Topical Antiseptics in Minimizing Ocular Surface Bacterial Load Before Ophthalmic Surgery: A Randomized Controlled Trial

PURPOSE

To investigate the reduction of the ocular surface bacterial load induced by 2 commercially available ophthalmic antiseptic formulations, povidone-iodine (PVI) 0.6% and chlorhexidine (CLX) 0.02%, before ocular surgery.

DESIGN

Randomized controlled trial.

METHODS

Seventy adult patients undergoing intraocular surgery (phacoemulsification) were randomized to receive in the index eye PVI (group A) 4 times a day for 3 days or CLX (group B) 4 times a day for 3 days before surgery. The untreated eye was used as control. A conjunctival swab was taken in both eyes before (T0) and after (T1) therapy. Microbial DNA was quantified with real-time polymerase chain reaction (PCR) analysis. The Mick algorithm was used to compare the abundance of each genus/genera against the distribution of abundances from the reference. At T1, patients filled a questionnaire to evaluate therapy-induced symptoms. Primary outcome was the reduction of bacterial DNA at T1 (microbial load), vs control arm, expressed as mean number of real-time PCR cycle times (CTs). Secondary outcomes were taxonomic composition, differential abundance, and therapy-induced ocular symptoms.

RESULTS

The T0-T1 difference in CT was significant in group B, but not in group A (mean [95% CI], 0.99 [0.33] vs 0.26 [0.15], P < .001, and 0.65 [0.3] vs 0.45 [0.41], P = .09, respectively). The taxonomic composition, alpha, and beta diversity remained consistent at all time points in both groups. The rate of patients reporting therapy-induced ocular symptoms and the mean discomfort grade were greater in group A than in group B (97% vs 26% and 4.97±2.48 vs 0.66±1.53, respectively).

CONCLUSIONS

Compared with PVI 0.6%, CLX 0.02% induced a greater reduction of ocular surface bacterial load, with no significant alterations of the taxonomic composition. Moreover, CLX was better tolerated than PVI.

Subretinal hyperreflective material in retinal and chorioretinal disorders: A comprehensive review

Subretinal hyperreflective material (SHRM) is a common and remarkable optical coherence tomography (OCT) biomarker whose importance is emerging in several retinal and chorioretinal diseases, including age-related macular degeneration, central serous chorioretinopathy, polypoidal choroidal vasculopathy, pathologic myopia, posterior uveitis, vitelliform lesions and macular dystrophies, and rarer disorders. Multimodal imaging, also thanks to the introduction of OCT angiography, allowed a deeper characterisation of SHRM components and its morphological changes after treatment, suggesting its usefulness in clinical practice. We discuss and summarize the nature, multimodal imaging characteristics, and prognostic and predictive significance of SHRM in the different retinal and choroidal disorders in which it has been described.

A minimum specification dataset for liquid ocular endotamponades: recommendations by a European expert panel

PURPOSE

To propose a minimum specification dataset to characterize liquid ocular endotamponades (OEs), namely silicone oil (SO), heavy SO (HSO), perfluorodecalin (PFD), and perfluoro-octane (PFO), in terms of physicochemical properties, purity and available evidence of safety, in line with ISO16672:2020.

METHODS

An evidence-based consensus using the expert panel technique was conducted. Two facilitators led a committee of 11 European experts. Facilitators prepared a dataset for each compound including the list of specifications relevant for the safety, identified by the group members on the basis of expertise and a comprehensive literature review. Each item was ranked by each member using a 9-point scale from 1 "absolutely to not include" to 9 "absolutely to include" in two rounds followed by discussion. Only items reaching consensus (score ≥ 7 from ≥ 75% of members) were included in the final datasets.

RESULTS

For all OEs, consensus was reached to include manufacturer, density, refractive index, chemical composition, dynamic viscosity, interfacial and surface tension, endotoxins, in vitro cytotoxicity assessment, and any evidence from ex vivo and/or in vivo tests for safety assessment. Additional specifications were added for SO (molecular weight distribution, content of oligosiloxanes with MW ≤ 1000 g/mol, spectral transmittance) and PFD/PFO (% of pure PFD/PFO in the final product, vapor pressure, chemical analyses performed for safety assessment).

CONCLUSION

The proposed evidence-based minimum specification datasets for SO, HSO, PFD, and PFO have the potential to provide surgeons and health service purchasers with an easily available overview of the most relevant information for the safety assessment of OEs.

TANGENTIAL RETINAL DISPLACEMENT INCREASES AFTER MACULAR PUCKER SURGERY: An Apparent Nonsense

PURPOSE

To measure the tangential retinal displacement and vision before and after macular pucker surgery and study if pars plana vitrectomy with epiretinal membrane peeling allows the reconstitution of previous anatomy or else it results in a different configuration.

METHODS

Retrospective series of patients undergoing pars plana vitrectomy for epiretinal membrane, with >6-month follow-up before and after surgery, complete with best-corrected visual acuity, optical coherence tomography, M-Charts, and infrared retinography. Tangential retinal displacement between earliest visit (T E ), time of surgery (T 0 ), and latest available visit (T L ) of the examined retina, concentric circles at 0.5, 1.5, and 4.5 mm radii, and the central horizontal and vertical meridians were measured. Tangential displacement was calculated as the optical flow of consecutive infrared photographs.

RESULTS

The study comprised 32 patients: 15 men and 17 women. Average preoperative and postoperative follow-up were 23.4 ± 27.9 months and 19.2 ± 11.8 months, respectively. Best-corrected visual acuity reduced before surgery (0.69 ± 0.16 Snellen to 0.46 ± 0.17; P < 0.001) and increased after (0.866 ± 0.16 Snellen; P < 0.001). Horizontal and vertical metamorphopsia increased between before surgery but only horizontal metamorphopsia significantly reduced after. Average tangential displacement before surgery was 35.6 ± 29.9 µ m versus 56.6 ± 41.3 µ m after ( P = 0.023). Preoperative and postoperative displacement within the fovea was less than over the entire area ( P < 0.001).

CONCLUSION

Retinal tangential displacement between diagnosis and surgery (T E - T 0 ) is less than the displacement occurring after surgery (T 0 - T L ). Postoperative displacement does not represent the restoration of the anatomy existing before the disease ensued but rather the resulting equilibrium of newly deployed forces.

Small-Incision new generation implantable miniature telescope surgical technique and patient outcomes

BACKGROUND

Various ocular implants were suggested as a means of enhancing vision in patients with advanced age related macular degeneration. Recently, a new generation of implantable telescopes has been released. The purpose of this study is to report the surgical technique of implantation along with patient outcomes.

METHODS

This work focuses on the surgical technique. Crucial surgical steps are carefully reported along with discussion on main drawbacks and limitations.

RESULTS

This approach uses a preloaded delivery system with improved features and requires a smaller incision. First patient outcomes are also reported.

CONCLUSIONS

Surgical steps to implant this preloaded intraocular telescope are easier than previous versions, however this remains a complex procedure. Initial patient functional outcomes look promising.

The effect of optical degradation from cataract using a new Deep Learning optical coherence tomography segmentation algorithm

PURPOSE

To assess the validity of the results of a freely available online Deep Learning segmentation tool and its sensitivity to noise introduced by cataract.

