Outcomes of Primary Vitrectomy for Rhegmatogenous Retinal Detachment With No Postoperative Positioning

Purpose: To evaluate the anatomic and visual outcomes of primary vitrectomy for rhegmatogenous retinal detachment (RRD) repair using no amount of postoperative prone positioning to clarify the role of face-down posturing for RRD reattachment. Methods: This retrospective consecutive interventional case series comprised patients who had primary vitrectomy for RRD repair. The surgical outcomes, single-surgery anatomic success rate, and postoperative best-corrected visual acuity (BCVA) were assessed. The primary objective was to evaluate the anatomic and visual outcomes of vitrectomy RRD reattachment using no postoperative prone positioning. Results: This study comprised 116 eyes of 116 patients. Single-surgery anatomic success was achieved in 112 (96.5%) of 116 eyes. The single-surgery anatomic success rate was 100% in phakic patients (n = 56) and 93% in pseudophakic patients (n = 60), with both groups having an improvement in the mean BCVA. Conclusions: Primary vitrectomy with no postoperative prone positioning is a successful surgical intervention for RRD repair. The anatomic closure rate in this study is one of the highest reported in the literature and involved a large number of macula-off RRDs, with minimal complications and a significant improvement in BCVA, primarily using 14% perfluoropropane for gas tamponade.

Diagnostic implications of Gardner Syndrome, case report of a familial adenomatous polyposis (FAP) variant, for eye care professionals

INTRODUCTION

Gardner Syndrome (GS) is a variant of Familial Adenomatous Polyposis (FAP). FAP is characterized by several precancerous adenomatous intestinal polyps while GS has additional distinct extraintestinal features such as congenital hypertrophy of retinal epithelium (CHRPE), which we describe here.

PRESENTATION OF CASE

42-year-old male with GS presenting with flashes and floaters observed to have CHRPE-like lesions characteristic of GS.

DISCUSSION

Subtle CHRPE findings differentiate pathological, described in the present case, from non-pathological etiologies and may guide further management.

CONCLUSION

Here we present the signs and symptoms that raise suspicion for GS associated with CHRPE and how to approach management late in the disease presentation.

Relationship Between Macular Thickness and Visual Acuity in the Treatment of Diabetic Macular Edema With Anti-VEGF Therapy: Systematic Review

Purpose:

To examine the relationship between central macular thickness (CMT) measured by optical coherence tomography (OCT) and visual acuity (VA) in patients with center-involving diabetic macular edema (DME) receiving antivascular endothelial growth factor (anti-VEGF) treatment.

Methods:

Peer-reviewed articles from 2016 to 2020 reporting intravitreal injections of bevacizumab, ranibizumab, or aflibercept that provided data on pretreatment (baseline) and final retinal thickness (CMT) and visual acuity (VA) were identified. The relationship between relative changes was assessed via a linear random-effects regression model controlling for treatment group.

Results:

No significant association between the logarithm of the minimum angle of resolution (logMAR) VA and CMT was found in 41 eligible studies evaluating 2667 eyes. The observed effect estimate was a 0.12 increase (95% CI, −0.124 to 2.47) in logMAR VA per 100 µm reduction in CMT after treatment change. There were no significant differences in logMAR VA between the anti-VEGF treatment groups.

Conclusions:

There was no statistically significant relationship between the change in logMAR VA and change in CMT as well as no significant effect of the type of anti-VEGF treatment on the change in logMAR VA. Although OCT analysis, including measurements of CMT, will continue to be an integral part of the management of DME, further exploration is needed on additional anatomic factors that might contribute to visual outcomes.

Vitrectomy with Silicone Oil Tamponade and Single-Dose Intravitreal Methotrexate for Recurrent Retinal Detachment with Proliferative Vitreoretinopathy

Our case emphasizes the approach of a single-dose of intraoperative methotrexate (MTX) - applied directly into silicone oil - to arrest the anomalous progression of proliferative vitreoretinopathy (PVR). A 78-year-old male presented with severe vision loss secondary to a pseudophakic macula-off rhegmatogenous retinal detachment oculus sinister (OS). He was initially treated with primary pars plana vitrectomy and intraocular gas; however, the patient developed recurrent macula-off retinal detachment complicated by proliferative vitreoretinopathy OS. Subsequent management involved vitrectomy with membrane removal, silicone oil tamponade, and adjuvant intravitreal MTX. The patient had an uneventful postoperative recovery with a dramatic vision improvement after silicone oil removal OS. Here, we highlight the use of silicone oil tamponade with single-dose adjuvant MTX for the management of complex retinal detachment associated with proliferative vitreoretinopathy.

Combined Retinoschisis and Rhegmatogenous Retinal Detachment With a Very Large Outer Retinal Hole

This case report describes a diagnosis of retinoschisis and retinal detachment in a patient in their 40s who presented with acute onset of flashes and floaters.

Retrolenticular Vitreous Opacities as a Diagnostic Indicator of Systemic Amyloidosis

Purpose: Systemic amyloidosis is a group of rare, life-threatening disorders characterized by the deposition of amyloid plaques in numerous tissues. Vitreous involvement can occur in amyloidosis and here we describe critical diagnostic findings. Methods: Case report of vitreous amyloidosis diagnosis confounded by non-specific presentation. Results: Despite false-negative vitreous biopsies, in the setting of previous vitreoretinal surgery, the case reveals vitreous opacities, decreased visual acuity, and retinal neovascularization as critical signs in ocular amyloidosis. Conclusions: Here we present the signs and symptoms that raise suspicion for vitreous amyloidosis and how to approach diagnosis early in the disease presentation.

