Clinical Features and Treatment Outcomes of Carbapenem-Resistant Pseudomonas aeruginosa Keratitis

Importance

Evaluation of the microbiological diagnostic profile of multidrug-resistant Pseudomonas aeruginosa keratitis and potential management with rose bengal-photodynamic antimicrobial therapy (RB-PDAT) is important.

Objective

To document the disease progression of carbapenemase-resistant P aeruginosa keratitis after an artificial tear contamination outbreak.

Design, Setting, and Participants

This retrospective observation case series included 9 patients 40 years or older who presented at Bascom Palmer Eye Institute and had positive test results for multidrug-resistant P aeruginosa keratitis between January 1, 2022, and October 31, 2023.

Main Outcomes and Measures

Evaluation of type III secretion phenotype, carbapenemase-resistance genes blaGES and blaVIM susceptibility to antibiotics, and in vitro and in vivo outcomes of RB-PDAT against multidrug-resistant P aeruginosa keratitis.

Results

Among the 9 patients included in the analysis (5 women and 4 men; mean [SD] age, 73.4 [14.0] years), all samples tested positive for exoU and carbapenemase-resistant blaVIM and blaGES genes. Additionally, isolates were resistant to carbapenems as indicated by minimum inhibitory concentration testing. In vitro efficacy of RB-PDAT indicated its potential application for treating recalcitrant cases. These cases highlight the rapid progression and challenging management of multidrug-resistant P aeruginosa. Two patients were treated with RB-PDAT as an adjuvant to antibiotic therapy and had improved visual outcomes.

Conclusions and Relevance

This case series highlights the concerning progression in resistance and virulence of P aeruginosa and emphasizes the need to explore alternative therapies like RB-PDAT that have broad coverage and no known antibiotic resistance. The findings support further investigation into the potential effects of RB-PDAT for other multidrug-resistant microbes.

New Approaches to Overcoming Antimicrobial Resistance in Endophthalmitis

Endophthalmitis is a rare but vision-threatening infection characterized by marked inflammation of intraocular fluids and tissues, uncommonly seen following surgery and intravitreal injection. Antimicrobials are used worldwide in the prophylaxis and treatment of bacterial and fungal infections of the eye and are standard treatment in the preoperative and postoperative care of surgical patients. However, antimicrobials are reported to be overprescribed in many parts of the world, which contributes to antimicrobial resistance (AMR). AMR complicates the prophylaxis and treatment of endophthalmitis. This article examines the prevalence and mechanisms of AMR in ocular microorganisms, emphasizing the importance of understanding AMR patterns for tailored treatments. It also explores prophylaxis and management strategies for endophthalmitis, with a discussion on the use of intracameral antibiotic administration. The use of prophylactic intracameral antibiotics during cataract surgery is common in many parts of the world but is still controversial in some locations, especially in the US. Finally, it highlights the role of stewardship in ophthalmology and its benefits in the treatment of endophthalmitis.

Proliferative Sickle Cell Retinopathy: Outcomes of Vitreoretinal Surgery

PURPOSE

To report the clinical presentation and outcomes in patients who underwent surgery for proliferative sickle cell retinopathy (PSCR).

DESIGN

Retrospective, consecutive case series.

SUBJECTS

All patients who underwent vitreoretinal surgery for complications secondary to PSCR between January 1, 2014, and December 31, 2021, at a university referral center.

METHODS

Retrospective consecutive case series.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), single operation anatomic success rate.

RESULTS

The study included 65 eyes of 61 patients. Disease distribution included 24 (44.4%) eyes with hemoglobin SC disease, 14 (25.9%) with hemoglobin SS disease, 13 (24.1%) with sickle cell trait, and 3 (5.6%) with sickle cell-β thalassemia. Preoperative transfusion was not performed in any study patients. Regional anesthesia with monitored anesthesia care (RA-MAC) was utilized in 58 (89.2%) eyes and general anesthesia in 7 (10.8%). In eyes that underwent surgery for retinal detachment (RD; N = 52) the rate of single operation anatomic success was 72.4% with combined scleral buckling/pars plana vitrectomy (SB/PPV; N = 29) compared with 47.8% with PPV alone (N = 23; P = 0.07). Mean BCVA at the last follow-up examination was 1.27 (20/372) in the SB/PPV group and 1.05 (20/226) in the PPV group (P = 0.48). In all SB cases, an encircling band was utilized and there were no known cases of anterior segment ischemia. All eyes that had surgery for vitreous hemorrhage (N = 13) underwent PPV with endolaser and mean BCVA improved from 1.67 (20/944) preoperatively to 0.45 (20/56) at last follow-up examination (P < 0.001). Mean preoperative BCVA, indication for surgery, single operation success rate, and mean BCVA at last follow-up examination did not differ based on sickle cell disease type (P > 0.05).

CONCLUSIONS

In patients with RD, SB/PPV achieved slightly higher rates of single operation anatomic success compared with PPV alone. Visual acuity outcomes were similar in the 2 groups. The majority of patients received RA-MAC anesthesia and preoperative transfusions were not performed. There were no cases of postoperative anterior segment ischemia. Hemoglobin SC disease was the most common disease type in the current study and surgical outcomes did not differ between sickle cell disease types.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Endophthalmitis caused by Burkholderia cepacia complex (BCC): clinical characteristics, antibiotic susceptibilities, and treatment outcomes

PURPOSE

To report the clinical characteristics, antibiotic susceptibilities, and review the literature of Burkholderia cepacia complex (BCC) associated endophthalmitis.

STUDY DESIGN

Retrospective, observational case series.

METHODS

Clinical and microbiology records were reviewed for patients evaluated at the Bascom Palmer Eye Institute and diagnosed wisth culture-confirmed endophthalmitis due to BCC. Antibiotic susceptibility profiles were generated using standard microbiologic protocols via an automated VITEK system.

RESULTS

Endophthalmitis associated with BCC was diagnosed in three patients. Infection occurred in the setting of post-penetrating keratoplasty (PKP), glaucoma filtering surgery, and suspected trauma. All isolates demonstrated in vitro susceptibility to ceftazidime and meropenem. Presenting visual acuity (VA) ranged from hand motion to light perception. Initial treatment strategies included intravitreal ceftazidime (2.25 mg/0.1 mL) and vancomycin (1.0 mg/0.1 mL) injections with fortified topical antibiotics in 2 patients, and surgical debridement of a corneoscleral melt with patch graft along with both topical fortified antibiotics oral antibiotics in the third patient. In all 3 patients, there was no VA improvement at last follow-up, as 2 eyes ultimately underwent enucleation and 1 eye exhibited phthisis bulbi at last follow-up. BCC related endophthalmitis was reviewed among 13 reports. Treatment outcomes were generally poor and antibiotic resistance was common. These BCC isolates cases demonstrated broad resistance patterns, with susceptibilities to ceftazidime (58%), ciprofloxacin (53%), and gentamicin (33%).

CONCLUSIONS

Endophthalmitis caused by B. cepacia is a rare clinical entity with generally poor visual outcomes despite prompt treatment with appropriate antibiotics.

NATIONWIDE DEMOGRAPHIC DISPARITIES IN UNITED STATES EMERGENCY DEPARTMENT VISITS IN PATIENTS WITH RHEGMATOGENOUS RETINAL DETACHMENT

BACKGROUND/PURPOSE

Within the evolving landscape of healthcare in the United States (US), delineating the demographic nuances and financial implications of emergent conditions, such as rhegmatogenous retinal detachment (RRD), is paramount. This study seeks to analyze the demographic and hospital billing amount/cost of service disparities in RRD visits to emergency departments (EDs) nationwide.