METHODS

The OCT images were collected with a Spectralis SD-OCT (Heidelberg Engineering, Heidelberg, Germany) as part of normal clinical practice. Data were segmented using a freely available online tool called Relayer ( https://www.relayer.online/ ), based on a cross-platform Deep Learning segmentation architecture specifically adapted for retinal OCT images. The segmentations were read into MATLAB (The MathWorks, Natick, MA, USA) and analyzed.

RESULTS

There was an excellent agreement between the ETDRS measurements obtained from the two algorithms. Upon visual inspection, the segmentation based on Deep Learning obtained with Relayer appeared more accurate except in one case of apparent good quality image showing interrupted segmentations in some of the B-scans.

CONCLUSION

A freely available online Deep Learning segmentation tool showed good and promising performance in healthy retinas before and after cataract surgery, proving robust to optical degradation of the image from media opacities.

Phenomenology of spontaneous closure in degenerative and mixed type lamellar macular hole

PURPOSE

To the describe OCT imaging characteristics of a cohort of patients showing spontaneously closing degenerative or mixed type lamellar macular holes (LMH) and to compare them to the ones of a sex and age matched group showing stable lesions.

METHODS

Patients diagnosed with degenerative and mixed type LMHs showing OCT-documented spontaneous anatomical closure were retrospectively selected from 3 specialized retina centres. An equal number of age and sex matching subjects were randomly selected among patients with anatomically stable lesions.

RESULTS

Eleven (11) spontaneously closing (SC group) and 11 stable (ST group) degenerative LMH with a mean follow up of 4 years were recruited. Hyperreflective inner border (HIB) and linear hyperreflectivity in the outer plexiform layer (LHOP) at baseline were significantly more prevalent in SC group in processed images (respectively p = 0.007 and p = 0.003). A borderline significance in lamellar hole associated epiretinal proliferation (LHEP) at last follow up was detected (p = 0.085). As for mixed type LMH, 10 patients for SC group and 10 for ST group were recruited. LHOP at baseline in processed images was significantly more prevalent in SC group (p = 0.005).

CONCLUSIONS

Spontaneously closing LMHs show higher prevalence of HIB and LHOP at the beginning of the closing process, a difference which is enhanced by image processing. These signs might be a signal of microglial and Muller cells coordinated activation.

Neurotrophic Keratopathy after wide retinal endolaser and postoperative Ketorolac eye drops: A case series

PURPOSE

We report a series of 5 cases, happened in a period of 5 months, who developed neurotrophic keratopathy (NK) following pars plana vitrectomy (PPV) and retinal endolaser for rhegmatogenous retinal detachment (RRD). In our several decennary experience of surgical center predominantly based on vitreoretinal surgery, we had rare cases of postoperative NK. These recent cases of post-surgical NK happened contextually to our change of postoperative non-steroidal anti-inflammatory drugs (NSAIDs) drops, based on Ketorolac Tromethamine 0.5% eye drops.

CASES PRESENTATION

Five patients with a mean age of 61 ± 7.3 years were treated with one or more PPV with intraoperative peripheral endolaser for RRD. Nobody had previous herpetic keratitis, systemic disease like diabetes mellitus or other predisposing factors for NK. In the postoperative period, all patients received Ketorolac Tromethamine 0.5% eye drops for a mean period of 54 ± 25 days. During follow-up visits they developed NK and they were successfully treated with suspension of Ketorolac eye drops, application of therapeutic contact lens or amniotic membrane patch and topical lubricant therapy.

CONCLUSIONS

Postoperative Ketorolac eye drops, in patients who underwent PPV with endolaser, may reduce the corneal sensitivity, predispose to epithelial disruption and NK development. Studies are needed to explore the effect of NSAIDs on corneal sensitivity reduction in patient who will undergo PPV and extensive endolaser.

RETINAL TECTONICS AFTER MACULAR PUCKER SURGERY: Thickness Changes and En Face Displacement Recovery

PURPOSE

To study visual function, retinal layer thickness changes, and tangential displacement after pars plana vitrectomy for epiretinal membrane.

METHODS

Retrospective series of patients undergoing pars plana vitrectomy for epiretinal membrane, with 6-month follow-up including best-corrected visual acuity, optical coherence tomography, M-charts, epiretinal membrane grading, and infrared fundus photograph at time 0 (T0, preop) at months 1 (T1), 3 (T3), and 6 (T6) postop (±1 week). Retinal layer thickness and tangential ( en face ) retinal displacement between successive times for the entire retinal surface and the central horizontal and vertical meridian were also measured. En face displacement was calculated as optical flow of consecutive images.

RESULTS

Average best-corrected visual acuity improved from 0.28 ± 0.08 logarithm of Minimum Angle of Resolution at T0 to 0.16 ± 0.25 at T6 ( P = 0.05), best-corrected visual acuity improvement correlated with best corrected visual acuity (BCVA) at T0 ( P < 0.001). Vertical metamorphopsia decreased from 1.33° ± 0.70° at T0 to 0.82° ± 0.69° at T6 ( P < 0.05). Foveal thickness reduced from 453 ± 53 µ m at T0 to 359 ± 31 µ m at T6 ( P < 0.05) and reduction correlated with best-corrected visual acuity improvement ( P < 0.05). Foveal layers decreased ( P < 0.05) in all cases. The mean en face deformation was 155.82 ± 50.17 µ m and mostly occurred in the first month: T0-T1 displacement was 83.59 ± 30.28 µ m, T1-T3 was 36.28 ± 14.45 µ m, while T3-T6 was 39.11 ± 22.79 µ m ( P < 0.001) on average. Perifoveal and parafoveal deformation correlated with optical coherence tomography foveal thickness reduction at all time intervals (1, 3, and 6 months: P < 0.01).

CONCLUSION

Epiretinal membrane peeling affects all retinal layer thickness and results in new force balance across the entire retina and tangential displacement. Both en face and in-depth changes correlate with visual function.

Differential diagnosis of myopic choroidal neovascularization (mCNV): insights from multimodal imaging and treatment implications

PURPOSE

The aim of this article is to conduct a comprehensive systematic review about the current understandings and differential diagnosis of myopic choroidal neovascularization (mCNV) and other several similar diseases, describing their multimodal imaging analysis, prognostic implications, and current types of management.

METHODS

This systematic review was performed based on a search on the PubMed database of relevant papers regarding mCNV and other entities discussed in the paper, according to our current knowledge.

RESULTS

Through the integration of a multimodal imaging approach, especially optical coherence tomography (OCT), along with accurate demographic and clinical assessment, it becomes possible to effectively differentiate mCNV from similar yet heterogeneous entities. These conditions include macular hemorrhage due to new lacquer crack (LC) formation, inflammatory diseases such as punctate inner choroidopathy (PIC)/multifocal choroidits (MFC) and epiphenomenon multiple evanescent white dot syndrome (Epi-MEWDS), neovascular age-related macular degeneration (nAMD), idiopathic CNV (ICNV), dome-shaped macula (DSM) with subretinal fluid, retinal pigment epithelium (RPE) humps, angioid streaks (AS), choroidal rupture (CR), and choroidal osteoma (CO). Each one of these entities will be described and discussed in this article.

