Conflict with Yourself

A poem about how your thoughts can influence internal conflict with yourself

Chapter Twelve - Microbiome manipulation as a target for eye diseases: lessons from humans

The gut microbiome has been found to influence diseases of the gastrointestinal tract as well as diseases in remote sites such as the brain, lung, and eye. As such, gut microbiome manipulation has been explored as a treatment for several diseases including, Clostridium difficile infection, inflammatory bowel disease (IBD), and rheumatic diseases. Microbiome manipulation techniques include dietary changes, pre and probiotics, and fecal microbiota transplantation (FMT). Some dietary changes in IBD, including gluten-free and vegetarian diets, were shown to change the gut microbiome (e.g., genera Bacteroides, Faecalibacterium, Blautia) but had a limited effect on clinical outcomes (e.g., surgical complication, fistula formation, hospitalization). While other diets, such as low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet and high adherence to a Mediterranean diet, were shown to improve IBD and rheumatoid arthritis disease activity (e.g., stool frequency, joint tenderness), as well as change the gut microbiome (e.g., F. pransnitzii spp, Blautia). Pre and probiotic therapies have had more promising results, especially in IBD, with significant improvements in disease activity, intestinal permeability, and endoscopic findings following the intervention. Lastly, while FMT has been most frequently studied as a treatment for C. difficile infection, it has also been applied to immune diseases (e.g., ulcerative colitis, graft vs. host disease (GVHD), immune-mediated dry eye), with the goal of transplanting beneficial bacteria (e.g., Blautia, Faecalibacterium, and Bacteroides) from a healthy donor. Finally, probiotics have also been delivered to locations outside the gut, with Lactobacillus eye drops investigated for vernal keratoconjunctivitis. This chapter discusses how microbiome manipulations (gut and eye) have been used to modulate clinical outcomes of diseases that have relevance to the eye (e.g., autoimmune diseases) and discusses how these strategies may be applied in the future to the treatment of eye diseases in which microbiome abnormalities have been implicated (e.g., uveitis, dry eye, diabetic retinopathy)

Idiopathic Vitreomacular Traction Managed with Initial Observation: Clinical Course and Outcomes

To review the clinical course and outcomes of patients with idiopathic vitreomacular traction (VMT) managed initially by observation. Retrospective chart review including patients with idiopathic VMT based on clinical symptoms and findings on OCT between January 1, 2015, and February 15, 2021. The study included 436 eyes of 317 patients with a mean age of 72.2 years ± 8.9 at initial visit and mean follow-up time of 34 months ± 19.2. Vitreomacular traction severity grade was ascribed to each patient using previously published grading criteria. Grade 1 denoted incomplete cortical vitreous separation with attachment at the fovea and visible distortion of the foveal surface. Grade 2 included intraretinal cysts or clefts along with grade 1 findings. Grade 3 included subfoveal fluid along with grade 2 traits. The rate of spontaneous release, grade at baseline compared with grade at final follow-up, and outcomes of interventions, if performed. At baseline, mean best corrected visual acuity (BCVA) was 20/40. Baseline OCT demonstrated grade 1 VMT in 212 eyes (48.6%), grade 2 VMT in 172 eyes (39.4%), and grade 3 VMT in 52 eyes (11.9%). Among eyes that were initially grade 1, 25.0% had spontaneous release of VMT (median, 290.0 days; mean, 404.5 days ± 323.9), 50.9% remained stable, and 10.4% worsened. Among eyes that were initially grade 2, 14.5% had spontaneous release of VMT (median, 570.0 days; mean, 692.9 days ± 477.5), 55.2% remained stable, 4.7% improved, and 2.3% worsened. Among eyes that were initially grade 3, 5.8% had spontaneous release of VMT (median, 790.0 days; mean, 839.3 days ± 246.7), 28.8% remained stable, and 5.8% improved. Of the 436 eyes, macular hole development occurred in 42 eyes (9.6%). Pars plana vitrectomy was performed in 94 of 436 eyes (21.6%) with mean BCVA before pars plana vitrectomy of 20/78 and final follow-up BCVA of 20/55. This study demonstrates the generally stable clinical course of VMT when managed initially by observation. Stable VMT grade was the most frequent outcome, and eyes with grade 1 VMT were more likely to undergo spontaneous release than eyes with grade 2 or 3

Trends in Sports-Related Ocular Trauma in United States Emergency Departments from 2010 to 2019: Multi-Center Cross-Sectional Study

Traumatic eye injury is one of the leading causes of visual impairment in the United States, but there is limited information available in the literature about ocular trauma related to sports. To evaluate the primary ocular diagnosis, type of sport, seasonal prevalence, and injury severity following ocular sports-related trauma. Cross-sectional study United States (US) hospital emergency departments (ED). Patients with sports-related ocular injuries in the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP) database from January 1, 2010 to December 31, 2019. To identify and compare the type of sport, primary diagnosis of ocular injury, and injury severity. For 4,671 sports-related ocular injuries identified, the mean age of injury was 19.4±15.2 years (median: 15.0 years, 79% male). The largest proportion of injuries occurred in the 12-17 years of age cohort (38.6%), occurring during summer months (P< .001). The most common sports associated with eye injury were basketball (37.8%), baseball (13.8%),, and football (12.3%). There were 3,214 injuries (68.8%) deemed 'minor' anterior segment injuries, 359 injuries (7.7%) deemed 'major' anterior segment injuries, 31 injuries (0.7%) deemed 'minor' posterior segment injuries, 77 injuries (1.7%) deemed 'major' posterior segment injuries, and 990 injuries (21.2%) of unknown severity. Basketball-related ocular trauma had a greater frequency of corneal/scleral abrasions than baseball (P < .001), soccer (P < .001), tennis (P = .03), softball (P = .001), and paintball (P = .02). Baseball-related ocular trauma had a greater frequency of contusions than basketball (P < .001), football (P < .001), soccer (P < .001), volleyball (P< .001). Paintball and soccer were more associated with 'major' anterior and posterior ocular injuries than basketball (P < .001, for both). Sports-related trauma remains a highly prevalent cause of eye-related visits to the emergency room, particularly in young male adolescents in the spring and summertime. While most diagnoses were deemed 'minor' injuries with basketball associated with corneal/scleral abrasions and baseball with contusions, paintball, and soccer were more significantly associated with 'major' anterior and posterior ocular injuries