Trocar-Based Surgical Approach to Suprachoroidal Hemorrhage Drainage

Purpose:

Suprachoroidal hemorrhage is an uncommon but serious ocular condition that typically occurs in the setting of intraocular surgery and trauma. We present an external trans-conjunctival vitreoretinal trocar-cannula-based drainage of suprachoroidal hemorrhage as a viable surgical approach.

Methods:

Case report.

Results:

Trans-conjunctival trocar-cannula-based drainage of suprachoroidal hemorrhage is a safe and efficacious surgical approach to drainage of large choroidal hemorrhages.

Conclusions:

Although discrepancies persist regarding the optimal surgical approach to suprachoroidal hemorrhage management; herein, we describe the successful execution of an external trans-conjunctival vitreoretinal trocar-cannula-based drainage of suprachoroidal hemorrhage.

Iatrogenic Subretinal Triamcinolone During Primary Surgical Repair of a Retinal Detachment With a Giant Retinal Tear

Purpose:

We describe the outcome of a 23-year-old man undergoing vitreoretinal surgery for a macula-off rhegmatogenous retinal detachment secondary to a giant retinal tear.

Methods:

Patient underwent combined 25- gauge 3-port pars plana vitrectomy with scleral buckle, perfluorocarbon liquid, and perfluoropropane gas tamponade. During surgery, triamcinolone inadvertently entered the subretinal space and was retained.

Results:

The subretinal triamcinolone deposits spontaneously absorbed over a 2-month period. No adverse sequelae were associated with this complication.

Conclusion:

This may support avoiding aggressive mechanical removal of iatrogenic subretinal triamcinolone in the context of retinal detachment repair.

Recurrent Spontaneous Macular Hole Formation and Resolution in a Patient With Previous Vitrectomy

Purpose:

We report a case of recurrent macular hole (MH) formation and spontaneous closure in the absence of any vitreoretinal interface abnormality.

Methods:

A 49-year-old man presented for his annual ocular examination with no specific ocular complaints. He had a history of retinal detachment in the left eye, which was treated years prior with vitrectomy and scleral buckle. During a routine follow-up, the patient was discovered to have a full-thickness MH. Optical coherence tomography revealed the formation of an MH with spontaneous closure after 3 months without intervention. One month later, the MH recurred but once again closed spontaneously over 4 months.

Results:

The patient remained asymptomatic during the entire follow-up without any symptoms, vision changes, or therapeutic intervention.

Conclusions:

To our knowledge, this is the first known case report of recurrent spontaneous opening and closure of an MH in the absence of any vitreoretinal interface abnormality, as revealed by macular optical coherence tomography imaging.

Chronic Unilateral Uveitis with Macular Edema Secondary to Dabrafenib for Pilocytic Astrocytoma

This report describes a unique case of chronic unilateral anterior uveitis associated with macular edema while on oral dabrafenib treatment for chronic recurrent pilocytic astrocytoma. After gradual taper of prednisolone acetate OS, the patient developed recurrent mild low-grade anterior uveitis and macular edema OS that required low dose of prednisolone acetate OS to prevent recurrences while on oral dabrafenib. When oral dabrafenib was temporarily discontinued for 3 months due to her ocular inflammation, she had no flares of her uveitis; however, her tumor increased significantly in size. The collaborative decision was made to continue her oral dabrafenib while on topical anti-inflammatory therapy for her uveitis. Clinicians should be aware of this potential unilateral sequela of uveitis secondary to dabrafenib. Further investigation should be conducted to identify factors that may place certain patients at higher risk for this complication.

Antioxidants for the Treatment of Retinal Disease: Summary of Recent Evidence

Retinal tissue is prone to oxidant burden and oxidative stress secondary to the generation of reactive oxygen species from high metabolic demand. The formation of reactive oxygen species occurs primarily from the mitochondrial respiratory chain as well as several enzymatic and oxidation reactions that occur in the neurosensory retina and retinal pigment epithelium. This oxidative stress has been implicated in the pathogenesis of several retinal diseases and the role of antioxidants as a therapeutic treatment shows promise in slowing the progression of certain diseases. The aim of this narrative review is to describe the mechanisms of retinal oxidative stress and summarize the current available evidence for antioxidants as a treatment for vitreoretinal disorders.

Idiopathic retinal arterial occlusive vasculitis in the setting of multiple arterial occlusions

Purpose

We present a patient with vaso-occlusive retinal vasculitis to summarize this uncommon entity and review the clinical features and management challenges applicable to patients with retinal vasculitis.

Observations

A 76-year-old male presented with sudden-onset severe central vision loss. On examination, vitreous hemorrhage, neovascularization of the optic nerve, peripheral segmental periphlebitis, vessel sclerosis, vascular sheathing, and retinal hemorrhages were observed, and a diagnosis of active vaso-occlusive retinal vasculitis was made. The patient then underwent a complete infectious, inflammatory, and neoplastic workup which returned negative. The patient was treated with locally with a sub-Tenon's injection of 40 mg triamcinolone on presentation and later with oral prednisone. At three-month follow-up, vision improved to 20/300 with regressing neovascularization and clearing of vitreous hemorrhage in the right eye (OD).

Conclusions

Considering novel associations of occlusive retinal vasculitis, it is important to recognize that idiopathic occlusive retinal vasculitis, although uncommon, can occur and represents a prototypical disease form. It is imperative that these patients have a complete infectious, inflammatory, and neoplastic workup owing to the possible overlap of masquerade clinical signs and symptoms.