METHODS

We conducted a retrospective, cross-sectional, population-based study using International Classification of Diseases, 10th revision , and Current Procedural Terminology codes in the 2016 to 2019 Nationwide Emergency Department Sample databases to identify RRD visits. The analysis included demographics, hospital billing amount, and cost of service of RRD ED management.

RESULTS

A total of 12,492 RRD encounters were identified with men constituting 64% and a prominent age group being 50 to 64 years (49.3%). Most patients (90%) were managed in metropolitan teaching hospitals, predominantly in the southern U.S. region (56.1%). Private insurance covered 45% of patients. Same-day RRD repair odds increased in November and December. Whites had a higher likelihood for same-day treatment. Hospital billing amount rose from $23,600 in 2016 to $30,354 in 2019, with stable mean total cost of service. Rhegmatogenous retinal detachment ED visit incidence did not show seasonal variation ( P = 0.819).

CONCLUSION

Most patients with RRD in U.S, EDs were middle-aged men, with Whites more likely to receive same-day repair. There was no sex bias observed in same-day repair decision-making. Although hospital billing amount increased over the study period, total cost of service remained stable. The incidence of RRD ED visits showed no seasonal variation.

Patients With Dragged Optic Disc Vessels and Retinal Folds: Clinical Features, Multimodal Imaging, and Histopathology

BACKGROUND AND OBJECTIVE

To describe the multimodal imaging and histopathological features of patients with dragged optic disc vessels (DODV).

PATIENTS AND METHODS

This is a retrospective, observational analysis using multimodal imaging of eyes with DODV in patients with retinal vascular diseases including familial exudative vitreoretinopathy, inflammatory disease, and others. In addition, two additional enucleated eyes with DODV underwent histopathological analysis.

RESULTS

Of the 13 patients, eight were girls and five were boys. Mean age was 5 years (ranging from 4 months to 10 years old). Of the 15 eyes, 12 (80%) demonstrated temporal dragging and three (20%) had nasal dragging. Retinal vascular abnormalities were present in 11 of the fellow eyes. Multimodal imaging demonstrated features of DODV including direction of traction, outer retinal thickening, increased flow, and other features. Only two (13.3%) eyes required surgical intervention. Mean follow-up was 14 (range 3 to 30 months) months. At last follow-up all eyes remained stable. Last visual acuity ranged from 20/100 to counting fingers. As well, two enucleated globes of adults with retinopathy of prematurity underwent histopathologic evaluation, showing optic nerve fibers that extended from the optic nerve into the DODV.

CONCLUSIONS

DODV is a sign of various late-stage retinal vascular diseases, associated with poor visual function. Multimodal imaging and histopathology can assist in understanding the disease pathology. [Ophthalmic Surg Lasers Imaging Retina 2023;54:634-642.].

MULTIMODAL IMAGING OF BILATERAL IDIOPATHIC MULTIFOCAL RETINAL PIGMENT EPITHELIAL DETACHMENTS IN YOUNG PATIENTS

PURPOSE

The aim of this study was to describe two cases of multiple epithelial detachments (pigment epithelial detachments [PEDs]) occurring in otherwise young, healthy patients.

METHODS

The medical and imaging records of two cases were reviewed retrospectively.

RESULTS

Multiple serous nonvascularized PEDs were present in two young, healthy patients who underwent multimodal imaging. The first patient, a 38-year-old woman, was incidentally found to have a visual acuity of 20/20 in both eyes and multiple bilateral PEDs. Imaging and a systemic work-up was negative for secondary causes, and at 36 months, vision remained stable although some of the PEDs had coalesced. The second patient, a 32-year-old woman, presented with distortion and perceived scotomas in both eyes progressive over the course of 2 years. The visual acuity was 20/20, and multimodal imaging confirmed the presence of bilateral PEDs.

CONCLUSION

Bilateral idiopathic multifocal retinal PEDs in otherwise healthy young adults is a rare condition. Longer term follow-up is needed to evaluate secondary complications and visual outcomes.

Clinical Outcome of Cystoid Macular Edema in Silicone Oil-Filled Eyes

Purpose: To investigate the clinical outcome of cystoid macular edema (CME) in eyes undergoing silicone oil (SO) tamponade with subsequent SO removal (SOR). Methods: A retrospective case series of adult patients with CME treated with SO tamponade and SOR was conducted between January 2015 and January 2021. Exclusion criteria included eyes with a prior SO tamponade, those that did not undergo SOR, or those with infectious/inflammatory diagnoses. The primary outcomes were the incidence and resolution rates of CME in eyes with SO tamponade that had undergone SOR. The secondary outcomes included changes in best-corrected visual acuity (BCVA) and central field thickness (CFT). Results: Nineteen eyes of 19 patients (58% men) aged 52 years (interquartile range [IQR], 45-66 years) met the study inclusion criteria. The median (IQR) follow-up duration post SOR was 22 (8-35) months. The mean CFT decline for the CME-resolved cases was 13.1 µm/mo (P = .257). CME resolved in only 10 eyes (53%), 7 (67%) of which occurred after SOR. The median (IQR) BCVA was 20/400 (20/200 to 20/1262) at CME diagnosis and 20/796 (20/252 to hand motions) after SOR, with 0.184 worsening in logMAR BCVA (P = .340). Medical treatment was not associated with CME resolution compared with observation (50% vs 89%, respectively; P = .069). Eyes with proliferative vitreoretinopathy (PVR) had a higher rate of persistent CME compared with eyes with other diagnoses (78% vs 10%, respectively; P = .005). Conclusions: Nearly half had nonresolution of CME after SO was removed. The VA at the last follow-up was unaffected by CME resolution. Preoperative PVR may be a risk factor for unresolved CME.

Retinal Detachment Associated with Retinal Dialysis: Clinical Features and Outcomes of Surgery in a 10-Year Study

PURPOSE

To report the surgical approaches and outcomes in patients undergoing surgery for retinal detachment associated with retinal dialysis.

DESIGN

Retrospective, consecutive case series.

SUBJECTS

All patients who underwent surgery for retinal detachment secondary to retinal dialysis between January 1, 2012, and January 1, 2022.

METHODS

Retrospective consecutive case series.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), single-operation success rate.

RESULTS

The study cohort included 60 eyes of 58 patients with a mean age of 26.4 (standard deviation, 13.0) years. Males comprised 49 (84.5%) patients. Known trauma occurred in 35 (61.4%) cases. Initial surgical management included scleral buckling (SB) in 49 (81.7%) eyes and combined SB and pars plana vitrectomy (PPV) in 11 (18.3%) eyes. Preoperative BCVA correlated with BCVA at last follow-up visit (r = 0.66; P < 0.001). At last visit, the SB group had a mean logarithm of the minimum angle of resolution BCVA of 0.36 (20/46) and a single-operation success rate of 76.9% at 6 months, whereas the SB/PPV group had a mean logarithm of the minimum angle of resolution BCVA of 1.08 (20/238) and single-operation success rate of 77.8% (P = 0.04 and P = 0.96, respectively). Six eyes in the SB/PPV group received silicone oil tamponade. In eyes with at least 1 year of follow-up, 4 (14.8%) in the SB group and 6 (100%) in the SB/PPV group developed a visually significant cataract requiring cataract surgery (P < 0.001).

CONCLUSIONS

Retinal detachment associated with retinal dialysis is typically associated with trauma and more often occurs in young male patients. The current study confirms that SB without PPV is an effective initial treatment strategy for most patients with retinal dialysis and has a low rate of cataract formation.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

INTRAOCULAR INFLAMMATION INCIDENCE AFTER INTRAVITREAL BROLUCIZUMAB INJECTION FOR EXUDATIVE AGE-RELATED MACULAR DEGENERATION

PURPOSE

We evaluated the clinical outcomes of intraocular inflammation (IOI) of eyes with neovascular age-related macular degeneration (AMD) injected with brolucizumab in our tertiary referral center.