CONCLUSION

Myopic choroidal neovascularization is a common retinal condition, especially among young individuals. Accurate diagnosis and differentiation from similar conditions are crucial for effective treatment. Multimodal imaging, particularly OCT, plays a crucial role in precise assessment. Future research should focus on defining biomarkers and distinguishing features to facilitate prompt treatment.

Myopic macular schisis: Insights into distinct morphological subtypes and novel biomechanical hypothesis

PURPOSE

To analyze the features of myopic macular schisis (MMS) in different retinal layers and to explore the role of Müller cells in the pathophysiology of such condition.

METHODS

Spectral-domain optical coherence tomography (SD-OCT) images of myopic eyes with staphyloma and macular schisis were reviewed. The morphological features of MMS were analyzed and correlated with their geographical location in the parafoveal and perifoveal region. A biomechanical model was adopted to explain MMS morphological differences. The effect of the different schisis subtypes with best corrected visual acuity (BCVA) was also explored.

RESULTS

A total of 36 eyes from 26 patients were included in this study. MMS was classified into inner, middle and outer retinal subtypes. The prevalence of middle retinal schisis was significantly lower in the parafovea, within a central 3 mm-diameter circle (p < 0.001) centered at the fovea . The prevalence of inner retinal schisis was significantly higher outside the central 3-mm diameter circle, in the perifoveal region (p < 0.001). No significant differences were noted in the prevalence of outer retinal schisis for these two locations (p = 0.475). The presence of middle retinal schisis within the central 3-mm diameter circle showed a weak association with lower BCVA (p = 0.058). The presence of outer retinal schisis within the central 3-mm diameter circle was significantly related with lower BCVA (p = 0.024).

CONCLUSION

Three major forms of MMS are distinguished: inner, middle and outer retinal schisis. This classification may have clinical importance as only the outer grade of schisis was associated with vision loss.

Macular hole Delphi consensus statement (MHOST)

PURPOSE

To derive a Delphi method-based consensus for the surgical management of Full Thickness Macular Hole (FTMH) and Lamellar Macular Hole (LMH).

METHODS

37 expert VR surgeons from 21 mainly European countries participated in Delphi method-based questionnaire for diagnosis and treatment of FTMHs and LMHs.

RESULTS

A total of 36 items were rated in round 1 by 37 participants, of which 10 items achieved consensus: intraoperative verification of PVD; clinical superiority of OCT-based FTMH classification; practical ineffectiveness of ocriplasmin; circular 360° ILM peeling for small macular holes; use of regular surgical technique for the size of the hole in concomitant retinal detachment; performing complete vitrectomy; SF6 gas as preferred tamponade; cataract surgery if crystalline lens is mildly/moderately opaque; removal of both ILM and LHEP in LMH surgery. In round 2, 18 items with moderate consensus (45-70% agreement) in round 1 were rated by 35 participants. Final consensus was reached in 35% of questions related to both diagnosis and surgical procedures.

CONCLUSIONS

This Delphi study provides valuable information about the consensus/disagreement on different scenarios encountered during FTMH and LMH management as a guide tosurgical decision-making. High rate of disagreement and/or variable approaches still exist for treating such relatively common conditions.

Recommendation for Presbyopia-Correcting Intraocular Lenses: A Delphi Consensus Statement by the ESASO Study Group

PURPOSE

To establish consensus among experts in lens and refractive surgery to guide general ophthalmologists on issues related to presbyopia-correcting intraocular lenses (IOLs).

DESIGN

A modified Delphi method to reach a consensus among experts.

METHODS

A steering committee formulated 105 relevant items grouped into four sections (preoperative considerations, IOL selection, intraoperative considerations, and postoperative considerations). The consensus was defined as ≥ 70% of experts agreeing with the evaluation of a statement.

RESULTS

Ten experts participated and completed all rounds of questionnaires (100% response rate). Of 68 items considered in the preoperative considerations, consensus was achieved in 48 (70.6%). There was a lack of consensus over IOL selection, the experts only agreed on the importance of the patient's habits for the optical IOL design selection. Of the 14 considerations related to intraoperative issues, the experts reached a consensus on 10 (71.4%). The postoperative considerations section reached the highest consensus in 10 items of 13 (76.9%).

CONCLUSIONS

Key recommendations for a diffractive multifocal IOL were a potential postoperative visual acuity > 0.5, a keratometry between 40-45 diopters, a pupil >2.8 mm under photopic conditions and <6.0 mm under scotopic conditions, a root mean square of higher order corneal aberrations <0.5 µm for 6-mm pupil size, while monofocal or non-diffractive IOLs should be considered for patients with coexisting eye disorders. A lack of agreement was found in the issues related to the IOL selection.

INTRAOCULAR EMULSION OF SILICONE OIL (ITEMS) GRADING SYSTEM: An Evidence-Based Expert-Led Consensus

PURPOSE

To propose the InTraocular EMulsion of Silicone oil (ITEMS) grading system for the assessment of silicone oil (SiO) emulsion, applicable in a routine clinical setting and validated through an expert-led consensus procedure.

METHODS

Seven experts on intraocular liquid tamponades, led by a facilitator, performed a literature review on the detection of SiO emulsion. Based on the proposed ideas, a questionnaire was developed and submitted to the experts on the methods to detect SiO emulsion and the items to grade. After 2 rounds of individual ranking using a 9-point scale and related discussion, the final grading system was developed including items that reached consensus (score ≥7 from ≥75% of members).

RESULTS

The agreed ITEMS grading system includes the identification of SiO microbubbles and large SiO bubbles through slit-lamp biomicroscopy, gonioscopy, fundus examination under mydriasis, or ultra-wide-field fundus photography. Moreover, macular and disk optical coherence tomography are used to detect SiO-associated hyperreflective dots.

CONCLUSION

An evidence-based expert-led consensus was conducted to develop grading system of SiO emulsion, allowing, for the first time, homogenous collection of data on SiO emulsion. This has the potential to improve the understanding of the role and clinical relevance of SiO emulsion, allowing comparisons between different studies.

The Role of Subretinal Injection in Ophthalmic Surgery: Therapeutic Agent Delivery and Other Indications

Subretinal injection is performed in vitreoretinal surgery with two main aims, namely, the subretinal delivery of therapeutic agents and subretinal injection of fluid to induce a controlled and localized macular detachment. The growing interest in this technique is mainly related to its suitability to deliver gene therapy in direct contact with target tissues. However, subretinal injection has been also used for the surgical management of submacular hemorrhage through the subretinal delivery of tissue plasminogen activator, and for the repair of full-thickness macular holes, in particular refractory ones. In the light of the increasing importance of this maneuver in vitreoretinal surgery as well as of the lack of a standardized surgical approach, we conducted a comprehensive overview on the current indications for subretinal injection, surgical technique with the available variations, and the potential complications.

How to Set Up Genetic Counselling for Inherited Macular Dystrophies: Focus on Genetic Characterization

Inherited macular dystrophies refer to a group of degenerative conditions that predominantly affect the macula in the spectrum of inherited retinal dystrophies. Recent trends indicate a clear need for genetic assessment services in tertiary referral hospitals. However, establishing such a service can be a complex task due to the diverse skills required and multiple professionals involved. This review aims to provide comprehensive guidelines to enhance the genetic characterization of patients and improve counselling efficacy by combining updated literature with our own experiences. Through this review, we hope to contribute to the establishment of state-of-the-art genetic counselling services for inherited macular dystrophies.

