis. Removal of the lateral orbital rim resulted in a mean reduction in proptosis of 2.5 mm (range: 0.5–5.0 mm, P < 0.001). There was no significant change in diplopia, lagophthalmos, margin reflex distance (MRD) 1, MRD2, or exposure keratopathy. No canthal deformities were noted. All subjects reported satisfaction with functional and cosmetic outcomes of lateral orbital rim removal, and none reported problems with external contour irregularities of the lateral canthal region. CONCLUSION: Removal of the lateral orbital rim as part of a maximal orbital bony decompression adds to the decompressive effect of proptosis reduction with minimal side effects.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

Purpose: Stereotactic navigation is being increasingly used for orbital decompression (OD). Recent studies have cited clinical benefits of navigation including greater proptosis reduction but have differed regarding effects on operative time. This study aimed to evaluate navigated vs. non-navigated OD with respect to operative time and proptosis reduction. Materials and Methods: Retrospective nonrandomized comparative trial of navigated vs. nonnavigated OD. Operative time and proptosis reduction were recorded and analyzed for all patients. Results: A total of 30 orbital decompressions were included; 14 were performed with stereotactic navigation (SN), and 16 were performed without SN. On average, the SN group took 19 minutes longer for 3-wall decompressions (p = 0.185), 25 minutes shorter for balanced decompressions (p = 0.025), and 18 minutes longer (p = 0.067) for lateral wall decompressions. Mean proptosis reduction (PR) in 3-wall decompressions was greater in the SN group (p = 0.02). Among balanced wall decompressions, mean PR was 4.25 mm and 3.67 mm for the SN and non-SN groups (p = 0.30), respectively. For lateral wall decompressions, mean PR was 2.63 mm with SN and 2.50 mm without SN (p = 0.45). Conclusions: This study showed no difference in operative times between navigated and non-navigated OD, although empirical experience showed variable times required for registration and intraoperative troubleshooting of the navigation system. This study also found that navigation increased proptosis reduction for all types of OD. Further randomized controlled trials are needed to better understand the impact of navigation technology on operative times and surgical outcomes.

[ABSTRACT]  [FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]

[FULL TEXT]  [PDF]  [Mobile Full text]  [EPub]