METHODS

A retrospective case series for which clinical records of all eyes that received intravitreal brolucizumab at Bascom Palmer Eye Institute between December 1, 2019, and April 1, 2021, were reviewed.

RESULTS

There were 345 eyes of 278 patients who received 801 brolucizumab injections. IOI was detected in 16 eyes of 13 patients (4.6%). In those patients, baseline Logarithm of Minimu Angle of Resolution (logMAR) best-corrected visual acuity was 0.32 0.2 (20/42), while it was 0.58 0.3 (20/76) at IOI presentation. The mean number of injections among eyes experiencing IOI was 2.4, and the interval between the last brolucizumab injection and IOI presentation was 20 days. There was no known case of retinal vasculitis. Management of IOI included topical steroids in seven eyes (54%), topical and systemic steroids in five eyes (38%), and observation in one eye (8%). Best-corrected visual acuity returned to baseline and inflammation resolved in all eyes by the last follow-up examination.

CONCLUSION

Intraocular inflammation after brolucizumab injection for neovascular AMD was not uncommon. Inflammation resolved in all eyes by the last follow-up visit.

Update on current pharmacologic therapies for diabetic retinopathy

INTRODUCTION

Diabetic retinopathy is a major cause of visual loss worldwide. The most important clinical findings include diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR).

AREAS COVERED

PubMed was used for our literature review. Articles from 1995 to 2023 were included. Pharmacologic treatment of diabetic retinopathy generally involves the use of intravitreal anti-vascular endothelial growth factor (VEGF) therapy for DME and PDR. Corticosteroids remain important second-line therapies for patients with DME. Most emerging therapies focus on newly identified inflammatory mediators and biochemical signaling pathways involved in disease pathogenesis.

EXPERT OPINION

Emerging anti-VEGF modalities, integrin antagonists, and anti-inflammatory agents have the potential to improve outcomes with reduced treatment burdens.

Endophthalmitis Associated With XEN Stent Implantation

PURPOSE

The aim of this study is to report the clinical characteristics, causative organisms, and treatment outcomes in patients presenting with endophthalmitis related to XEN stent implants.

DESIGN

Retrospective, noncomparative consecutive case series.

METHODS

Clinical and microbiologic review was performed for 8 patients presenting to the Bascom Palmer Eye Institute Emergency Room between 2021 and 2022 with XEN stent-related endophthalmitis. Data collected included clinical characteristics of patients at presentation, organisms identified in ocular cultures, treatments received, and visual acuity at last follow-up.

RESULTS

The current study included 8 eyes from 8 patients. All cases of endophthalmitis occurred >30 days after implantation of the XEN stent. At the time of presentation, there were external exposures of the XEN stent in 4 of 8 patients. Five of the 8 patients had positive intraocular cultures, all of which were variants of staphylococcus and streptococcus species. Management included intravitreal antibiotics in all patients, explantation of the XEN stent in 5 patients (62.5%), and pars plana vitrectomy in 6 patients (75%). At last follow-up, 6 of the 8 patients (75%) had a visual acuity of hand motion or worse.

CONCLUSIONS

Endophthalmitis in the setting of XEN stents results in poor visual outcomes. The most common causative organisms are staphylococcus or streptococcus species. At time of diagnosis, prompt treatment with broad-spectrum intravitreal antibiotics is recommended. Consideration can be made to explant the XEN stent and perform early pars plana vitrectomy.

Endophthalmitis caused by Burkholderia cepacia complex (BCC): Clinical characteristics, antibiotic susceptibilities, and treatment outcomes

Purpose

To report the clinical characteristics, antibiotic susceptibilities, and review the literature of Burkholderia cepacia complex (BCC) associated endophthalmitis.

Study design

Retrospective, observational case series.

Methods

Clinical and microbiology records were reviewed for patients evaluated at the Bascom Palmer Eye Institute and diagnosed with culture-confirmed endophthalmitis due to BCC. Antibiotic susceptibility profiles were generated using standard microbiologic protocols via an automated VITEK system.

Results

Endophthalmitis associated with BCC was diagnosed in three patients. Infection occurred in the setting of post-penetrating keratoplasty (PKP), glaucoma filtering surgery, and suspected trauma. All isolates demonstrated in vitro susceptibility to ceftazidime and meropenem. Presenting visual acuity (VA) ranged from hand motion to light perception. Initial treatment strategies included intravitreal ceftazidime (2.25 mg/0.1 mL) and vancomycin (1.0 mg/0.1mL) injections with fortified topical antibiotics in 2 patients, and surgical debridement of a corneoscleral melt with patch graft along with both topical fortified antibiotics oral antibiotics in the third patient. In all 3 patients, there was no VA improvement at last follow-up, as 2 eyes ultimately underwent enucleation and 1 eye exhibited phthisis bulbi at last follow-up. BCC related endophthalmitis was reviewed among 13 reports. Treatment outcomes were generally poor and antibiotic resistance was common. These BCC isolates cases demonstrated broad resistance patterns, with susceptibilities to ceftazidime (58%), ciprofloxacin (53%), and gentamicin (33%).

Conclusions

Endophthalmitis caused by B. cepacia is a rare clinical entity with generally poor visual outcomes despite prompt treatment with appropriate antibiotics.

Retinal displacement following repair of rhegmatogenous retinal detachment

Retinal displacement following the repair of rhegmatogenous retinal detachment (RRD) has been reported in recent studies. It was described as vertical movement of the retinal relative to its original location, as evidenced by retinal vessel printing on fundus autofluorescence imaging. This review reports the current literature on retinal displacement. We conducted an English literature search using Medline, PubMed, Embase, and Web of Science. We have reviewed 22 articles describing the diagnosis, frequency, and possible risk factors for retinal displacement. The reported rate of retinal displacement ranged from 6.4% to 62.8%, and the possible risk factors included the detachment-to-repair time, location and extent of RRD, macula-off RD, presence of subretinal fluid, use of perfluorocarbon, use of tamponade, postoperative facedown positioning, type of RRD repair, and presence of proliferative vitreoretinopathy, especially high grade. This review increases awareness of retinal displacement and its associated visual effects.

Identification of macular neovascularization in central serous chorioretinopathy using swept-source OCT angiography

Purpose

Swept-source optical coherence tomography angiography (SS-OCTA) was used to detect the presence of macular neovascularization (MNV) in eyes with exudative central serous chorioretinopathy (CSCR).

Observations

Case 1 is a 73-year-old man using prednisolone drops with 20/40 vision and a retinal pigment epithelial detachment (PED) associated with subretinal fluid (SRF) and no clinical signs of age-related macular degeneration (AMD) in his left eye. Three months after presentation he underwent SS-OCTA imaging that revealed MNV. He received a series of intravitreal anti-vascular endothelial growth factor (VEGF) injections and SS-OCTA imaging showed a decrease in the MNV lesion size with resolution of the SRF. VA improved to 20/25. Case 2 is a 65-year-old man with recent oral steroid use, presenting with 20/20 vision, a PED, SRF, and no evidence of AMD. SS-OCTA imaging at presentation revealed MNV, which worsened on interval SS-OCTA imaging after the patient deferred treatment. Intravitreal anti-VEGF therapy was then performed with resolution of the SRF and VA improved to 20/15. A total of six cases of type 1 MNV were diagnosed with CSCR. Most were men with a history of steroid or testosterone use and were treated with good response.