Vision Recovery Velocity, Momentum and Acceleration: Advanced Vitreoretinal Analytics as Measure of Treatment Efficacy for Neovascular Age-Related Macular Degeneration

Purpose

Currently, varying treatment paradigms and different clinical trial constructs preclude cross-trial comparison between different available vascular endothelial growth factor (VEGF) inhibitors. This study aimed to review the evidence and compare the efficacy of anti-VEGF therapies for neovascular age-related macular degeneration (nAMD), and to develop metrics as a means of facilitating standardized comparison between different anti-VEGF agents within the Advanced VitreoRetinal Analytics (AVRA) model.

Methods

The study analyzed key outcomes in clinical trials of bevacizumab, ranibizumab, aflibercept, and brolucizumab, including best corrected visual acuity (BCVA), number of injections, and duration of follow-up (minimum follow-up of 48 weeks).

Results

The AVRA model includes 1) vision recovery velocity (VRV; letters per unit time), which provides a metric of letters gained or lost over time (or the speed of improvement); 2) injection momentum (InjMom; number of injections multiplied by letters per unit time; units of injections•(letters/time)), which is defined as the number of injections multiplied by VRV and describes the quantity of treatment needed to achieve a vision outcome; and 3) vision recovery acceleration (VRA; letters per unit time squared; units of letters/time²), which denotes final VRV minus initial VRV, per unit time, and describes the rate of change in letters gained or lost over time.

Conclusion

AVRA stipulates that the ideal VEGF inhibitor to treat nAMD would have a higher positive VRV (more letters gained per unit time), low InjMom (lower treatment burden requiring fewer interventions for a given visual acuity outcome), and VRA approximating zero (indicating stable vision over time). AVRA allows comparisons across different trials to determine the optimal anti-VEGF agent for the treatment of nAMD.

Lipemia Retinalis in a Patient with Familial Hypertriglyceridemia

A 45-year-old female with a history of hypertension presented with complaints of intermittent vision loss and blurred vision. Clinical examination revealed diffuse retinal whitening in the peripapillary area with multiple visible emboli in the first- and second-order arteries. The patient’s retinal findings were keeping within features of lipemia retinalis, and serum lipids were ordered which returned a triglyceride level of 1504 mg/dL. The patient was referred to primary care for vascular risk factor management and potential genetic testing. Ocular signs of hypertriglyceridemia manifest as lipemia retinalis, characterized by white vascular lesions and retinal lipid infiltration. The high comorbidity of hypertriglyceridemia and hypertension may warrant close monitoring hypertensive complications such as hypertensive retinopathy.

Management and Visual Outcomes of Acute Bacterial Endophthalmitis Following Intravitreal Injection of Contaminated Bevacizumab in a Single Day

BACKGROUND AND OBJECTIVE

Bevacizumab requires compounding for off-label intravitreal injection, thus creating a risk of possible contamination during preparation.

PATIENTS AND METHODS

This retrospective, consecutive case series from a single site included patients who developed culture-proven acute endophthalmitis after intravitreal injection with contaminated bevacizumab. All patients suspected of endophthalmitis had vitreous biopsy and microbial cultures prior to initiation of treatment and were managed with immediate tap and injection of antibiotics followed early by pars plana vitrectomy. Main outcome measures included best-corrected visual acuity (BCVA) at 3-month follow-up after treatment.

RESULTS

Twenty-four patients developed acute bacterial endophthalmitis following intravitreal injection of contaminated bevacizumab single-dose syringes in a single day. Twenty-three cases (95.8%) grew Streptococcus species and one (4.2%) grew Enterococcus species. Six cases (25.0%) had optic nerve atrophy, three (12.5%) developed retinal detachment, one (4.2%) had vitreous hemorrhage, and one (4.2%) had band keratopathy. At 3-month follow-up, compared to BCVA at the time of initial presentation, 11 patients (45.8%) had improved vision, eight (33.3%) had unchanged BCVA, and five (20.8%) had worse BCVA. However, when compared to BCVA prior to endophthalmitis (baseline), 22 cases (91.7%) had significantly worse BCVA at 3-month follow-up.

CONCLUSIONS

Contamination of off-label bevacizumab poses devastating risk of endophthalmitis following intravitreal injection. Vigilance is needed to ensure all possible safeguards are in place to prevent contamination. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:346-352.].

An Atypical Presentation of Acute Macular Neuroretinopathy after Non-Ocular Trauma

Purpose

Acute macular neuroretinopathy (AMN) is a rare clinical entity with an uncertain etiology. We report an atypical case presenting with retinal hemorrhages (RH) and cotton-wool spots (CWS) following non-ocular trauma.

Observations

A 49-year-old male presented with an acute onset of a paracentral scotoma in his left eye, immediately following a motor vehicle accident 1 day prior. Fundus findings revealed a unilateral nasal petalloid perifoveal lesion with the tip pointing toward the fovea associated with CWS and RH. Optical coherence tomography demonstrated disruption of the ellipsoid zone. Symptoms and exam findings improved at 2-week follow-up without any intervention, consistent with the natural history of the disease process.

Conclusion

We report a rare case of AMN following non-ocular trauma with the unique fundus findings of CWS and RH. This presentation supports the role of ischemia in the retinal deep capillary plexus, of which trauma contributed to the pathophysiological process.

Summary

AMN is a rare condition whose pathophysiological process remains speculative. We report an atypical case of AMN, which supports the role of trauma in the pathophysiology of deep retinal capillary plexus compromise.

