December 15, 2021

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In this week's issue

  • The mortality rate after rhino-orbito cerebral mucormycosis is high, especially in patients with severe COVID-19
  • Difluprednate monotherapy may be an effective treatment for non-infectious anterior scleritis
  • Microvascular changes measured by OCTA showed decreased vessel density in the deep capillary plexus of eyes with high myopia

Mortality in COVID-19-Associated Mucormycosis

JAMA Ophthalmology

COVID-19 and the rise of Rhizopus. Rhino-orbital-cerebral mucormycosis (ROCM) has been considered an exceedingly rare disease with high morbidity and mortality. However, recent studies have shown a markedly increased incidence in ROCM in patients with SARS-CoV-2 infection. While risk factors for ROCM such as diabetes and immunosuppression have been well characterized, relatively little is known about mortality and its predictors. In a retrospective case-control study of 73 patients diagnosed with COVID-19-associated ROCM, cumulative probability of death was 26% (95% CI 16-41%) at day 7 and 53% (95% CI 39-69%) at day 21. In a multivariate Cox proportional-hazards model, prior need for mechanical ventilation was a risk factor for death (hazard ratio [HR] 8.98, 95% CI 2.13-38.65). Protective factors included light perception or better visual acuity (HR 0.56, 95% CI 0.32-0.98) and intravenous amphotericin B (HR 0.31, 95% CI 0.06-1.43), although the latter effect was not statistically significant. These findings suggest a high mortality rate associated with mucormycosis infection following SARS-CoV-2 infection.

Difluprednate for the Treatment of Anterior Scleritis

American Journal of Ophthalmology

“Help my eye is inflamed!” Stand back, Difluprednate to the rescue! Anterior scleritis is a serious inflammatory condition which has been associated with a variety of autoimmune conditions, such as granulomatosis with polyangiitis or rheumatoid arthritis.  Currently, treatment for scleritis has been restricted to NSAIDs, corticosteroids, or immunosuppressives.  Liberman et. al has proposed an alternative corticosteroid, Difluprednate to be used specifically for the treatment of anterior scleritis. Utilizing a retrospective interventional case series design, the investigators set to pinpoint the side effect profile and efficacy of Difluprednate in the treatment of anterior scleritis. 25 patients (35 eyes) who utilized difluprednate as a single treatment agent were compiled and assessed for clinical resolution, increased best corrected visual acuity (BCVA), change in lens status, and decreased IOP. 86% of eyes were able to achieve resolution of scleritis with a median resolution time of 6 weeks. Initial dose of >4 times daily was associated with disease resolution (hazard ratio [HR] = 3.43, 95% [CI] 1.19, 9.88). Difluprenate monotherapy should be considered as an effective means to treat non-infectious anterior scleritis, however, this drug needs further study in a larger cohort of scleritis subgroups.

Longitudinal changes in macular and choroidal microvasculature in high myopia


Can you list some macular vascular pathologies associated with high myopia? Irreversible vision loss or even blindness can be complications of high myopia due to chorioretinal atrophy, choroidal neovascularization, and lacquer crack formation. Changes that occur to retinal and choroidal microvasculature therefore should be investigated over time to evaluate changes to these blood vessels. In a prospective, longitudinal study over a mean 14-month follow-up period, 71 eyes (32 with high myopia and 39 healthy controls) were examined using optical coherence tomography angiography (OCTA). Primary measurements included capillary density (CD) of the superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris (CC). Eyes with high myopia exhibited a faster rate of overall CD loss (-1.44% vs. -0.11% per year) and CD loss in the outer ring of the DCP (-1.67% vs. -0.14% per year) compared to healthy eyes. This faster rate of CD loss was correlated with longer axial length at baseline. The absence of larger blood vessels and optic nerve fibers in the DCP may make this localized region less resistant to excessive axial elongation, contributing to the faster rate in CD reduction compared to other regions such as the SCP or CC. Despite these regional variations, the findings highlight the importance of monitoring development of microvascular changes in high myopia as these may serve as key factors underlying complications related to this disease. Future longitudinal studies are needed to shed light on the natural history of these microvascular complications. 

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Nicotinamide and Pyruvate for Neuroprotection in Open Angle Glaucoma

JAMA Ophthalmology

We have AREDS2 for AMD but what about some vitamins for POAG? Mitochondrial abnormalities are thought to be early contributors to the development of POAG neurodegeneration. Investigators sought to determine if nicotinamide adenine dinucleotide (NAD) and pyruvate, key molecules in energy and redox metabolism, can provide neuroprotection in patients with POAG.  In a three-week double-blind, placebo-controlled trial, POAG patients were given daily oral NAD and pyruvate or placebo followed by four visual field tests. Measurements included visual field test locations improving beyond normal variability in the study eye and the rates of change of visual field global indices (mean deviation [MD], pattern standard deviation [PSD], and visual field index [VFI]). Number of improving test locations were significantly higher in the treatment group (median [IQR], 15 [6-25] vs 7 [6-11]). Rates of change of PSD improved in the treatment groups (median, −0.06 vs 0.02 dB per week; 95% CI, 0.02 to 0.24), however there were no significant changes in MD (0.04 vs −0.002 dB per week; 95% CI, −0.27 to 0.09) or VFI (0.09 vs −0.02% per week; 95% CI, −0.53 to 0.36) with treatment. NAD and pyruvate showed some evidence of short-term improvement in visual function, but long-term studies are needed to evaluate the usefulness of these agents in POAG progression.

Global Health

Challenges to Providing Primary Eye Care in Nigeria

BMC Health Serv Res.

The World Health Organization’s Africa regional office has developed a primary eye care (PEC) package which includes materials on eye health promotion and intervention targeting sub-Saharan Africa. Capacity gaps in the primary health care delivery system would undermine the ability to deliver effective PEC, so this study examined the human resource and governance challenges for implementation of PEC in Anambra State, Nigeria. Investigators performed facility surveys, targeted interviews, and desk review of pertinent health policy documents. Data were analyzed using the World Health Organization’s health system framework. A minimum of quarterly supervision was conducted in 54% of facilities, and 56% of facilities didn't follow the standard clinical management guidelines. Roughly 82% of health facilities were operating with less than 20% of the number of healthcare workers recommended. About half of the workers in health facilities were volunteers or ad hoc workers to relieve staff shortages. To ensure the success of PEC in Nigeria, policy, governance, and health workforce gaps need to be addressed with PEC-specific policy.

Question of the Week

A 28-year-old male presents to the urgent care clinic with unilateral red eye, severe pain, sensitivity to light, blurry vision, and ocular discharge. The patient wears soft contact lenses and does not always remove them before he showers or sleeps, especially in the last month. There is no history of ocular trauma, ocular surgery, corneal disease, or recent antibiotic use. Photograph from slit lamp examination is shown below.
Photograph from slit lamp examination is shown below. What is the most likely diagnosis?
a.     Fungal keratitis
b.     Bacterial keratitis
c.     HSV keratitis

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Quiz Answer: B
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