Conclusions and importance

SS-OCTA imaging provides a convenient non-invasive strategy for identifying CSCR eyes with MNV without the need for dye-based angiography.

Infectious Endophthalmitis vs Noninfectious "Pseudohypopyon" After Intravitreal Triamcinolone Acetonide

Introduction: To describe a patient who presented with visual loss and an apparent hypopyon but none of the other symptoms or signs most common with infectious endophthalmitis. Methods: A case and its findings were analyzed. Results: A 73-year-old woman was treated with intravitreal triamcinolone acetonide (IVTA) for cystoid macular edema. The eye had 12 previous injections without complication. After the 13th injection, the patient noted painless visual loss. An examination showed a visual acuity (VA) of finger counting and an apparent hypopyon, which shifted after a head-tilt test, suggesting a noninfectious "pseudohypopyon." Two days later, the VA worsened to hand motions and the hypopyon had increased in size. The eye was treated with a vitreous tap and injection with vancomycin and ceftazidime. The inflammation resolved, VA improved to 20/40, and cultures showed no growth. Conclusions: Distinguishing infectious endophthalmitis from noninfectious inflammation remains challenging. There is no definitive technique by which to distinguish between the 2 conditions; thus, clinicians must use their best judgment and follow the patient closely.

Giant Retinal Tears: Long-Term Outcomes of Fellow Eyes

BACKGROUND AND OBJECTIVE

Determine clinical characteristics and long-term outcomes of fellow eyes for patients with prior repair of rhegmatogenous retinal detachments due to a giant retinal tear (GRT).

STUDY DESIGN

Retrospective case series of patients who underwent vitreoretinal surgery between January 2005 and August 2017 for GRT at the Bascom Palmer Eye Institute with a minimum of one year of follow-up information. Patients with a traumatic or post-vitrectomy GRT were excluded.

MAIN OUTCOME MEASURES

Visual acuity and rate of retinal events in fellow eyes.

RESULTS

The study group included 51 patients; 40 others were excluded due to having less than one year of follow-up (n = 27), a history of inciting trauma (n = 11), or a GRT occurring post-vitrectomy (n = 2). The mean age was 49.9 years (range 14 to 81) and mean follow-up duration was 6.9 years (range 1 to 16). During the follow-up interval, prophylactic laser retinopexy was performed in 5 fellow eyes for retinal breaks (9.8%) and in one fellow eye with a progressing retinoschisis cavity (2.0%). One patient had a previous history of a retinal break in the fellow eye. Vitreoretinal surgery was performed in 6 (11.8%) fellow eyes for rhegmatogenous retinal detachments, of which one was caused by a GRT. Three patients (5.9%) already had a retinal detachment repair in the fellow eye prior to presentation and one patient presented with bilateral giant retinal tear associated retinal detachments (GRT-RDs) at the initial visit. Overall, there was a retinal event in 33.3% of fellow eyes. Myopia was the most commonly documented associated factor (31%), followed by lattice degeneration (22%), and known or suspected inherited vitreoretinopathy (4%).

CONCLUSIONS

Retinal tears and/or detachments were encountered relatively frequently in the fellow eye of patients with a history of GRT-RD during follow-up, but the rate of GRTs in the fellow eye (4%) was below what has been generally reported in the literature. Regular dilated fundus exams are warranted for patients with a history of GRT. [Ophthalmic Surg Lasers Imaging Retina 2022;53:619-625.].

Natural History and Surgical Timing for Idiopathic Epiretinal Membrane

PURPOSE

This study assessed the prevalence of progression to surgery on idiopathic epiretinal membrane (iERM) and compared the results with those of immediate surgery.

DESIGN

Retrospective study with nested case-control comparison.

SUBJECTS

Patients with mild iERM at initial presentation METHODS: A retrospective study with a nested case-control study was conducted to compare the outcomes of those who later progressed to surgery ("deferred surgery") with those of a control group that underwent surgery within 6 months of initial presentation ("immediate surgery").

MAIN OUTCOME MEASURES

The prevalence of performing vitrectomy with membrane peeling after initial deferral, features associated with deferred surgery, and the visual acuity (VA) outcomes of surgery compared with those with immediate surgery.

RESULTS

A total of 413 patients were included in the base study cohort: 369 did not undergo iERM peeling, whereas 44 (10.7%) underwent deferred surgery at a mean duration of 18.1 months after initial presentation. The factor most associated with later progression to surgery, determined using a multivariate analysis, was symptoms at initial presentation (odds ratio [95% confidence interval], 8.75 [3.80-20.15]; P < 0.0001). The immediate surgical group (controls) had a poorer logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) at presentation compared with the deferred surgery group (cases), but this decreased in the latter group to about the same preoperative level immediately before the deferred surgery (typically why they underwent surgery). The final logMAR BCVA was similar in the deferred and immediate surgical groups when only pseudophakic cases were analyzed. An analysis of the change from preoperative BCVA (instead of initial) to final BCVA showed no difference in the magnitude of change between the pseudophakic subgroups of the deferred and immediate surgery groups (median [interquartile range] preoperative VA of 0.52 [0.40-0.60] in the deferred surgery group and 0.44 [0.39-0.60] in the immediate surgery group [P = 0.7256]). Within the deferred and immediate surgery groups, the median change from preoperative BCVA to final BCVA in the pseudophakic subgroups was 0.22 (P = 0.0082) in the former and 0.21 (P = 0.0001) in the latter.

CONCLUSIONS

The vast majority of eyes with iERM remain stable after initial presentation. The deferral of surgery in the minority of patients who progress does not have a disadvantageous final outcome compared with immediate surgery.

Acute-onset postoperative endophthalmitis after cataract surgery performed by resident and attending physicians at a university teaching hospital

PURPOSE

To evaluate acute-onset postoperative endophthalmitis following cataract surgery and to compare rates between resident and attending physician-performed cohorts.

SETTING

Bascom Palmer Eye Institute, Miami, Florida.

DESIGN

Retrospective chart review.

METHODS

Records of patients diagnosed with endophthalmitis within 6 weeks of surgery performed by attending and resident physicians between January 1, 2015, and December 31, 2020, were reviewed. Total cataract volume was obtained from institutional records, and resident case totals were obtained from case logs. Endophthalmitis cases were obtained from billing records and confirmed with chart review.

RESULTS

There were 22 cases of endophthalmitis among 32 505 cases (0.068%). Endophthalmitis occurred in 6 of 6447 (0.093%) resident cases and 16 of 26 058 (0.061%) attending cases ( P = .55). The most common bacterial isolates were coagulase-negative Staphylococcus (8/22, 36.3%) and Streptococcus species (3/22, 13.6%), with negative cultures in 10 (10/22, 45.5%). Initial treatment with vitreous tap and injection of intravitreal antibiotics was performed in 21 eyes (21/22, 95.4%) and vitrectomy with intravitreal antibiotic injection in one (1/22, 4.5%). Vitrectomy was performed secondarily in 9 patients (9/22, 40.9%). Corrected distance visual acuity (CDVA) at last follow-up was ≥20/40 in 13 eyes (13/22, 59%) and ≤hand motions in 3 eyes (3/22, 13.6%). CDVA (logMAR mean ± SD) was 1.22 ± 1.16 in resident and 0.49 ± 0.79 in attending cases ( P = .11).

CONCLUSIONS

In the current study, acute-onset postoperative endophthalmitis developed infrequently following cataract surgery. The rates and visual outcomes of endophthalmitis were similar in resident and attending cases.