Fibrin Glue and Internal Limiting Membrane Abrasion for Optic Disc Pit Maculopathy

BACKGROUND AND OBJECTIVE

To describe a novel surgical technique using pars plana vitrectomy (PPV), internal limiting membrane (ILM) abrasion, and intravitreal fibrin glue for the treatment of optic disc pit maculopathy.

PATIENTS AND METHODS

Surgical case series technique with scanning electron microscopy (SEM) of human post-mortem eyes.

RESULTS

Using SEM, the authors demonstrate the persistent adherence of vitreous fragments to the optic disc following induction of posterior vitreous detachment in human postmortem eyes. The authors describe a surgical technique using PPV, Tano Diamond Dusted Membrane Scraper for an ILM abrasion, intravitreal fibrin glue (Tisseel), and gas-air exchange to seal optic disc pits. The authors report successful long-term visual and anatomical outcomes in three patients.

CONCLUSIONS

Intravitreal fibrin glue, when combined with ILM abrasion, may be a viable treatment option for optic disc pit maculopathy with good short- and long-term visual acuity outcomes. SEM shows that ILM abrasion removes vitreous fragments, which are persistently adherent and may lead to failure with other interventional techniques. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e271-e277.].

Endophthalmitis after Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitors: Management and Visual Outcomes

PURPOSE

We describe the presentation of patients developing endophthalmitis after intravitreal injection with vascular endothelial growth factor (VEGF) inhibitors. Moreover, we evaluate the management by comparing the outcomes of immediate tap and injection of intravitreal antibiotics (TAI) versus initial surgical pars plana vitrectomy (PPV). Finally, we analyze the predictive factors of visual outcomes at 6-month follow-up.

DESIGN

Retrospective, single-center, nonrandomized interventional study.

PARTICIPANTS

Patients developing endophthalmitis after receiving an intravitreal injection of anti-VEGF agent between 2006 and 2016.

METHODS

All patients received a vitreous biopsy sent for cultures before the initiation of treatment: TAI group versus PPV with intravitreal antibiotics (PPV group).

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) at 6-month follow-up after treatment for endophthalmitis.

RESULTS

A total of 258 357 intravitreal injections occurred over the course of the 10-year period, of which 40 patients (0.016%) had endophthalmitis within 3 weeks after injection. In total, 34 patients (85.0%) had pain and 25 patients (62.5%) had hypopyon on initial examination. Among 24 culture-positive cases, 66.7% of the causative organisms were coagulase-negative Staphylococcus, followed by Streptococcus species (10.0%). The best-corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution [logMAR]) at 6-month follow-up was significantly worse for patients who had a positive culture for Streptococcus species (4.0; standard deviation [SD], 0.8) (approximately light perception) compared with those who had a positive culture for coagulase-negative Staphylococcus (0.4; SD, 0.3) (∼20/50) (P < 0.0001). Compared with the TAI group, a higher proportion of samples were culture-positive in the PPV group (90.9% vs. 48.3%, P = 0.03). There was no statistically significant difference in BCVA at 6-month follow-up between the TAI and PPV groups. Younger age (<85 years) and lower intraocular pressure (IOP) (≤25 mmHg) at presentation were predictive of achieving a BCVA of 20/400 or better at 6-month follow-up after treatment. Initial management (TAI vs. PPV), duration of symptoms, presence of pain, presence of hypopyon, presenting BCVA, and culture status (positive vs. negative) were not found to be predictive of visual outcomes at 6-month follow-up.

CONCLUSIONS

No significant difference in BCVA at 6-month follow-up was detected between the TAI and PPV groups. Younger age and lower IOP at presentation were associated with better visual outcomes at 6-month follow-up.

Epiretinal membrane and cystoid macular edema as predictive factors of recurrent proliferative vitreoretinopathy

PURPOSE

Proliferative vitreoretinopathy (PVR) is the most common cause of recurrent retinal detachment (RD). We sought to determine the predictive factors of recurrent PVR formation and the need for additional vitreoretinal surgical intervention after uncomplicated primary RD repair.

METHODS

This is a retrospective single-center case-control study of consecutive patients with PVR formation after uncomplicated RD repair. Logistic regression was used to assess factors associated with recurrent PVR formation.

RESULTS

Thirty-seven eyes (37 patients) who had recurrent RD secondary to PVR formation were included. Among those, 27 eyes needed one additional surgery, whereas the remainder 10 eyes required two or more additional surgeries. In the univariate analysis, patients who had cystoid macular edema (CME) after the second surgery were 8.33 times (crude odds ratio [COR], 95% confidence interval [CI]: 1.23-56.67, p=0.0302) more likely to have recurrent PVR formation compared to those who did not have CME after the second surgery. Similarly, those who had epiretinal membrane (ERM) after the second surgery were 8.00 times (COR, 95% CI: 1.43-44.92, p=0.0182) more likely to have recurrent PVR formation compared to those who did not have ERM after the second surgery. In the multivariate analysis, patients who had ERM after the second surgery were 8.20 times (adjusted odds ratio [AOR], 95% CI: 1.08-62.40, p=0.0422) more likely to develop recurrent PVR compared to those who did not have ERM after the second surgery, when adjusted for age, sex, and CME after the second surgery.

CONCLUSION

ERM and CME are potential predictive factors for recurrent PVR formation after uncomplicated primary RD repair. Early recognition and treatment of ERM and CME may be critical to prevent subsequent PVR formation and improve visual outcomes.

