Optometric Physician



Vol. 23, #35  •   Monday, September 12, 2022


Off the Cuff: Consequential COVID Complications

Some of you may or may not know, I have been curating the journal abstracts section for Optometric Physician since 2004. During the pandemic, most of the articles I found were dealing with ocular signs and symptoms that were indicative of an undiagnosed COVID infection. Lately though, the articles have shifted to ocular complications of those who had confirmed COVID.

In my own practice in my small corner of the world, long stable glaucoma patients who contracted severe COVID have had progressive optic nerve loss and worsened visual field defects. My best hypothesis is infection-related ischemia allowing these otherwise stable patients to progress. I've seen strange optic nerve edemas that further testing shows no underlying systemic cause and a coin-shaped viral endotheliitis in an otherwise young, healthy post-LASIK patient.

Were the COVID infections these patients had to blame? Possibly. A quick PubMed search of ocular COVID shows top hits of foggy corneal epithelial disease found during COVID,1 bilateral optic neuritis and facial palsy following COVID infection,2 orbital myositis and scleritis after COVID vaccination,3 uveitis association with COVID vaccination,4 and the list goes on. COVID seems to be here to stay. I’ve added COVID infection and its severity to my medical health history intake to help make the possible associations. At the very least, it’s definitely something else to keep in mind when a patient presents with something out of the ordinary.

1. Li F, Yang R, Yang L, et al. J Clin Med. 2022 Aug 30;11(17):5092 2. Behera G, Gera P, Stephen M, et al. Cureus. 2022 Sep 3;14(9):e28735. 3. Savino G, Gambini G, Scorcia G, et al. Eur J Ophthalmol. 2022 Sep 4:11206721221123780. Online ahead of print. 4. Waseem S, Ahmed SH, Fatima S, et al. Ann Med Surg (Lond). 2022 Sep;81:104472.

Note about Epstein:
two steps forward and one step back. Arthur was released from the hospital last Tuesday but collapsed a few steps towards our front door. One ambulance ride later, he was back in the hospital two hours after being released. We've had way more complications than either of us could have predicted. On Saturday, he was released again and is recuperating at home with the help of our friends, staff, and my family. Thoughts and prayers are always welcome, and I thank you for the notes of encouragement and support.


Shannon L. Steinhäuser, OD, MS, FAAO
Co-Chief Medical Editor

Want to share your perspective?
Write to Dr. Epstein at artepstein@optometricphysician.com. The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.




Case Report: Optic Nerve Atrophy Secondary to Sjögren´s Syndrome

Optic neuropathy associated with Sjögren's syndrome is rare and usually has an acute onset. These researchers report a case of asymmetric optic nerve atrophy attributed to Sjögren's syndrome.

A 37-year-old woman was referred to the neuro-ophthalmology service due to right optic nerve atrophy of unknown etiology. The patient was asymptomatic. Best-corrected visual acuity was 20/200 Snellen equivalent in the right eye and 20/20 Snellen equivalent in the left eye. The right eye had a relative afferent pupillary defect. The visual field demonstrated dense temporal loss, superior arcuate involvement and an inferior paracentral defect in the right eye. Slit-lamp examination showed mild fluorescein staining of the cornea, moderate lissamine green staining of the conjunctiva and abnormal tear break-up time in both eyes. Fundus examination revealed diffuse pallor of the right optic disc and a normal left optic disc. Optical coherence tomography showed inferior and superior retinal nerve fiber layer (RNFL) atrophy in the right eye and inferior RNFL atrophy in the left eye. A diagnosis of right optic nerve atrophy was made. Immunologic studies were significant for positive anti-Ro and anti-La antibodies. Magnetic resonance imaging of the brain and orbit ruled out any intracranial or white matter pathology. A diagnosis of optic nerve atrophy secondary to Sjögren´s syndrome was suspected, so corticosteroid treatment was started.

Researchers wrote that optic nerve atrophy may be the initial manifestation of Sjögren's syndrome; thus, optic neuropathy associated with Sjögren's syndrome remains a diagnostic challenge. They suggested that, in such cases, specific antibodies such as anti-Ro and anti-La facilitate early diagnosis and can prevent vision-threatening complications.

SOURCE: Remolí-Sargues L, García-Villanueva C, Monferrer-Adsuara C, et al. Case report: optic nerve atrophy secondary to Sjögren´s syndrome. Optom Vis Sci. 2022; Sep 6. [Epub ahead of print].