Mechanical Property Comparison of 23-, 25-, and 27-Gauge Vitrectors across Vitrectomy Systems

To investigate the mechanical properties of 23-, 25-, and 27-gauge vitrectomy vitrectors across 3 different vitrectomy systems to inform surgical techniques.An experimental study that did not involve any human subjects.Nine vitrectors (3 each of 23-, 25-, and 27 gauge) from Alcon, Dutch Ophthalmic Research Center (DORC), and Bausch and Lomb (B/L) were measured. Measurements were performed using electroforce displacement at the tip and 15 mm from the tip. Five measurements were performed at each location, and fully elastic deformation was ensured.The main parameter being measured was the force in grams (gf) necessary to deflect the vitrectors vertically downward by 1 mm, either at the tip of the vitrector or 15 mm from the tip.A total of 90 measurements were performed. Across brands, B/L demonstrated the least stiffness at both the tip and at the 15-mm point for 23-gauge (8.0[0.3]gf, 67.3[1.0]gf), 25-gauge (6.8[0.3]gf, 60.5[0.4]gf), and 27-gauge (3.3[0.1]gf, 33.9 [0.5]gf) vitrectors. Although there was only a small decrease in the stiffness in the 25-gauge vitrector compared with the 23-gauge vitrector at the 15-mm point, this difference was statistically significant for Alcon (P < 0.001), DORC (P < 0.001), and B/L (P < 0.001).Based on this study, 25-gauge vitrectors, although larger than the 27-gauge vitrectors and less stiff than the 23-gauge vitrectors, may offer favorable compromise between stiffness and gauge size. However, surgeon experience, preference, and the type of surgery being performed should be paramount when making the final vitrector selection. Knowledge of these mechanical properties may aid surgeons in choosing between gauge size and vitrectomy system to optimize their comfort and efficiency

Intraocular Inflammation Incidence Following Intravitreal Brolucizumab Injection for Exudative Age-Related Macular Degeneration

PURPOSEWe evaluated the clinical outcomes of Intraocular inflammation (IOI) of eyes with neovascular age-related macular degeneration (AMD) injected with brolucizumab in our tertiary referral center. METHODSA retrospective case series for which clinical records of all eyes that received intravitreal brolucizumab at Bascom Palmer Eye Institute between December 1, 2019, and April 1, 2021 were reviewed. RESULTSThere were 345 eyes of 278 patients who received 801 brolucizumab injections. IOI was detected in 16 eyes of 13 patients (4.6%). In those patients, baseline logMAR best-corrected visual acuity (BCVA) was 0.32 0.2 (20/42), while it was 0.580.3 (20/76) at IOI presentation. The mean number of injections among eyes experiencing IOI was 2.4, and the interval between the last brolucizumab injection and IOI presentation was 20 days. There were no known case of retinal vasculitis. Management of IOI included topical steroids in 7 eyes (54%), topical and systemic steroids in 5 eyes (38%), and observation in one eye (8%). BCVA returned to baseline and inflammation resolved in all eyes by last follow-up examination. CONCLUSIONSIntraocular inflammation following brolucizumab injection for neovascular AMD was not uncommon. Inflammation resolved in all eyes by last follow-up visit

Unexplained Vision Loss Associated With Intraocular Silicone Oil Tamponade in Rhegmatogenous Retinal Detachment Repair

Purpose: To evaluate the visual outcomes with unexplained vision loss during or after silicone oil (SO) tamponade. Methods: This multicenter retrospective case series comprised patients with unexplained vision loss associated with SO tamponade or its removal. Eyes with other clear secondary identifiable causes of vision loss were excluded. Results: Twenty-nine eyes of 28 patients (64% male) were identified. The mean age was 50 ± 13 years (range, 13-78 years). The mean duration of SO tamponade was 148 ± 38 days. Eighteen eyes (62%) developed unexplained vision loss while under SO; 11 (38%) had vision loss after SO removal. The most common optical coherence tomography (OCT) finding was ganglion cell layer (GCL) thinning (55%). Eyes with vision loss after SO removal had a mean logMAR best-corrected visual acuity (BCVA) of 0.6 ± 0.7 (Snellen 20/85) before SO tamponade and 1.2 ± 0.4 (20/340) before SO removal. By the last follow-up after SO removal, the BCVA had improved to 1.1 ± 0.4 (20/235). In eyes with vision loss after SO removal, the BCVA before SO removal was 0.7 ± 0.7 (20/104), which deteriorated to 1.4 ± 0.4 (20/458) 1 month after SO removal. By the last follow-up, the BCVA had improved to 1.0 ± 0.5 (20/219). Conclusions: Unexplained vision loss can occur during SO tamponade or after SO removal. Vision loss was associated with 1000-centistoke and 5000-centistoke oil and occurred in macula-off and macula-on retinal detachments. The duration of tamponade was 3 months or longer in the majority of eyes. Most eyes had GCL thinning on OCT. Gradual visual recovery can occur yet is often incomplete