Efficacy of the Intravitreal Sustained-Release Dexamethasone Implant for Diabetic Macular Edema Refractory to Anti-Vascular Endothelial Growth Factor Therapy: Meta-Analysis and Clinical Implications

BACKGROUND AND OBJECTIVE

To assess the effect on best-corrected visual acuity (BCVA) and efficacy of the intravitreal sustained-release 0.7 mg dexamethasone implant (Ozurdex; Allergan, Irvine, CA) in patients with recalcitrant diabetic macular edema (DME).

PATIENTS AND METHODS

Meta-analysis utilizing the MOOSE framework and a random effects model. Studies included adults undergoing treatment with Ozurdex for DME. The methodologic quality of each study was assessed using the MINORS and the Cochrane Collaboration Risk of Bias for randomized studies.

RESULTS

A total of 3,859 patients among 15 studies were included in the final analysis. The mean difference in BCVA was a gain of four lines or 20 Early Treatment of Diabetic Retinopathy Study letters with Ozurdex at a mean follow-up period of 6 months.

CONCLUSIONS

Treatment with Ozurdex is associated with significant mean improvement in visual acuity. Clinicians should have a multimodality approach to treating DME and be aware of this treatment option in those who have a suboptimal response to anti-VEGF therapy. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:160-166.].

SURGICAL EMBOLECTOMY FOR FOVEA-THREATENING ACUTE RETINAL ARTERY OCCLUSION

Supplemental Digital Content is Available in the Text.

The authors describe a surgical technique to facilitate the exposure and retrieval of embolus in cases of fovea-threatening retinal artery occlusion without a patent cilioretinal artery. The authors include a number of surgical pearls based on our experience that may facilitate intraocular emboli retrieval and minimize the common complication of vitreous hemorrhage associated with retinal embolectomy.

To describe a technique of surgical intraocular embolectomy in patients with acute fovea-threatening branch retinal artery occlusion.

Deer tick masquerading as pigmented conjunctival lesion

Purpose

Conjunctival adherence of a tick is an uncommon event with few reports previously cited in the literature. We report a unique case of tick penetration, specifically a black-legged deer tick (Ixodes scapularis), into the conjunctiva.

Observations

This patient experienced a 3-week history of unilateral mild ocular pain, decreased vision, and pigmented lesion of her right eye. Slit lamp examination demonstrated a tick attached to the conjunctiva. Pathology confirmed the insect exoskeleton. Visual appreciation of the tick demonstrated probable deer tick larval stage given the shape, size, pigmentation pattern and geographic location of the specimen. Polymyxin-trimethoprim eye drops were prescribed for use three times daily and loteprednol twice daily.

Conclusions and importance

Despite the low risk for Lyme disease, which is endemic to the Adirondack region where the patient was affected, doxycycline was prescribed for prophylaxis. In any case of suspected tick penetration to the ocular surface, immediate ophthalmologic consultation and prompt removal via the method mentioned above is recommended, as well as attention paid to the Infectious Diseases Society of America guidelines regarding prophylaxis.

Five-Port Combined Limbal and Pars Plana Vitrectomy for Infectious Endophthalmitis

Pars plana vitrectomy for acute infectious endophthalmitis can be challenging due to severe inflammation in the anterior chamber creating significant media opacity. We describe a surgical technique combining limbal based vitrectomy and pars plana vitrectomy to manage acute infectious endophthalmitis. Limbal based vitrectomy facilitates removal of anterior chamber fibrin and inflammatory membranes for safe and optimal posterior pars plana vitrectomy.

Retinal Injury Secondary to Laser Pointers in Pediatric Patients

This case report describes 4 male children (age, 9-16) who had laser-related retinal injury to the macula of 1 eye or both eyes due to the mishandling of the laser pointer devices at a single vitreoretinal clinical practice. The presenting symptoms associated with laser pointer injury include central vision loss, central scotoma, and metamorphopsia. Clinical findings of laser-related retinal injury include reduced visual acuity, disruption of the photoreceptor ellipsoid zone, retinal pigment epithelium atrophy, and choroidal neovascular membrane formation. Disruption of the foveal ellipsoid zone (photoreceptor inner segment/outer segment layer) is the most common finding on optical coherence tomography imaging. Three patients had potential irreversible vision loss. Laser pointers are readily available and appropriate use of laser pointers in the pediatric population must be emphasized due to the potential irreversible retinal injury. Health professionals, school teachers, and parents should raise public awareness of this emerging public health issue by educating children about the dangers of laser pointers. Laser pointer devices among children should be discouraged and limited due to the possibility of permanent harm to themselves and others. Legislation and laws may be required to better control the sale and use of these devices.

Delayed fungal endophthalmitis secondary to Curvularia

Purpose

To describe a case of fungal endophthalmitis secondary to Curvularia after cataract surgery.

Observations

This case showed delayed and recalcitrant fungal endophthalmitis secondary to Curvularia despite treatment with pars plana vitrectomy, intravitreal antifungal therapy, and systemic antifungals.

Conclusions and importance

Curvularia-associated endophthalmitis should be considered in the differential diagnosis of delayed post-cataract endophthalmitis, especially in tropical or subtropical geographical areas. Awareness and early identification, timely removal of the nidi of sequestration, and prolonged antifungal treatments are important for the eradication of Curvularia-associated endophthalmitis.

Comparison of microbiology and visual outcomes of patients undergoing small-gauge and 20-gauge vitrectomy for endophthalmitis

Background

The role of pars plana vitrectomy (PPV) for endophthalmitis has evolved over recent decades but the literature is lacking on comparisons between small-gauge and 20-gauge vitrectomy.

Objective

To evaluate evolving etiological and microbiological trends in patients undergoing vitrectomy for endophthalmitis and to compare culture-positive rates and visual outcomes between small-gauge (23- and 25-gauge) and 20-gauge instrumentation during vitrectomy for endophthalmitis.