Clinical Practice Update: Management of Infectious Endophthalmitis After Intravitreal Anti-VEGF Injection

Although infectious endophthalmitis after intravitreal antivascular endothelial growth factor injections is rare, it is the most feared and potentially devastating complication of this procedure. There is no high-level evidence to provide definitive guidance on the management of endophthalmitis occurring after intravitreal injection (IVI). This clinical practice update reviews the published literature regarding post-IVI endophthalmitis and highlights areas in which further research is needed to better guide its management.

Acute Onset Endophthalmitis Following Bilateral Upper and Lower Eyelid Blepharoplasty

A 59-year-old woman presented with iritis and uveitis in the OD approximately 3 weeks after she underwent a bilateral upper and lower blepharoplasty by an outside oculoplastic specialist. Examination revealed a visual acuity of hand motion in the OD, scleral ulceration suspicious for prior globe perforation, dense vitritis, and loculations and membranes on echography. The patient was diagnosed with acute onset exogenous endophthalmitis. Vitreous aspiration and intravitreal injection of vancomycin and ceftazidime were performed. The patient underwent a pars plana vitrectomy, and vitreous culture demonstrated Streptococcus pseudoporcinus . Postoperative vision improved to 4/200 but was limited by a full-thickness macular hole. Despite silicone oil removal and macular hole repair, the macular hole remained open at month 7 and limited vision to 5/200. During eyelid surgery, surgeons should take precautions against intraoperative needle perforation including possible use of protective shield. Postoperative vision loss after eyelid surgery requires further evaluation.

Comparison of Outcomes From Delayed-Onset Bleb-Related Endophthalmitis Treated With Pars Plana Vitrectomy Versus Vitreous Biopsy

PRCIS

Bleb-related endophthalmitis (BRE) is a serious complication of glaucoma filtration surgery. The current study reports similar visual and intraocular pressure (IOP) outcomes in eyes treated with pars plana vitrectomy (PPV) compared with vitreous biopsy and injection of intravitreal antibiotics (TI).

PURPOSE

The purpose of this study was to investigate the isolated organisms, visual acuity (VA), and IOP outcomes associated with delayed-onset BRE in eyes treated with PPV versus TI.

PATIENTS AND METHODS

A retrospective chart review was conducted at the Bascom Palmer Eye Institute (Miami, Florida) and the University of Florida (Gainesville, FL) identifying patients treated for BRE with at least 1 month of follow-up from the inception of an electronic health record (2014 and 2011, respectively) through 2021. All patients had undergone bleb-forming glaucoma surgery at least 1 month before endophthalmitis diagnosis.

RESULTS

Thirty-nine eyes from 39 patients (33 from Bascom Palmer, 6 from University of Florida) were included. Trabeculectomy was performed in 34 of 39 eyes (87.2%). Streptococcus species (9 eyes, 23.1%) and Staphylococcus species (8 eyes, 20.5%) were the most common isolated organisms and were similar in both treatment groups ( P =0.49). Baseline VA was worse in the PPV group (logarithm of the minimum angle of resolution: 2.51 vs. 2.16, P =0.04), but VA at last follow-up was similar ( P =0.48) in both groups. After recovery from BRE, the average IOP in the PPV group was 15.1 mm Hg on 0.9 IOP-lowering medications compared with 12.6 mm Hg on 1.2 medications in the TI group (IOP: P =0.56; medications: P =0.80). Additional glaucoma surgery was performed in 44.4% of the PPV eyes and 16.7% of the TI eyes ( P =0.09).

CONCLUSION

In eyes with delayed-onset BRE, isolated organisms, visual outcomes, and IOP control were similar after initial PPV compared with TI.

EVALUATION OF RETINAL DISPLACEMENT FOLLOWING PRIMARY SCLERAL BUCKLING FOR MACULA-INVOLVING RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To evaluate the incidence and degree of retinal displacement following scleral buckling surgery for macula-involving rhegmatogenous retinal detachment.

METHODS

Retrospective interventional case series comprised of patients treated with primary scleral buckling procedure without gas tamponade for macula-involving rhegmatogenous retinal detachment and imaged postoperatively with fundus autofluorescence imaging between June 1, 2016 and July 25, 2021. Clinical notes, operative reports, fundus autofluorescence photographs, and optical coherence tomography images were reviewed. The presence and degree of retinal displacement were recorded.

RESULTS

Twelve eyes of 11 patients were included. One (8%) eye with an epiretinal membrane demonstrated 0.1 mm of retinal displacement along the superior arcade and in the superotemporal periphery. The remainder of eyes (92%) did not show any identifiable signs of retinal displacement.

CONCLUSION

Retinal displacement does not seem to be a frequent complication of primary scleral buckling surgery for macula-involving rhegmatogenous retinal detachment.

Favorable Anti-VEGF Crunch Syndrome: Nonsurgical Relief of Vitreoretinal Traction in Eyes With Proliferative Diabetic Retinopathy and Tractional Retinal Detachment

Herein are reported four eyes among three patients with favorable anti-vascular endothelial growth factor crunch syndrome by which contraction of fibrovascular tissue led to relief of vitreoretinal traction without surgical intervention. This phenomenon led to complete or partial retinal reattachment in two patients with diabetic tractional retinal detachments. These cases represent favorable anatomic outcomes of crunch syndrome secondary to anti-vascular endothelial growth factor pharmacotherapy and are unique compared with most cases, which have been associated with negative outcomes. [Ophthalmic Surg Lasers Imaging Retina 2022;53:455-459.].

Recurrent, bilateral endogenous Candida endophthalmitis with multiple focal chorioretinal lesions: management with pars plana vitrectomy and focal endolaser

PURPOSE

Bilateral endogenous Candida endophthalmitis (ECE) treatment usually involves administering systemic and intravitreal antifungal medications. In advanced cases with vitreous seeding, pars plana vitrectomy (PPV) is considered. The use of focal endolaser treatment to chorioretinal lesions has not been reported. We present a case of bilateral recurrent ECE treated with PPV and endolaser to elevated focal lesions.

CASE

A 45-year-old diabetic male presented with decreased visual acuity in both eyes (20/50 right eye, 20/150 left eye) and was found to have bilateral ECE with moderate vitritis and chorioretinal lesions. The initial treatment consisted of multiple intravitreal voriconazole injections to both eyes as well as systemic antifungal therapy. Resolution of ECE occurred after three months, but one year later despite therapy recurred bilaterally. Patient underwent PPV with endolaser to the elevated chorioretinal lesions in both eyes. One year later, his vision improved to 20/40 in both eyes, focal lesions were flat and resolved along with the ECE.

CONCLUSION

Advanced or recurrent ECE that is refractive to intravitreal antifungal therapy may be treated with PPV. Endolaser therapy to the chorioretinal lesions is an additional local option that can resolve the activity of ECE.

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

OBJECTIVE

To review the clinical course and outcomes of patients with idiopathic vitreomacular traction (VMT) managed initially by observation.

DESIGN

Retrospective chart review including patients with idiopathic VMT based on clinical symptoms and findings on optical coherence tomography (OCT) between January 1, 2015 and February 15, 2021.

SUBJECTS

The study included 436 eyes of 317 patients with a mean age of 72.2 years ± 8.9 at initial visit and mean follow-up time of 34 months ± 19.2.

METHODS

VMT severity grade was ascribed to each patient using previously published grading criteria. Grade 1 denoted incomplete cortical vitreous separation with attachment at the fovea and visible distortion of the foveal surface, grade 2 included intraretinal cysts or clefts along with grade 1 findings, and grade 3 included sub-foveal fluid along with grade 2 traits.

MAIN OUTCOME MEASURES

The rate of spontaneous release, grade at baseline compared to grade at final follow-up, and outcomes of interventions if performed.