Optical-Quality Assessment of a Miniaturized Intraocular Telescope

Age-related macular degeneration (AMD) causes severe vision impairments, including blindness. An option to improve vision in AMD patients is through intraocular lenses and optics. Among others, implantable miniaturized telescopes, which direct light to healthy lateral regions of the retina, can be highly effective in improving vision in AMD patients. Yet, the quality of the restored vision might be sensitive to the optical transmission and aberrations of the telescope. To shed light on these points, we studied the in vitro optical performance of an implantable miniaturized telescope, namely, the SING IMT™ (Samsara Vision Ltd., Far Hills, NJ, USA) designed to improve vision in patients affected by late-stage AMD. Specifically, we measured the optical transmission in the spectral range 350-750 nm of the implantable telescope with a fiber-optic spectrometer. Wavefront aberrations were studied by measuring the wavefront of a laser beam after passing through the telescope and expanding the measured wavefront into a Zernike polynomial basis. Wavefront concavity indicated that the SING IMT™ behaves as a diverging lens with a focal length of -111 mm. The device exhibited even optical transmission in the whole visible spectrum and effective curvature suitable for retinal images magnification with negligible geometrical aberrations. Optical spectrometry and in vitro wavefront analysis provide evidence supporting the feasibility of miniaturized telescopes as high-quality optical elements and a favorable option for AMD visual impairment treatments.

Phacoemulsification Tip Elongation Under Standardized Resistance: An Objective Measure of Human Crystalline Lens Hardness

Purpose

To establish a correlation between phacoemulsification tip normalized driving voltage (NDV) and crystalline lens hardness and use it as an objective measure of lens hardness. The study used a phaco tip equipped with previously validated elongation control adjusting the driving voltage (DV) to produce invariant elongation regardless of resistance.

Methods

The laboratory study measured the mean and maximum DV of the phaco tip immersed in glycerol-balanced salt solution and correlated the DV with the kinematic viscosity at 25, 50, and 75 µm tip elongation. The NDV were obtained by dividing the DV in glycerol by the DV in the balanced salt solution. The clinical arm of the study recorded DV of 20 consecutive cataract surgeries. The correlation of mean and maximum NDV to Lens Opacities Classification System (LOCS) III classification, patient's age and effective phaco time were evaluated.

Results

The mean and maximum NDV correlated with the kinematic viscosity of the glycerol solution (P < 0.001 in all cases). Mean and maximum NDV during cataract surgery correlated with patients' age, effective phaco time, LOCS III nuclear color, and nuclear opalescence (P < 0.001 in all cases).

Conclusions

When a feedback algorithm is running, DV variation strictly correlates with encountered resistance in glycerol solutions and real-life surgery. NDV significantly correlates with the LOCS classification. Future developments might include sensing tips that react to lens hardness in real time.

Translational Relevance

The study correlates for the first time phaco tip DV and crystalline lens mechanical properties, establishing an objective and reliable measure of lens hardness. This may lead to smart phaco tips reacting to cataract hardness change in real time and sparing ultrasound dispersion.

The Short-Term Results of Autologous Platelet-Rich Plasma as an Adjuvant to Re-Intervention in the Treatment of Refractory Full-Thickness Macular Holes

The purpose of this study was to investigate the short-term efficacy and safety of autologous platelet-rich plasma (a-PRP) as an adjuvant to revisional vitrectomy for refractory full-thickness macular holes (rFTMHs). We conducted a prospective, non-randomized interventional study including patients with rFTMH after a pars plana vitrectomy (PPV) with internal limiting membrane peeling and gas tamponade. We included 28 eyes from 27 patients with rFTMHs: 12 rFTMHs in highly myopic eyes (axial length greater than 26.5 mm or a refractive error greater than -6D or both); 12 large rFTMHs (minimum hole width > 400 μm); and 4 rFTMHs secondary to the optic disc pit. All patients underwent 25-G PPV with a-PRP, a median time of 3.5 ± 1.8 months after the primary repair. At the six-month follow-up, the overall rFTMH closure rate was 92.9%, distributed as follows: 11 out of 12 eyes (91.7%) in the highly myopic group, 11 out of 12 eyes (91.7%) in the large rFTMH group, and 4 out of 4 eyes (100%) in the optic disc pit group. Median best-corrected visual acuity significantly improved in all groups, in particular from 1.00 (interquartile range: 0.85 to 1.30) to 0.70 (0.40 to 0.85) LogMAR in the highly myopic group (p = 0.016), from 0.90 (0.70 to 1.49) to 0.40 (0.35 to 0.70) LogMAR in the large rFTMH group (p = 0.005), and from 0.90 (0.75 to 1.00) to 0.50 (0.28 to 0.65) LogMAR in the optic disc pit group. No intraoperative or postoperative complications were reported. In conclusion, a-PRP can be an effective adjuvant to PPV in the management of rFTMHs.

Comparison of Perfluorocarbon Liquids Cytotoxicity Tests: Direct Contact Versus the Test on Liquid Extracts

The purpose of this study is to compare the in vitro cytotoxicity tests according to the ISO 10993-5 (2009) standards using direct contact and the test on liquid extracts of compounds previously identified as possible toxic impurities in perfluorocarbon liquids (PFCLs) for use in vitreoretinal surgery. Compounds including perfluorooctanoic acid (PFOA), 1H-perfluorooctane (1H-PFO), 2H-tridecafluoro-2-methylpentane, 1H,2H-octafluorocyclopentane, and 2H,3H-decafluoropentane were analyzed by ¹⁹F NMR before and after extraction using an aqueous solution and tested by both the direct contact and liquid extract tests in L929, BALB 3T3, and ARPE-12 cells. The concentration that reduced in vitro cell viability by 30%, the cytotoxicity concentration threshold (CC₃₀), was determined for each compound. ¹⁹F NMR spectroscopy confirmed the immiscibility of perfluoro-n-octane (PFO) and 1H-PFO and the solubility of PFOA with the extraction vehicle. The other samples reacted with the extraction vehicle, releasing fluoride ions. Using the direct contact test, the CC₃₀ of PFOA, 1H-PFO, 2H-tridecafluoro-2-methylpentane, 1H,2H-octafluorocyclopentane, and 2H,3H-decafluoropentane corresponded to 48 124, 50, 14, 8035, and 46 ppm, respectively. The method on liquid extracts did not detect cytotoxicity in three out of five tested compounds, and CC₃₀ could not be determined. In conclusion, the in vitro cytotoxicity test by direct contact revealed a positive correlation between cell toxicity and the concentration of the tested substance. Conversely, the test on liquid extracts hardly detected the cytotoxicity of toxic impurities in PFCLs. Thus, only the cytotoxicity test by direct contact, according to ISO 10993-5 (2009), is a sensible and reliable method to detect possible cytotoxic impurities in PFCLs to guarantee patient safety.

Safety Profile of Lutein- Versus Triamcinolone Acetonide-Based Vitreous Staining

Purpose

To assess the safety profile of a new lutein-based vitreous dye (LB-VD) formulation compared with various triamcinolone acetonide (TA) formulations with and without subsequent exposure to perfluorodecalin (PFD) in vitro.