Methods

Ten-year retrospective comparative case series and prospective laboratory in vitro testing. Tertiary care academic referral center. Patients who underwent PPV for endophthalmitis between 2003 and 2013. Vitreous biopsies were obtained in all cases. The effect of vitrectomy gauge (20-, 23-, and 25-gauge) and vitreous cutting rate (1,500 and 5,000 cuts per minute) on the viability of bacterial culture was evaluated in an in vitro prospective laboratory investigation.

Main outcome measures

Comparison of etiology, microbiology culture-positive rates, and visual outcomes between small-gauge and 20-gauge instrumentation in patients undergoing PPV for infectious endophthalmitis.

Results

A total of 61 cases of vitrectomy for endophthalmitis were identified over a 10-year period; of these, 34 were treated with small-gauge (23- and 25-gauge) vitrectomy and 27 were treated with 20-gauge vitrectomy. In the small-gauge group, 12 cases (35.3%) yielded culture-positive results versus 20 cases (74.1%) with culture positivity in the 20-gauge cohort (P=0.002). The most common cause of endophthalmitis was cataract surgery and the most frequently identified organism was coagulase-negative Staphylococci in both groups. There was no significant difference in mean postoperative visual acuities between groups (P=0.33). Etiological trends indicate an increase in endophthalmitis due to intravitreal injection in the small-gauge group (n=9) compared to the 20-gauge group (n=3) (P=0.001). In vitro laboratory testing revealed no significant difference in rates of culture growth for different vitrectomy gauge sizes or vitreous cutting speeds.

Conclusion and relevance

Small-gauge vitrectomy for endophthalmitis yields final visual outcomes comparable to 20-gauge instrumentation. A significant difference in culture-positive rates was observed between small-gauge and 20-gauge instrumentation for vitrectomy in endophthalmitis; however, laboratory testing indicates this is not related to either vitreous gauge size or cutter speed. Intravitreal injections are emerging as a common etiology of vitrectomy for endophthalmitis.

ELEVATED INTRAOCULAR PRESSURE FOLLOWING PARS PLANA VITRECTOMY DUE TO TRAPPED GAS IN THE POSTERIOR CHAMBER

PURPOSE

Elevated intraocular pressure is relatively common following pars plana vitrectomy and intraocular gas tamponade. We discuss a series of patients who experienced elevated intraocular pressure from pupillary block and angle closure secondary to trapped gas in the posterior chamber.

METHODS

Case series.

RESULTS

Case 1 is a patient who underwent pars plana vitrectomy for retinal detachment repair. The intraocular pressure was elevated on postoperative Day 3 because of trapped gas in the posterior chamber, and it did not lower with prone positioning, maximal medical therapy, and laser peripheral iridotomies. Aspiration of the trapped gas was done with the patient sitting upright using a 27-gauge needle at the limbus, which was curative. Case 2 provides anterior-segment optical coherence tomography images that confirmed the location of the trapped gas resulting in angle closure. Case 3 demonstrates the unfortunate sequelae of a central retinal artery occlusion following delayed recognition of this entity. Case 4 highlights the challenges encountered when migratory gas is also seen elsewhere in the eye.

CONCLUSION

Clinicians should be aware of elevated intraocular pressure secondary to trapped gas in the posterior chamber, which may be recalcitrant to medical therapy. Aspiration of the trapped gas can alleviate both pupillary block and angle closure without compromising the gas tamponade.

Spontaneous dislocation of a fluocinolone acetonide implant (Retisert) into the anterior chamber and its successful extraction in sympathetic ophthalmia

PURPOSE

To report a case of spontaneous fluocinolone acetonide (Retisert) implant dislocation and migration into the anterior chamber.

METHODS

Retrospective case report.

PATIENTS

One patient with sympathetic ophthalmia uveitis was well controlled by fluocinolone acetonide implants.

RESULTS

The fluocinolone acetonide implant spontaneously migrated into the anterior chamber causing corneal edema and anterior chamber reaction. The implant was subsequently successfully removed through a temporal corneal wound.

CONCLUSION

Clinicians should be aware of the spontaneous dislocation and migration of an intact fluocinolone implant as a potential surgical complication, particularly in pseudophakic eyes with iridectomy.

Positive Auto-Antibody Activity With Retina and Optic Nerve in Smokers and Non-Smokers: The Controversy Continues

Auto-antibodies assist with the diagnosis of ocular paraneoplastic syndromes and autoimmune ocular conditions; however, the frequency of positive test results as a possible precursor to future disease is unknown. The frequency of positive antibodies in heavy smokers who may be at risk for autoimmune-related retinopathy and optic neuropathy was evaluated. Serum antibody activity was evaluated through the use of Western blot reactions from pig retina and optic nerve extract. Fifty-one patients were included: 35 patients were smokers (average: 40.9 pack-year history) and 26 patients had no past smoking history. None of the patients had any visual complaints or known eye disease. Of the patients studied, 76.5% (39 patients: 18 smokers, 21 non-smokers) had positive antiretinal antibodies, and 19.6% (10 patients: 3 smokers, 7 non-smokers) had positive antioptic nerve antibodies. Anti-retinal antibodies were seen in a majority of randomly selected patients with and without a past smoking history. Anti-optic nerve bodies were less common, but more prevalent in those who never smoked. The specificity of these antibodies remains greatly uncertain and clinical correlation is warranted.