RESULTS

At baseline, mean best corrected visual acuity (BCVA) was 20/40. Baseline OCT demonstrated grade 1 VMT in 212 eyes (48.6%), grade 2 VMT in 172 eyes (39.4%), and grade 3 VMT in 52 eyes (11.9%). Among initially grade 1 eyes, 25.0% had spontaneous release of VMT (median: 290.0 days, mean: 404.5 days ± 323.9), 50.9% remained stable, and 10.4% worsened. Among initially grade 2 eyes, 14.5% had spontaneous release of VMT (median: 570.0 days, mean: 692.9 days ± 477.5), 55.2% remained stable, 4.7% improved, and 2.3% worsened. Among initially grade 3 eyes, 5.8% had spontaneous release of VMT (median: 790.0 days, mean: 839.3 days ± 246.7), 28.8% remained stable, and 5.8% improved. Of the 436 eyes, macular hole development occurred in 42 eyes (9.6%). PPV was performed in 94 of 436 eyes (21.6%) with mean BCVA prior to PPV of 20/78 and final follow-up BCVA of 20/55.

CONCLUSION

This study demonstrates the generally stable clinical course of VMT when managed initially by observation. Stable VMT grade was the most frequent outcome, and grade 1 VMT eyes were more likely to undergo spontaneous release compared to grades 2 and 3 eyes.

Laser-induced choroidal neovascularization detected on optical coherence tomography angiography in patients with diabetic retinopathy

Purpose

To report two cases of laser-induced choroidal neovascularization (CNV) using swept source optical coherence tomography (SS-OCTA) imaging in patients with proliferative diabetic retinopathy.

Observations

Two patients developed CNV adjacent to laser scars, and these neovascular lesions were detected on SS-OCTA imaging. Historically, both patients had subretinal fluid associated with these lesions. Visual acuity for both patients was 20/25 in the affected eyes. Both patients were observed over multiple years with stable CNV and visual acuity.

Conclusions and importance

SS-OCTA was able to detect laser-induced CNV in a rapid and non-invasive manner. When there is no foveal involvement and excellent visual acuity, we recommend close observation since the CNV may not progress.

Risk and Impact of Severe Acute Respiratory Syndrome Coronavirus 2 Infection on Corneal Transplantation: A Case-Control Study

PURPOSE

The purpose of this study was to evaluate the risk of symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection after corneal transplantation surgery, with cataract surgeries as controls, and the impact of the novel coronavirus disease pandemic in the clinical and surgical complications of corneal transplantation and cataract surgeries.

METHODS

A retrospective matched case-control study of 480 consecutive individuals who underwent surgery at the Bascom Palmer Eye Institute between May 2020 and November 2020. A total of 240 patients who underwent corneal transplantation with tissue obtained from the Florida Lions Eye Bank were age, race, ethnicity, and sex matched with 240 patients who underwent cataract surgery during the same day and by the same surgical team. Only the first corneal transplant or cataract surgery during this period was considered for each individual. All donors and recipients were deemed SARS-CoV-2 negative by a nasopharyngeal polymerase chain reaction test before surgery. Postoperative SARS-CoV-2 infections were defined as previously SARS-CoV-2(-) individuals who developed symptoms or had a positive SARS-CoV-2 polymerase chain reaction test during the first postoperative month.

RESULTS

Mean age, sex, race, and ethnicity were similar between groups. There were no differences between the corneal transplant and cataract groups in the rates of SARS-CoV-2 infection before (5.8% vs. 7.5%, P= 0.6) or after surgery (2.9% vs. 2.9%, P = 1). The rates of postoperative complications did not increase during the pandemic, compared with previously reported ranges.

CONCLUSIONS

In this study, postoperative SARS-CoV-2 infection was similar for individuals undergoing corneal transplantation or cataract surgery. Further research is required to evaluate the transmission of SARS-CoV-2 through corneal tissue.

Ocular and Systemic Complications of COVID-19: Impact on Patients and Healthcare

There is increasing information available about the effects of the SARS-CoV-2 virus on the systemic and ocular health of patients, as well as the effects of delayed health care. This mini-review summarizes the potential complications and treatments of COVID-19. Systemic findings include respiratory illness, risk of thromboembolic events, and neurologic findings. Some patients may develop persistent symptoms even after the infection resolves. Effective treatment options include glucocorticoids, antivirals, interleukin-6 antagonists, monoclonal antibodies, Janus kinase inhibitors and vaccines. Potential ocular findings of COVID-19 include conjunctivitis, cranial nerve palsies, and microvascular changes in the retina; most symptoms resolved over time. During the lockdown periods, teleophthalmology was utilized to triage non-urgent issues; patients who did present to emergency departments tended to have more severe disease with worse visual prognoses. While transient delays in outpatient ophthalmic care may be tolerated in some patients, others experienced significant vision loss with interruptions in treatments. Resumption of ophthalmic care as soon as possible may help mitigate the effects of delayed care due to the pandemic.

Transient central retina artery occlusion in patients undergone intravitreal anti-vascular endothelial growth factor injections

PURPOSE

To evaluate the occurrence of transient central retinal artery occlusion following intravitreal anti-vascular endothelial growth factor injection.

METHODS

Prospective, observational study of 807 patients (807 eyes) who were given intravitreal injections of ranibizumab or aflibercept to treat any cause of retinal vascular diseases between 1 January 2017 and 30 November 2018 at the Federal Fluminense University Hospital in Niteroi, and a private facility in Rio de Janeiro, Brazil. Patients who did not present transient central retinal artery occlusion were excluded.

RESULTS

Among 4069 injections, only 18 patients (0.44%) presented transient central retinal artery occlusion, 14 mild cases (77.7%), and 4 severe cases (22.3%). The clinical factors associated with more severe cases of transient central retinal artery occlusion were the duration of the transient central retinal artery occlusion (p = 0.001), number of prior injections (p = 0.01), and a positive carotid Doppler test (p = 0.01). Twelve cases (66.6%) had positive carotid artery obstruction (atheroma plaque size ≥70%) while 6 cases (33.3%) had negative carotid artery obstruction (atheroma plaque size <70%). The age group >60 years old (p = 0.06), cup/disc ratio >0.6 (p = 0.06), and pseudophakic lens status were also factors with association with transient central retinal artery occlusion, although did not meet criteria for statistical significance. The only patient who experienced a recurrent episode of transient central retinal artery occlusion had diabetic macular edema, positive carotid Doppler test, and cup/optic disc ratio >0.6.

CONCLUSION

Transient central retinal artery occlusion is a rare adverse event that can appear in patients with retinal vascular disease receiving anti-vascular endothelial growth factor therapy. The atheroma plaque size and the number of prior injections can be associated with the severity of the event.

INVOLUTION OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION AFTER ENDOPHTHALMITIS

PURPOSE

To report patients who demonstrated an alteration in the clinical and optical coherence tomography features of neovascular age-related macular degeneration after resolution of endophthalmitis.

METHODS

Retrospective case series of the subsequent changes in the macula and need for anti-vascular endothelial growth factor therapy in patients with neovascular age-related macular degeneration who developed endophthalmitis after intravitreal injection.

RESULTS

The study included seven eyes of seven patients with follow-up ranging between 3 months and 11 years. The vitreous cultures (n = 7) before intravitreal antibiotic injection were the following: culture-negative (4) and coagulase-negative Staphylococcus (3). Initial treatment included vitreous tap and injection (4) and pars plana vitrectomy (3). In 5/7 eyes, the optical coherence tomography showed resolution of subretinal fluid and serous pigment epithelial detachment, and there was no additional anti-vascular endothelial growth factor treatment administered.

CONCLUSION

After successful treatment of endophthalmitis in patients with neovascular age-related macular degeneration, there was relative involution of the maculopathy and reduced anti-vascular endothelial growth factor treatment burden in this series.