Methods

Human adult retinal pigment epithelial cells (ARPE-19) were treated with the following formulations: undiluted preserved TA (TA-BA), diluted preserved TA (D-TA-BA), preservative-free TA (TA-PF), and LB-VD. First, cell tolerability was evaluated with MTT, LDH, and ATPlite assays after 1, 5, and 30 minutes of exposure to each tested formulation. Then, cells were sequentially exposed to formulations and PFD. After 24 hours of exposure to PFD, cell tolerability was evaluated through MTT and ATPlite assays.

Results

Among the formulations tested, LB-VD showed the highest levels of cell viability, cell metabolism, and cell proliferation and induced the lowest release of LDH, whereas the TA-based formulations demonstrated a cytotoxic effect on ARPE-19 cells in vitro. After subsequent 24-hour exposure to PFD, a greater reduction of cell viability was noted for all the formulations; however, this reduction was not significant only for the combination LB-VD-PFD, which was the best tolerated condition.

Conclusions

LB-VD showed a better safety profile compared with all TA-based formulations, even when used in combination with PFD.

Translational Relevance

In surgical practice, LB-VD may be preferred to TA-based formulations for vitreous staining in the light of its more favorable safety profile.

Pneumatic retinopexy versus scleral buckling for the management of primary rhegmatogenous retinal detachment

BACKGROUND AND OBJECTIVE

To compare pneumatic retinopexy (PnR) and scleral buckling (SB) for repair of primary rhegmatogenous retinal detachment.

MATERIALS AND METHODS

Single-centre retrospective analysis of patients undergoing PnR and SB. Inclusion criteria comprehend phakic patients with a single retinal break or a group of breaks in detached retina in the same quadrant above the 8- and 4-o'clock meridians. A total of 184 patients were included, respectively 106 underwent PnR and 78 SB. Follow-up time was 6 months.

RESULTS

Final visual outcome did not differ significantly between the two procedures (P  =  0.12). Single-procedure reattachment rate was significantly higher in SB (94%) than in PnR (68%) (P < 0001). Anatomical success rate was not influenced by macular involving. Reattachment rate in repeated PnR was 95% and in these patients visual outcome did not statistically differ compared to those reattached with first attempt (P  =  0.196). Total reattachment rate including repeated procedures was 87% in PnR group and 94% in SB group, the difference was not significant (P  =  0.06).

CONCLUSION

SB has a higher single reattachment rate than PnR. However, final visual outcomes of both procedures are comparable. In selected cases, PnR can be repeated with a high successful rate.

A retrospective, multicenter study on the management of macular holes without residual internal limiting membrane: the refractory macular hole (ReMaHo) study

Purpose

To evaluate the surgical management, outcomes and prognostic factors of full thickness macular holes without residual internal limiting membrane (NO-ILM FTMHs).

Methods

We performed a multicenter, retrospective study of 116 NO-ILM FTMHs. Human amniotic membrane (hAM) plug, autologous ILM free flap transplantation (AILMT), and autologous retinal graft transplantation (ART) were performed in 58, 48, and 10 patients, respectively. Data were collected before and up to 12 months after surgery. The primary outcomes were hole closure and final best-corrected visual acuity (BCVA).

Results

The final BCVA (0.78 ± 0.51 logMAR) was significantly better than and correlated with the initial BCVA (p < 0.0001 and p = 0.004, respectively). Hole closure was achieved in 92% of eyes. The minimum FTMH diameter was wider and final BCVA was lower in the ART group than in the other groups (p < 0.003 and p < 0.001, respectively). FTMHs with diameter > 680 μm had a higher closure rate with hAM than with AILMT (p = 0.02).

Conclusions

AILMT and hAM were the most frequently performed surgeries with both high closure rate and significant functional improvement. Preoperative BCVA was correlated with final BCVA. The minimum FTMH diameter may guide the treatment choice.

25 Simulation of eye surgery in porcine eye globes and evaluation of retinal cytotoxicity

PURPOSE

To simulate pars plana vitrectomy in porcine eyes ex-vivo using intraoperative devices and to evaluate viability of retinal cells.

METHODS

25 enucleated porcine eyes were divided in following groups Group A) No surgery control: Group B) Sham surgery; Group C) Cytotoxic control; Group D) Surgery with residues; Group E) Surgery with minimal residues. The retina was extracted from each eye bulb and the cell viability was determined by MTT assay. The in vitro cytotoxicity of each used compounds was tested on ARPE-19 cells.

RESULTS

No cytotoxicity was detected in retinal samples in groups A, B and E. Samples from eye bulbs that had undergone surgery with minimal removal of residues (group D) and cytotoxic controls (group C) showed high retinal cytotoxicity. The simulation of vitrectomy indicated that the combined use of compounds does not affect retinal cells viability if all the compounds are properly removed, whereas the cytotoxicity detected in group D may suggest that the presence and accumulation of the residues of the compounds used intraoperatively could negatively impact retinal viability.

CONCLUSIONS

The present study demonstrate the crucial role of an optimal removal of the intraoperative devices used in eye surgery to ensure safety to the patient.

Genetic Aspects of Age-Related Macular Degeneration and Their Therapeutic Potential

Age-related macular degeneration (AMD) is a complex and multifactorial disease, resulting from the interaction of environmental and genetic factors. The continuous discovery of associations between genetic polymorphisms and AMD gives reason for the pivotal role attributed to the genetic component to its development. In that light, genetic tests and polygenic scores have been created to predict the risk of development and response to therapy. Still, none of them have yet been validated. Furthermore, there is no evidence from a clinical trial that the determination of the individual genetic structure can improve treatment outcomes. In this comprehensive review, we summarize the polymorphisms of the main pathogenetic ways involved in AMD development to identify which of them constitutes a potential therapeutic target. As complement overactivation plays a major role, the modulation of targeted complement proteins seems to be a promising therapeutic approach. Herein, we summarize the complement-modulating molecules now undergoing clinical trials, enlightening those in an advanced phase of trial. Gene therapy is a potential innovative one-time treatment, and its relevance is quickly evolving in the field of retinal diseases. We describe the state of the art of gene therapies now undergoing clinical trials both in the field of complement-suppressors and that of anti-VEGF.

[Visual acuity reduction and silicone oil tamponade]

Silicone oil is an established intraocular surgical aid, which enables the treatment of the most complex starting situations but no other alternative has been found; however, the available data indicate that an unclear loss of visual acuity during or after an intraocular silicone oil tamponade possibly occurs more frequently than assumed from the clinical routine. Various pathological mechanisms are under discussion as causes, but the exact causes are actually unclear. In addition to atrophic alterations in the optical coherence tomography (OCT) examination, there are a clear reduction in visual acuity and mostly a central scotoma with otherwise inconspicuous findings. Unclear loss of visual acuity can also occur after removal of the silicone oil. Whether this is caused by the same pathological mechanism is unclear. Furthermore, there are no reproducible risk factors that appear a priori to possibly cause an unclear loss of vision under silicone oil; however, oil removal as soon as possible and a good adjustment of the intraocular pressure are recommended by the authors. Overall, a silicone oil tamponade should be carefully weighed up even when using modern highly purified silicone oils and it should therefore continue to be reserved particularly for unfavorable initial situations or complicated courses with the necessity for a silicone oil tamponade. Against this background, a study for systematic recording and processing of cases of unclear loss of visual acuity after silicone oil tamponade seems to be meaningful.