Effect of internal limiting membrane abrasion on retinal tissues in macular holes

PURPOSE

The purpose of this study was to identify the structural and histological effects of a Tano diamond-dusted membrane scraper (DDMS) on the retinal surface after internal limiting membrane (ILM) abrasion in macular hole surgery.

METHODS

Institutional experimental study was performed in 11 eyes. All eyes underwent ILM abrasion in the operating room with a DDMS for macular hole repair as an alternative to traditional ILM peeling. Three human donor eyes underwent an identical procedure in the laboratory. Retinal tissues were removed by ILM abrasion with a DDMS during vitrectomy for macular hole repair and retinal tissues remaining in human donor eyes. Main outcome measures were microscopic and immunohistological characteristics of instrument tip tissues and retinal structure after ILM abrasion.

RESULTS

The tips of the Tano DDMS showed evidence of cellular membranes and ILM removal. The retinas showed distinct areas of lamellar ILM removal without penetration of the retinal nerve fiber layer (RNFL).

CONCLUSIONS

Application of the Tano DDMS instrument is sufficient to remove membranes from the surface of the ILM and layers of the ILM without disruption of the underlying RNFL. Internal limiting membrane abrasion can be a useful and effective alternative to complete ILM removal for macular surgery.

Macular Hole Closure With Internal Limiting Membrane Abrasion Technique

IMPORTANCE

Internal limiting membrane (ILM) abrasion is an alternative surgical technique for successful full-thickness macular hole (MH) repair.

OBJECTIVE

To study the effects of ILM abrasion as an alternative method of MH repair.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective consecutive case series from January 2006 to December 2008. Demographic data and preoperative, intraoperative, and postoperative examination records of all patients were reviewed for patients who underwent ILM abrasion with a diamond-dusted membrane scraper during vitrectomy for MH repair. A total of 100 eyes underwent ILM abrasion as an alternative to traditional ILM peeling.

MAIN OUTCOMES AND MEASURES

Rate of MH closure and visual acuity (VA) outcomes at 3 months after surgery.

RESULTS

Macular hole closure was achieved with a single surgical procedure in 94 of 100 eyes (94.0%; 95% CI, 87.4%-97.8%). Among all patients, the median preoperative VA was 20/100 (range, 20/30 to hand motions; 25th quartile, 20/60; and 75th quartile, 20/160), and the median postoperative VA at 3 months after surgery was 20/60 (range, 20/20 to hand motions; 25th quartile, 20/40; and 75th quartile, 20/100). Among all patients with stage 2 MHs, 30 of 38 patients (78.9%) had at least 2 lines of VA gain: 15 of 23 (65.2%) were phakic, and 15 of 15 (100%) were pseudophakic. Four of 38 patients (10.5%) with stage 2 MHs had at least 2 lines of VA loss, and all were phakic. Among all patients with stage 3 or 4 MHs, 42 of 62 (67.7%) had at least 2 lines of VA gain, of which 30 of 38 (78.9%) were phakic and 22 of 24 (91.7%) were pseudophakic. Six of 62 patients (9.7%) with stage 3 or 4 MHs had at least 2 lines of VA loss: 4 were phakic, and 2 were pseudophakic. In total, 35.0% (95% CI, 25.7%-44.3%) of patients achieved 20/40 vision or better, and 52.0% (95% CI, 42.2%-61.8%) of patients achieved 20/50 vision or better.

CONCLUSIONS AND RELEVANCE

Abrasion of the ILM with a diamond-dusted membrane scraper at the time of vitrectomy achieves high rates of MH closure. This technique avoids complete removal of the retinal ILM basement membrane and subjacent tissues and appears to provide MH closure rates similar to those of traditional ILM peeling.

Oral mineralocorticoid antagonists for recalcitrant central serous chorioretinopathy

PURPOSE

To evaluate the effect and tolerance of oral mineralocorticoid antagonists, eplerenone and/or spironolactone, in recalcitrant central serous chorioretinopathy.

METHODS

Retrospective consecutive observational case series. Primary outcome measures included central macular thickness (CMT, μm), macular volume (MV, mm(3)), Snellen visual acuity, and prior treatment failures. Secondary outcomes included duration of treatment, treatment dosage, and systemic side effects.

RESULTS

A total of 120 patients with central serous chorioretinopathy were reviewed, of which 29 patients were treated with one or more mineralocorticoid antagonists. The average age of patients was 58.4 years. Sixteen patients (69.6%) were recalcitrant to other interventions prior to treatment with oral mineralocorticoid antagonists, with an average washout period of 15.3 months. The average duration of mineralocorticoid antagonist treatment was 3.9±2.3 months. Twelve patients (52.2%) showed decreased CMT and MV, six patients (26.1%) had increase in both, and five patients (21.7%) had negligible changes. The mean decrease in CMT of all patients was 42.4 μm (range, -136 to 255 μm): 100.7 μm among treatment-naïve patients, and 16.9 μm among recalcitrant patients. The mean decrease in MV of all patients was 0.20 mm(3) (range, -2.33 to 2.90 mm(3)): 0.6 mm(3) among treatment-naïve patients, and 0.0 mm(3) among recalcitrant patients. Median visual acuity at the start of therapy was 20/30 (range, 20/20-20/250), and at final follow-up it was 20/40 (range, 20/20-20/125). Nine patients (39.1%) experienced systemic side effects, of which three patients (13.0%) were unable to continue therapy.

CONCLUSION

Mineralocorticoid antagonist treatment had a positive treatment effect in half of our patients. The decrease in CMT and MV was much less in the recalcitrant group compared to the treatment-naïve group. An improvement in vision was seen only in the treatment-naïve group. Systemic side effects, even at low doses, may limit its usage in some patients.