WIDE-FIELD SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF DIABETIC TRACTIONAL RETINAL DETACHMENTS BEFORE AND AFTER SURGICAL REPAIR

PURPOSE

Wide-field (WF) swept-source (SS) optical coherence tomography angiography (SS-OCTA) was used to image diabetic tractional retinal detachments (TRDs) before and after pars plana vitrectomy. The clinical utility of SS-OCTA was assessed.

METHODS

Patients with diabetic TRDs were imaged prospectively with SS-OCTA. Ultrawide-field imaging was obtained when possible. Postoperative WF SS-OCTA imaging was performed.

RESULTS

From January 2018 through December 2019, 31 eyes of 21 patients with diabetic TRDs were imaged. Wide-field SS-OCTA en-face images captured all areas of TRD and fibrovascular proliferation within the posterior pole that were visualized on ultrawide-field imaging. Optical coherence tomography angiography B-scans revealed the vascularity of preretinal membranes and identified areas of vitreoretinal traction and posterior vitreous detachment. Ten eyes underwent pars plana vitrectomy. Postoperative SS-OCTA imaging demonstrated removal of fibrovascular membranes, relief of traction, and resolution of TRDs. Retinal ischemia before and after surgical repair appeared similar.

CONCLUSION

All clinically relevant features of diabetic TRDs were identified at baseline and assessed longitudinally after pars plana vitrectomy using WF SS-OCTA, which showed resolution of vitreoretinal traction and no apparent change in the status of retinal perfusion after surgery. If the media are clear and fixation is adequate, WF SS-OCTA is likely the only imaging modality needed for the diagnosis and longitudinal evaluation of diabetic TRDs.

Can the Macula be Attached if View Is Obscured by a Bullous Retinal Detachment? A Mathematical Consideration

Purpose

The purpose of this study was to determine if it is possible for the macula to remain attached if a bullous retinal detachment blocks the examiner's view to the macula.

Methods

A mathematical analysis compared the arc length of the attached retina versus the length of a detached retina necessary to obscure the macula (hang over the visual axis). The shape (oblate ellipsoid) and dimensions of the retina were based on a published study. The complete path of the hanging retina was calculated as a static catenary so as to depict the lowest possible position (“worst case scenario”).

Results

The measured and calculated angle between the fovea and ora serrata was 105 degrees. When considering a catenary shape of the hanging retina, the macula could, mathematically, still be attached despite the retina hanging down 1.03 mm below the visual axis for an emmetropic eye. The maximal distance calculated was 1.095 mm for a −12 diopter (D) myopic eye.

Conclusions

If the macular center cannot be viewed due to a bullous superior retinal detachment hanging into the examiner's view, it is unlikely but possible that the macula remains attached. If the view is obscured by at least 1 mm below the fovea, it is not mathematically possible for the fovea to be attached.

Translational Relevance

The status of the macula being detached is subject to mathematical constraints, which, explored herein, offer a higher certainty of clinical decision making that could inform management for better clinical results.

Clinical Outcomes of Rhegmatogenous Retinal Detachment Treated With Pneumatic Retinopexy

IMPORTANCE

Pneumatic retinopexy (PR) is the only clinic-based method of rhegmatogenous retinal detachment (RRD) repair. Registry-acquired clinical practice setting outcomes data with this procedure have not yet been reported.

OBJECTIVE

To describe the clinical outcomes associated with RRD treated primarily with PR.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, data from patients 19 years and older with noncomplex RRD treated at academic and private ophthalmology practices participating in the American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight) were analyzed. Data were collected from January 1, 2013, to December 31, 2019, and data were analyzed from January to December 2020.

EXPOSURES

Data from the IRIS Registry were queried for eyes that underwent PR for noncomplex RRD and had at least 3 months of follow-up. Cases were identified by a combination of diagnosis code for RRD and a Current Procedural Terminology code for PR.

MAIN OUTCOMES AND MEASURES

The number of eyes that achieved single-operation success (SOS), defined as retinal reattachment without a subsequent retinal detachment surgery or repeated PR.

RESULTS

Of 9553 included patients, 5827 (61.0%) were male, and the mean (SD) age was 62 (10) years. A total of 9659 eyes were identified. SOS was achieved in 6613 eyes (68.5%). Best-corrected visual acuity significantly differed 9 to 12 months after treatment between the SOS group, with a mean of 0.24 logMAR (95% CI, 0.23-0.25; approximate Snellen equivalent, 20/35), and the single-operation failure group, with a mean of 0.43 logMAR (95% CI, 0.40-0.46; approximate Snellen equivalent, 20/54). Among all patients, the mean time to maximal visual recovery was 268 days (95% CI, 260-276). Endophthalmitis was observed in 3 eyes (0.03%). SOS was associated with female sex (odds ratio, 1.51; 95% CI, 1.38-1.65), while current smoking status was associated single-operation failure (odds ratio, 0.78; 95% CI, 0.68-0.91).

CONCLUSIONS AND RELEVANCE

In this registry-based study, which encompasses a large number of eyes drawn from multiple, heterogenous electronic health record systems, SOS was achieved in 68.5% of eyes with noncomplex RRD treated by primary PR. It is unknown how these outcomes would have compared with other methods of RRD repair in this cohort.

Trends in Endophthalmitis Associated With Intravitreal Injection of Anti-VEGF Agentsat a Tertiary Referral Center

BACKGROUND AND OBJECTIVE

To report the incidence and clinical features of infectious endophthalmitis after intravitreal (IV) injection of anti-vascular endothelial growth factor inhibitors (VEGF) between 2018 and 2020 and to compare to prior rates.

PATIENTS AND METHODS

Retrospective analysis of patients with endophthalmitis after anti-VEGF IV injections treated at Bascom Palmer Eye Institute between January 1, 2018, and December 31, 2020.

RESULTS

Between 2018 and 2020, the rate of clinically diagnosed endophthalmitis was 0.014% (10/71,858) and of culture-positive was 0.008% (6/71,858). Clinically diagnosed endophthalmitis rates per injection were: aflibercept (0.022%); ranibizumab (0.019%); bevacizumab (0%); and brolucizumab (0%). Clinically diagnosed endophthalmitis rates were similar in the present study compared to those from 2005 to 2017 (P = .84). Fifteen eyes were diagnosed with endophthalmitis (10 in-house, five external referrals). Of culture-positive eyes, the organisms were coagulase-negative Staphylococcus (8/11), Streptococcus species (2/11), and Abiotrophia defectiva (1/11). A universal face-masking policy in 2020 did not lower infection rates (P = .73).

CONCLUSION

Endophthalmitis rates after IV anti-VEGF remain low and are similar to prior reports. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:319-326.].

Multimodal Imaging in the Diagnosis of Exophytic Juxtapapillary Retinal Capillary Hemangioblastoma

PURPOSE

Exophytic juxtapapillary retinal capillary hemangioblastoma (JRCH) can be difficult to diagnose. We explore the value of multimodal imaging to aid in the diagnosis.

DESIGN

Retrospective case series.

METHODS

Medical records and multimodal imaging studies were reviewed on all patients diagnosed with RCH at Bascom Palmer Eye Institute, Miami, Florida, between January 2013 and December 2019. Patients with exophytic lesions within 2 mm of the disc were included. One patient from the Baylor College of Medicine, Houston, Texas was included. Patient demographics, referring diagnosis, history of von Hippel-Lindau syndrome, initial and last visual acuity, and treatments were recorded. Fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, optical coherence tomography (OCT), OCT angiography, and B-scan images were reviewed.