Dynamic Pressure Measurements During Vitrectomy in a Model of the Eye

Purpose

To accurately evaluate pressure changes during vitrectomy in a rigid model of the vitreous chamber and to test the efficiency of the EVA phacovitrectomy system (Dutch Ophthalmic Research Center) in terms of compensation of intraocular pressure variations.

Methods

We tested 23-, 25-, and 27-gauge double-blade vitreous cutters in both vented global pressure control and automatic infusion compensation (AIC) modes in a vitreous chamber model, mimicking the real surgical procedure. Balanced salt solution and artificial vitreous, similar to the real vitreous body, were used. We tested both standard-flow (SF) and high-flow (HF) infusion systems, varying the infusion pressure between 20 and 40 mm Hg. In each experiment, flow rate was also measured.

Results

Pressure drop was rapidly and efficiently compensated when 23- and 25-gauge cutters were used in AIC mode, with infusion pressures ranging between 30 and 55 mm Hg. The 27-gauge cutter was less efficient in compensating pressure variations. Pressure fluctuations related to the high-frequency motion of the cutter blade were small compared to the overall pressure variations. The use of the HF infusion system resulted in larger flow rates and lower pressure changes compared to the SF infusion system.

Conclusions

Despite the rigid material of the model, the present pressure measurements are in line with previous studies performed on porcine eye. The use of AIC mode compensates intraoperative pressure drops efficiently, with both 23- and 25-gauge cutters. The HF infusion system is more efficient than the SF infusion system.

Translational Relevance

The AIC infusion mode efficiently compensates intraoperative pressure drops, in both 23- and 25-gauge experimental vitrectomy. The HF infusion system resulted in larger flow rate and lower pressure changes.

Tips to optimize digital education in ophthalmology: Results from ESASO survey

PURPOSE

To identify audience and faculty preferences to optimize digital education sessions in ophthalmology.

METHODS

We distributed an online survey to ophthalmology trainees and specialists worldwide. The survey investigated respondents' preferences on various findings of hypothetical digital educational sessions. Data were analyzed using descriptive statistics, Fisher's exact probability and ANOVA tests.

RESULTS

The survey was completed by 655 respondents, from 53 different countries. According to most respondents, the optimal duration and timeframe for a valuable digital education session would be 30-60 min, without a break (52%), in the evening time-slot (6-8 p.m.) (45%) of a weekday (Monday-Thursday) (46%), regardless of age (p-value = 0.84, 0.39, 0.89, respectively) and job position (p-value = 0.31, 0.29, 0.08, respectively). The availability of webinars and recorded surgical videos/clinical cases, associated with live discussion, represented the most important opportunity of digital educational channels for 46% and 42% of respondents, respectively.

CONCLUSION

Appropriate planning of timing and structure of digital educational ophthalmology sessions may optimize their effectiveness. Using multiple e-learning formats may be helpful to ensure the continuity of learning activities, also in view of a long-term replacement of traditional in-person education.

Curcumin in Retinal Diseases: A Comprehensive Review from Bench to Bedside

Recent evidence in basic science is leading to a growing interest in the possible role of curcumin in treating retinal diseases. Curcumin has been demonstrated to be able to modulate gene transcription and reduce ganglion cell apoptosis, downgrade VEGF, modulate glucose levels and decrease vascular dysfunction. So far, the use of curcumin has been limited by poor bioavailability; to overcome this issue, different types of carriers have been used. Multiple recent studies disclosed the efficacy of using curcumin in treating different retinal conditions. The aim of this review is to comprehensively review and discuss the role of curcumin in retinal diseases from bench to bedside.

The Long Pentraxin PTX3 as a New Biomarker and Pharmacological Target in Age-Related Macular Degeneration and Diabetic Retinopathy

Age related macular degeneration (AMD) and diabetic retinopathy (DR) are multifactorial, neurodegenerative and inflammatory diseases of the eye primarily involving cellular and molecular components of the outer and inner blood-retina barriers (BRB), respectively. Largely contributed by genetic factors, particularly polymorphisms in complement genes, AMD is a paradigm of retinal immune dysregulation. DR, a major complication of diabetes mellitus, typically presents with increased vascular permeability and occlusion of the retinal vasculature that leads, in the proliferative form of the disease, to neovascularization, a pathogenic trait shared with advanced AMD. In spite of distinct etiology and clinical manifestations, both pathologies share common drivers, such as chronic inflammation, either of immune (in AMD) or metabolic (in DR) origin, which initiates and propagates degeneration of the neural retina, yet the underlying mechanisms are still unclear. As a soluble pattern recognition molecule with complement regulatory functions and a marker of vascular damage, long pentraxin 3 (PTX3) is emerging as a novel player in ocular homeostasis and a potential pharmacological target in neurodegenerative disorders of the retina. Physiologically present in the human eye and induced in inflammatory conditions, this protein is strategically positioned at the BRB interface, where it acts as a “molecular trap” for complement, and modulates inflammation both in homeostatic and pathological conditions. Here, we discuss current viewpoints on PTX3 and retinal diseases, with a focus on AMD and DR, the roles therein proposed for this pentraxin, and their implications for the development of new therapeutic strategies.

Effectiveness of a Hydrophilic Curcumin-Based Formulation in Coadjuvating the Therapeutic Effect of Intravitreal Dexamethasone in Subjects With Diabetic Macular Edema

Purpose: This study evaluates if the addition of a curcumin formulation with a polyvinylpyrrolidone-hydrophilic carrier (CHC; Diabec^®, Alfa Intes, Italy) to intravitreal injections of dexamethasone (DEX-IVT) can affect the morphological retinal characteristics, extending the steroid re-treatment period in patients with diabetic macular edema (DME).

Methods: A randomized controlled clinical trial was carried out in DME patients, randomly assigned to receive DEX-IVT or DEX-IVT and a CHC. The evaluation of the mean difference of central retinal thickness (CRT) was the primary aim. Secondary aims were the evaluations of best-corrected visual acuity, differences in the predetermined retinal layer thickness, the number/time of re-treatment, and the assessment of safety.

Results: A total of 73 DME patients were included (35 in the control group and 38 in the combined therapy group). In both the control and combined therapy groups, the mean CRT change from T₀ to the 6 months’ evaluation was significant (p = 0.00). The mean CRT result was significantly different at month 4 (p = 0.01) between the control and combined therapy groups, with a greater reduction in the combined therapy group, in particular, in patients with ≤10 years of diabetes. A trend of CRT reduction in the combined therapy group has been observed also considering patients with subfoveal neuroretinal detachment. In addition, we observed that the reduction of inner retinal layer thickness was greater in the combination group, in comparison with controls.

Conclusion: The combination of a CHC to DEX-IVT is a promising therapeutic option in case of DME, in particular, for patients with early-stage diabetes and with an inflammatory phenotype. Further studies will be necessary to confirm these findings.