Long-term outcomes in patients undergoing vitrectomy for retinal detachment due to viral retinitis

Purpose

To determine the outcomes in patients with rhegmatogenous retinal detachment (RRD) secondary to viral retinitis.

Patients and methods

This was a retrospective, consecutive, noncomparative, interventional case series of 12 eyes in ten patients with RRD secondary to viral retinitis. Results of vitreous or aqueous biopsy, effect of antiviral therapeutics, time to retinal detachment, course of visual acuity, and anatomic and surgical outcomes were investigated.

Results

There were 1,259 cases of RRD during the study period, with 12 cases of RRD secondary to viral retinitis (prevalence of 0.95%). Follow-up was available for a mean period of 4.4 years. Varicella zoster virus was detected in six eyes, herpes simplex virus in two eyes, and cytomegalovirus in two eyes. Eight patients were treated with oral valacyclovir and two patients with intravenous acyclovir. Lack of optic nerve involvement correlated with improved final visual acuity of 20/100 or greater. Pars plana vitrectomy (n=12), silicone-oil tamponade (n=11), and scleral buckling (n=10) provided successful anatomic retinal reattachment in all cases, with no recurrent retinal detachment and no cases of hypotony during the follow-up period.

Conclusion

Varicella zoster virus was the most frequent cause of viral retinitis, and lack of optic nerve involvement was predictive of a favorable visual acuity prognosis. Vitrectomy with silicone-oil tamponade and scleral buckle placement provided stable anatomical outcomes.

Comparison of retinal and choriocapillaris thicknesses following sitting to supine transition in healthy individuals and patients with age-related macular degeneration

IMPORTANCE

The effects of position on retinal and choroidal structure are absent from the literature yet may provide insights into disease states such as age-related macular degeneration (AMD).

OBJECTIVE

To evaluate the effect of postural change on retinal and choroidal structures in healthy volunteers and patients with non-neovascular AMD.

DESIGN, SETTING, AND PARTICIPANTS

Prospective observational case series at an academic tertiary care retina service from September 2013 to April 2014 involving 4 unaffected volunteers (8 eyes) and 7 patients (8 eyes) with intermediate AMD. Healthy volunteers selected for the study had no evidence of ocular disease. Patients with AMD were required to have at least 10 intermediate-sized drusen.

EXPOSURES

Spectral-domain optical coherence tomography with enhanced depth imaging in upright (sitting) and supine positions. Stable imaging was achieved using a rotating adjustable mechanical arm that we constructed to allow the optical coherence tomography transducer to rotate 90°. The Iowa Reference Algorithms were used to quantify choroid and choriocapillaris thicknesses.

MAIN OUTCOMES AND MEASURES

Changes in sitting and supine position central macular thickness (in micrometers), total macular volume (in cubic millimeters), choroidal thickness (in micrometers), and choriocapillaris-equivalent thickness (CCET, in micrometers).

RESULTS

Choriocapillaris-equivalent thickness was thinner in healthy participants (9.89 μm; range, 7.15-12.5 μm) compared with patients with intermediate AMD (16.73 μm; range, 10.31-27.38 μm) (P = .02); there was no difference in overall choroidal thickness between the 2 groups (P = .38). There was a 15% CCET reduction among healthy participants when transitioning from a sitting (9.89 μm) to supine (8.4 μm; range, 6.92-10.7 μm) position (P = .02) vs a CCET reduction of 11.1% from sitting (16.73 μm) to supine (14.88 μm; range, 8.76-20.8 μm) positioning (P = .10) in patients with intermediate AMD.

CONCLUSIONS AND RELEVANCE

Intermediate AMD appears to be associated with an increase in CCET and with a lack of positional responses that are observed in the CCET of normal eyes. Our results suggest that although outer portions of the choroid do not appear to be responsive to modest positional or hydrostatic pressure, the choriocapillaris capacity is, and this is measurable in vivo. Whether this physiologic deviation that occurs in AMD is related to atrophy, inflammation, or changes in autoregulatory factors or growth factors remains to be determined.

Incomplete vitreomacular traction release using intravitreal ocriplasmin

Purpose

To report the clinical course of our first 7 consecutive patients treated with intravitreal ocriplasmin (Jetrea^®).

Methods

Retrospective case series of the first 7 patients treated with ocriplasmin between January and December 2013 at an academic tertiary care center.

Results

The average age was 78.4 years (range: 63–92). Five patients were pseudophakic and 2 patients were phakic in the injected eye. The median baseline visual acuity (VA) was 20/60 (range: 20/25 to 20/200). The median 1-month postinjection VA was 20/70, with a mean loss of 2 lines of VA among all patients. None of the patients had complete resolution of their vitreomacular traction or macular hole at 1 month of follow-up. Three patients had subsequent pars plana vitrectomy and membrane peeling surgery. The mean follow-up period for those who did not undergo vitrectomy was 9 months (range: 1–13). One patient with known ocular hypertension had an increase in intraocular pressure requiring topical pressure-lowering eyedrops. There were no cases of postinjection uveitis, endophthalmitis, retinal tears, or retinal detachment.

Conclusions

While ocriplasmin may be a viable pharmacological agent for vitreolysis, we present a series of patients that all had incomplete resolution of vitreomacular traction with and without full-thickness macular hole. There was an associated reduction in VA after ocriplasmin treatment at 1 month of follow-up. Careful analysis of the vitreoretinal interface and comorbid eye conditions is required to optimize outcome success with ocriplasmin.