Anterior Segment Characteristics in Normal and Keratoconus Eyes Evaluated With a New Type of Swept-Source Optical Coherence Tomography

This study aimed to evaluate and compare the discriminating ability of corneal elevation maps generated using a swept-source optical coherence tomography (Anterion, Heidelberg Engineering). The maps were estimated with different reference surfaces, to distinguish normal corneas from those with keratoconus and keratoconus suspect. A total of 126 eyes of patients, which comprised 43, 37, and 46 keratoconus, keratoconus suspects, and normal controls, respectively, were included in this study. The anterior and posterior elevations at the thinnest point under the best-fit sphere (BFS) and toric-ellipsoid (BFT), respectively, and other corneal parameters were measured using the SS-OCT. In addition, the receiver operating characteristic (ROC) curve analysis and cut-off value were calculated to evaluate the diagnostic ability of the corneal elevation values in differentiating keratoconus and keratoconus suspects from normal eyes.

The mean total keratometric and corneal elevation values were significantly higher in the keratoconus group than in the other groups. Pachymetric parameters exhibited the lowest values for keratoconus. In addition, ROC curve analyses showed a high accuracy of the thinnest point anterior and posterior BFT for both keratoconus and keratoconus suspects and normal controls (area under the ROC were 0.969 and 0.961, respectively). Furthermore, the optimal cut-off point of the posterior elevation at the thinnest point under BFT was 16.44 μm (sensitivity and specificity of 86% and 98%, respectively) for differentiating keratoconus from normal and keratoconus suspect eyes.

Investigators wrote that the elevation map using the BFS and BFT references measured with the anterior segment SS-OCT appeared to be an effective indicator for keratoconus diagnosis. Therefore, they concluded, anterior segment SS-OCT effectively differentiated keratoconus from suspected keratoconus and normal corneas by measuring parameters such as posterior and anterior elevations, pachymetry, and keratometry.

SOURCE: Kim KY, Lee S, Jeon YJ, Min JS. Anterior segment characteristics in normal and keratoconus eyes evaluated with a new type of swept-source optical coherence tomography. PLoS One. 2022; Sep 1;17(9):e0274071.




Factors Associated With Follow-Up Visits in Parents With Myopic Children Wearing Orthokeratology Lens

Orthokeratology (Ortho-k) is an effective method for slowing the progression of myopia and correcting refractive error in school children. Although parents of children ages < 10 years play a major role in Ortho-k lens care, they have a generally low level of compliance in performing regular follow-up visits. This study was developed to analyze the associations between follow-up visits by parents of Ortho-k lens wearers ages < 10 years and, respectively, the Ortho-k-related knowledge of these parents and information resources promoting Ortho-k use. A cross-sectional study design was used. Parents of children who wear Ortho-k lenses were recruited through a private Facebook group with 3,500 members in 2020 that was created in 2018 for information sharing and exchange among parents of these children. The following data were collected: demographics of the parents and their children, four-item Ortho-k-related knowledge, information resources that prompted the decision to use Ortho-k, and the regularity of follow-up visits. These data were presented in terms of means, standard deviations, and percentages. Logistic regression was performed to compute the odds ratios (ORs) and 95% confidence intervals (CIs).

The study showed that 83.11% had regular follow-up visits. The correct response rate on Ortho-k-related knowledge was > 80%. However, 15.51% of the participants did not recognize axial length as an indicator for monitoring myopia progress, and 10.76% did not know that at least six hours of nighttime sleep is required for myopia control with Ortho-k. The most common information resource leading to Ortho-k use was self-acquisition from Internet sources. The spherical equivalent refraction of < -2.0D was 2.58 times higher in participants with regular follow-up visits than in their peers with irregular follow-up visits (OR=2.58, 95% CI [0.22, 5.63]). In addition, acknowledgment of "There is no need to change the Ortho-k lenses regularly as long as there is no discomfort" was 7.19 times higher in participants with regular follow-up visits than in their peers with irregular follow-up visits (OR=7.19, 95% CI [1.26, 13.93]). However, participants with regular follow-up visits did not receive Internet ophthalmology advertisements but used Ortho-k at a 2.62 times higher rate than their peers with irregular follow-up visits (OR=2.62, 95% CI [0.04, 4.29]).

The results support that both information sources and knowledge of Ortho-k use influence the frequency of follow-up visits among parents of Ortho-k lens wearers ages < 10 years. Related support from health professionals in terms of providing appropriate information and guidance is recommended to promote higher rates of regular follow-up visit attendance.

SOURCE: Hung LL, Liao LL, Chen HJ, et al. Factors associated with follow-up visits in parents with myopic children wearing orthokeratology lens. J Nurs Res. 2022; Sep 6. [Epub ahead of print].







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