Where Are We with RPE Replacement Therapy? A Translational Review from the Ophthalmologist Perspective

The retinal pigmented epithelium (RPE) plays a pivotal role in retinal homeostasis. It is therefore an interesting target to fill the unmet medical need of different retinal diseases, including age-related macular degeneration and Stargardt disease. RPE replacement therapy may use different cellular sources: induced pluripotent stem cells or embryonic stem cells. Cells can be transferred as suspension on a patch with different surgical approaches. Results are promising although based on very limited samples. In this review, we summarize the current progress of RPE replacement and provide a comparative assessment of different published approaches which may become standard of care in the future.

TWENTY-THREE-GAUGE HYPERSONIC VITRECTOMY: Real-World Surgical Evidence

PURPOSE

To evaluate the safety, effectiveness, and the best parameters setup of hypersonic vitrectomy.

METHODS

A prospective, multicentric, interventional study on 50 eyes that had undergone hypersonic vitrectomy because of various vitreoretinal diseases. We primarily assessed the effectiveness of vitreous removal, intraoperative complications, and surgical setup. Secondarily, we evaluated single-surgery anatomical success and postoperative best-corrected visual acuity.

RESULTS

Intraoperative complications occurred in 5 eyes (10%), whereas technical problems were detected in 23 eyes (46%), resulting in conversion to guillotine vitrectomy in 15 cases. The most common finding related to the technical problems was an inadequate vitreous liquefaction with the formation of vitreous strands and consequent inadequate vitreous outflow, sometimes complicated by vitreous incarceration in the vitrectomy probe. The best settings were considered a stroke of 60 µm and vacuum of 40 mmHg for both core and peripheral vitrectomy. At 3-month follow-up, primary anatomical success was achieved in 49 eyes (98%) and the mean best-corrected visual acuity overall improved.

CONCLUSION

The availability of hypersonic vitrectomy in the current surgical practice opens a new era in vitreoretinal surgery. Despite the potential advantages in fluidics, the performance of hypersonic vitrectomy system needs to be further optimized, mainly for the occurrence of inadequate vitreous liquefaction and vitreous strands formation.

Ex vivo evaluation of retinal cytotoxicity after the use of multiple medical devices in pars plana vitrectomy in porcine eyes

This study aimed to evaluate viability of retinal cells after the use of multiple intraoperative devices, namely a vitreal dye (triamcinolone acetonide,TA), a ERM/ILM dye (solution of trypan blue 0.15% and brilliant blue 0.025%), and two intraocular tamponades, namely perfluoro-n-octane, (PFO) and silicone oil (SO 1000 cSt), with minimal and maximal removal of their residues, during a simulated pars plana vitrectomy (PPV) in porcine eyes ex-vivo. The in vitro cytotoxicity of each of these compounds was verified on ARPE-19 cells by direct tests according to the ISO 10993-5 (2009). Pars plana vitrectomy was performed on 25 enucleated porcine eyes divided in five groups according to the following conditions: Group A) No surgery control: eye bulbs were kept at room temperature for 40 min; Group B) Sham surgery: PPV with the sole use of BSS for 40 min; Group C) Cytotoxic control: PPV with BSS infusion (20 min) followed by intravitreal injection of 1H-PFO (contact time: 20 min); Group D) Surgery with residues: PPV with BSS infusion and sequential intravitreal injection of TA, ERM/ILM dye, PFO and SO, with minimal removal of each compound after a specified contact-time (overall duration: 40 min); Group E) Surgery with minimal residues: PPV performed as in group D, but with maximal removal of each compound (overall duration: 40 min). All the experimental procedures were performed at room temperature. Immediately after surgery, the retina was extracted from each eye bulb and samples of 3-mm diameter were prepared. Retinal viability was determined for each sample by 3-(4,5-dimethylthiazole-2-yl)-2,5-diphenyltetrazolium bromide assay. A cell viability <70% was considered the cytotoxicity threshold. Kruskal-Wallis test was used to evaluate the differences in retinal viability between groups. No cytotoxicity was detected in retinal samples in groups A, B and E. Samples from eye bulbs that had undergone surgery with minimal removal of residues (group D) and cytotoxic controls (group C) showed high retinal cytotoxicity. The tested conditions indicated that the combined use of TA, ERM/ILM dye, PFO and SO during PPV does not affect retinal cells viability if all the devices are properly removed, whereas the cytotoxicity detected in group D may suggest that the presence and accumulation of the residues of the compounds used intraoperatively could negatively impact retinal viability due to a cumulative and/or synergistic cytotoxic effect between them, supporting the crucial role of an optimal removal of the intraoperative medical devices to ensure a safe vitrectomy to the patient.

Short-Term Outcomes After COVID-19-Related Treatment Interruption Among Patients with Neovascular Age-Related Macular Degeneration Receiving Intravitreal Bevacizumab

Purpose

To assess outcomes and recovery strategy of patients undergoing intravitreal injections for exudative age-related macular degeneration who experienced COVID-19 related interruption in treatment during complete lockdown.

Methods

This was a retrospective, observational case study. We used a mixed effect model with random intercepts to evaluate best corrected visual acuity (BCVA) accounting for measured central macular thickness (CMT) and individual variability of each eye. Furthermore, we analysed measures of the pigmented epithelium detachment as well as presence of subretinal fluid and intraretinal cysts.

Results

We included 39 patients and we found a significant reduction in the BCVA between the pre- and post-lockdown controlling for CMT. There was no significant difference in pigmented epithelium detachment and in presence of subretinal fluid and intraretinal cysts.

Conclusion

We detected a significant loss in visual function. The magnitude of the average loss was, however, limited suggesting good efficacy of the recovery strategy.

Macular Microvascular Modifications in Progressive Lamellar Macular Holes

Lamellar macular holes (LMHs) may show morphological and functional deterioration over time, yet no definite prognostic factor for progression has been identified. Since neurovascular retinal unit impairment may take part in neurodegeneration, we compare progressive LMHs to stable ones in optical coherence tomography (OCT) angiography parameters.

METHODS

OCT B scans of eyes with LMH were analyzed to detect the presence of tissue loss (TL) over time, allowing us to identify a TL group and a stable (ST) group (14 patients each). The best corrected visual acuity (BCVA) at each considered imaging time point was collected. Lastly, patients underwent macular OCT angiography.

RESULTS

BCVA at last follow up was significantly reduced in the TL group compared to both the ST group and TL group baseline assessment. SCP foveal vessel density (VD), SCP and deep capillary plexus (DCP) perfusion density (PD) and parafoveal PD were lower in the TL group. Linear correlations between quantitative TL over time and parafoveal PD in SCP and between the speed of TL and BCVA variation during follow up were also detected.

CONCLUSIONS

TL in LMHs is associated with both OCT angiography modifications and BCVA deterioration over time. We suggest these findings to be a manifestation of foveal Muller cell impairment in progressive LMHs.

Vitreoretinal Surgery in the Prevention and Treatment of Toxic Tumour Syndrome in Uveal Melanoma: A Systematic Review

Toxic tumour syndrome (TTS) is a particularly aggressive form of secondary vasculopathy occurring after radiation therapy of uveal melanoma due to the persistence of the necrotic tumour mass inside the eye. The development of TTS confers a particularly unfavourable functional and anatomical ocular prognosis, ultimately requiring enucleation in most cases if untreated. Vitreoretinal (VR) surgery has been successfully applied for treatment and prevention of TTS using both resecting and non-resecting techniques. In this systematic review, we aim to define characteristics of uveal melanomas benefiting the most from secondary VR surgery and to outline the optimal type and timing of VR intervention in such cases. Analysis of the literature reveals that endoresection should be performed within 3 months after radiotherapy to tumours thicker than 7 mm and with a largest basal diameter between 8 mm and 15 mm with post-equatorial location, especially after proton beam treatment. Alternatively, endodrainage remains a valid therapeutic option in eyes with macula-off retinal detachment, tumour diameter larger than 15 mm or ciliary body involvement. VR surgery can be successful in the management of TTS following radiotherapy for uveal melanoma when timing and indication are appropriately evaluated.

Macular capillary displacement in exudative and tractional macular oedema: a multimodal imaging study and pathophysiological hypothesis

PURPOSE

This study aims to describe vessel density differences in tractional versus exudative macular oedema with the aid of novel custom imaging analysis techniques.

METHODS

In this retrospective study, patients with exudative and tractional macular oedema were imaged with optical coherence tomography (OCT), en-face OCT, OCT-angiography and fluorescein angiography. A novel image processing algorithm was developed to extrapolate data from the vessel density maps.

RESULTS

Forty-one eyes of 36 patients were included. A total of 30 control eyes comprised the control group. At the deep capillary plexus (DCP), exudative eyes presented with a vessel density of 62.12 ± 5.7, significantly higher if compared to both tractional lamellar macular hole (57.6 ± 4.6, p = 0.004) and controls (52.07 ± 2.3, p < 0.001). At the superficial capillary plexus (SCP), there were no differences in vessel density between exudative eyes (51.9 ± 4.4) and both the tractional lamellar hole (54.9 ± 3.1, p = 0.083) and the control (51.72 ± 2.2, p = 0.083) groups. In the exudative subgroup, there was a direct correlation between areas of low flow and those of high flow at both the DCP and SCP (p = 0.001 and p = 0.042, respectively).

CONCLUSIONS

Intraretinal expansion of fluid may cause the displacement of the surrounding retinal parenchyma and capillaries.

Fluorescein Angiography Findings in Eyes With Lamellar Macular Hole and Epiretinal Membrane Foveoschisis

Purpose

The purpose of this paper was to study fluorescein angiography (FA) findings in eyes with lamellar macular hole (LMH), and epiretinal membrane (ERM) foveoschisis.

Methods

In this prospective, observational case series, 46 eyes of patients affected by either LMH or ERM foveoschisis were examined using optical coherence tomography (OCT) and FA. All patients underwent a comprehensive ophthalmological examination and a general workup to exclude uveitis. Main outcome measures were: presence of FA abnormalities, measurements of the areas of vascular leakage, and intensity of pixels in the vitreous.

Results

Twenty-four (52.2%) eyes with LMH and 22 (47.8%) with ERM foveoschisis were studied. Overall, FA abnormalities were found in 20 (83.3%) eyes with LMH and 18 (81.8%) with ERM foveoschisis. The median areas of posterior pole and peripheral leakage were 7.52 vs. 1.07 mm2 (P = 0.03) and 21.8 vs. 3.74 mm2 (P = 0.02) in the LMH and ERM foveoschisis group, respectively. Disk hyperfluorescence was found in 8 and 4 eyes and perivascular leak in 10 and 4 eyes with LMH and ERM foveoschisis, respectively. OCT-derived measurements of vitreous intensity did not differ between the two groups, and the investigational workup for uveitis was negative in all patients.

Conclusions

Discrete areas of central and peripheral leakage are commonly found in eyes with LMH and ERM foveoschisis, whereas perivascular leak and hyperfluorescence of the disc are less frequently observed. These findings suggest that breakdown of the retinal blood barrier, involving the posterior pole and the periphery, is frequently associated with these two vitreoretinal disorders.

Viscoelastic-assisted inverted cover and free ILM flap techniques

statement: Surgical technique: an innovative way of using cohesive viscoelastic to stabilize the ILM flap during the cover inverted-flap and free-flap procedures.Summary statement: Surgical technique: an innovative way of using cohesive viscoelastic to stabilize the ILM flap during the covering step in the inverted-flap and free-flap procedures.

Heads-up 3D eye surgery: Safety outcomes and technological review after 2 years of day-to-day use

BACKGROUND

3D heads-up visualization systems are aimed to improve the surgical experience by providing high-resolution imaging. Objective of our study is to analyze, over a long-time span, the grade of satisfaction and safety of day-to-day 3D surgery compared to standard surgery and to investigate the technical distinctiveness between the heads-up systems currently in use.

METHODS

In this retrospective observational case series. we reviewed all surgical records of our ophthalmology-dedicated operatory rooms since the arrival of 3D heads-up viewing system, in November 2017. In particular, we compared the procedural complications of 3D-equipped operatory room (3DR) with the standard microscope operatory room (2DR). Moreover, a satisfaction questionnaire was administered to those surgeons shifting on both rooms to test their preferences on seven specific parameters (comfort, visibility, image quality, depth perception, simplicity of use, maneuverability and teaching potential).

RESULTS

5483 eye surgeries were considered. 2777 (50.6%) were performed in 3DR and 2706 (49.3%) in 2DR. Procedural complication rate was comparable in 3DR and 2DR, also when considering different subtypes of surgery. Twelve surgeons (100% of our surgery team) participated in our satisfaction survey, expressing highest satisfaction score for 3D when applied in retina surgery. For cataract surgery, 3D scored best in all the parameters except for facility in use and depth of field perception.

CONCLUSION

Long-term day-to-day use of 3D heads-up visualization systems showed its safety and its outstanding teaching potential in all ophthalmic surgical subtypes, with higher surgeons confidence for retina and cataract surgery.

Curcuma-Based Nutritional Supplement in Patients with Neovascular Age-Related Macular Degeneration

To investigate effectiveness and safety of a curcumin-based nutritional supplement in neovascular age-related macular degeneration (AMD). We conducted a controlled retrospective study, reviewing the medical records of patients referred to the Eye Center, Humanitas Hospital, Bergamo due to neovascular AMD and treated with antivascular endothelial growth factor (VEGF) intravitreal injections (IVIs) and oral administration of a curcumin-based nutritional supplement vehiculated by enterosoma-I^®. We retrospectively collected data of 18 naive patients who received IVI and daily oral nutritional supplement and 24 naive age-matched controls with the same diagnosis undergoing only IVI. All patients underwent a loading-phase of one-per-month IVI for 3 months and then received IVI pro re nata. Median best-corrected visual acuity was significantly improved in treated patients compared with controls (P < .05), while there was no statistical difference in central macular thickness between groups (P > .05). The total number of injections (tIVI) was significantly (P < .05) reduced in the treated group compared with controls. The tIVI in treated group ranged from 3 to 5 with a median of 4 while control group received a tIVI that ranged between 6 and 7 with a median of 7. Treatment with curcumin-based nutritional supplement was safe and effective. Curcumin is a promising adjuvant of anti-VEGF treatment, improves functional outcomes, and prolongs duration.