RESULTS

Twelve patients were identified with exophytic JRCH. The mean age was 54 years (range 38-73 years). Five patients had von Hippel-Lindau syndrome. The most common referral diagnoses were choroidal neovascularization and neuroretinitis. Imaging features included nodular outer retinal thickening with shadowing and intra-/subretinal fluid on OCT, hypoautofluorescence on fundus autofluorescence, middle to outer retinal hypervascularity on OCT angiography, early hyperfluorescence with late leakage on fluorescein angiography, and lack of choroidal vascular lesion on indocyanine green angiography. Treatments included photodynamic therapy (6 patients), intravitreal anti-vascular endothelial growth factor therapy (6 patients), argon laser photocoagulation (2 patients), intravitreal or sub-Tenon's triamcinolone (3 patients), and observation (4 patients).

CONCLUSIONS

A key to the accurate diagnosis of exophytic JRCH is its intraretinal location, typically involving the outer retinal layers, which results in a clinical appearance that is distinct from the more common and easily recognizable endophytic RCH. Multimodal imaging can aid in ruling out choroidal neovascularization and disc edema by demonstrating an absence of involvement of those structures.

Genotypic and Phenotypic Antibiotic Resistance in Staphylococcus Epidermidis Endophthalmitis

BACKGROUND AND OBJECTIVE

To evaluate antibiotic resistance patterns in Staphylococcus epidermis endophthalmitis isolates, identify antibiotic resistance genes, and compare this to their phenotypic resistance.

MATERIALS AND METHODS

Retrospective case series of S. epidermidis isolates from January 2012 to December 2017. Phenotypic resistance was determined from minimum inhibitory concentration values. Genotypic resistance was determined from DNA microarray. The relationship between these was analyzed using Cohen's kappa and predictive value.

RESULTS

Seventy-five isolates were included. More than 60% were resistant to methicillin and erythromycin. Approximately 60% possessed the resistance genes for methicillin and erythromycin, and 25% for clindamycin. There was near perfect agreement between genotype and phenotype for erythromycin and methicillin (kappa = 0.88 and 0.89, respectively). Approximately 98% (P < 0.0001) of isolates with erythromycin and methicillin resistance genes and 90% (P = 0.0006) with clindamycin resistance genes were phenotypically resistant to those antibiotics. None were resistant to vancomycin.

CONCLUSION

The relationship between genotypic and phenotypic antibiotic resistance highlights that resistance may be polygenic, and genes may be silent. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:S13-S16.].

Endophthalmitis Caused by Streptococcus:Clinical Outcomes and Antimicrobial Susceptibilities 2014-2019

BACKGROUND AND OBJECTIVE

To report the clinical settings, antibiotic susceptibilities, and outcomes of streptococcal endophthalmitis.

PATIENTS AND METHODS

Retrospective case series evaluating culture-positive streptococcal endophthalmitis from January 1, 2014, to December 31, 2019.

RESULTS

Thirty-eight eyes met study criteria. The most common clinical setting was post-glaucoma surgery (33.3%, 12/36). The most frequent isolate was Streptococcus viridans (63.2%, 24/38). Isolates were susceptible to vancomycin (100%, 36/36), ceftriaxone (100%, 28/28), and levofloxacin (100%, 36/36). Final best-corrected visual acuity was 20/150 or better in 24.1% (7/29) but 20/200 or worse in 75.9% (22/29). Enucleation was performed in 11.1% (4/36). A subset (n = 11) of cases were evaluated for streptococcal-specific virulence factors: pneumolysin was present in 18.2% (2/11), autolysin in 45.5% (5/11), and hyaluronidase in 54.5% (6/11). Clinical setting, antibacterial susceptibilities, timing of pars plana vitrectomy, and virulence factor presence were not associated with better visual outcome or enucleation rate (P > .05).

CONCLUSION

Visual prognosis for streptococcal endophthalmitis is poor despite early and appropriate antibiotic treatment. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:182-189.].

Long-Term Favorable Visual Outcomes in Patients with Large Submacular Hemorrhage

Submacular hemorrhage (SMH) has been reported to be toxic to the retina based on animal studies. However, observational studies of patients with neovascular-related SMH and those treated with intravitreal anti-vascular growth factor (anti-VEGF) therapy have shown many favorable visual acuity outcomes. We report two cases of neovascular-related SMH with ten or more years of follow-up. The first case was an 83-year old female with a history of nonexudative age-related macular degeneration in both eyes presenting with sudden decrease in vision (20/400) in her right eye due to a large SMH, treated with anti-VEGF therapy. Over the next following months, there was resolution of the hemorrhage and return of good visual acuity. At 10-year follow-up, visual acuity was 20/30 in the right eye. The second case was a 49-year old female with a history of presumed ocular histoplasmosis syndrome (POHS), presenting with sudden vision loss (20/400) in her right eye due to large, thick SMH. With observation and intermittent anti-VEGF therapy, there was resolution of the hemorrhage. At 30-year follow-up, visual acuity was 20/20 in the right eye.

Nutritionally variant streptococci causing endophthalmitis associated with intravitreal anti-vascular endothelial growth factor injection

Purpose

To describe the clinical course and microbial properties of the first two reported cases of nutritionally variant Streptococci (Granulicatella adiacens and Abiotrophia defectiva) endophthalmitis following intravitreal anti-vascular endothelial growth factor injection (IVI).

Observations

A 74 year-old female developed Granulicatella adiacens endophthalmitis following IVI. The patient underwent a pars plana vitrectomy and visual acuity recovered to 20/30 in six weeks. Similarly, an 88 year-old male developed Abiotrophia defectiva endophthalmitis after IVI. After a pars plana vitrectomy, the visual acuity recovered to 20/60 at five weeks.

Conclusions and Importance

Endophthalmitis due to Streptococcus species has traditionally resulted in uniformly poor visual outcomes. However, nutritionally variant Streptococci, now reclassified as Granulicatella and Abiotrophia species, appear to have a less aggressive clinical course and better visual acuity outcomes. To the authors’ knowledge, these are the first reports of nutritionally variant Streptococci following IVI related endophthalmitis.

Outcomes of Pars Plana Vitrectomy Alone versus Combined Scleral Buckling plus Pars Plana Vitrectomy for Primary Retinal Detachment

PURPOSE

We compared the outcomes of primary uncomplicated rhegmatogenous retinal detachment (RRD) repair using pars plana vitrectomy (PPV) alone versus combined scleral buckling plus PPV (SB+PPV).

DESIGN

Retrospective, observational study.

PARTICIPANTS

Patients with primary RRD who underwent PPV or SB+PPV from June 1, 2014, through December 31, 2017.

METHODS

We performed a single-institution, retrospective, observational study of 488 consecutive patients with primary RRD repaired via PPV alone or SB+PPV and gas tamponade. We excluded patients younger than 18 years and those with advanced proliferative vitreoretinopathy, giant retinal tear, trauma, or secondary forms of RRD. We performed logistic regression and Cox proportional hazard regression analyses to identify potential risk factors associated with a retinal redetachment.

MAIN OUTCOME MEASURES

Single-operation anatomic success (SOAS), defined as adequate retinal reattachment achieved with only 1 procedure.

RESULTS

The mean follow-up interval was 14.3 months. Single-operation anatomic success and final anatomic success were achieved in 425 eyes (87.1%) and 487 eyes (99.8%), respectively. Single-operation anatomic success was achieved in 90 of 111 eyes (81.1%) with PPV alone compared with 345 of 374 eyes (92.2%) with SB+PPV (P = 0.0010). Scleral buckling plus PPV showed greater SOAS than PPV alone in phakic eyes (P < 0.0001), but not in eyes with a posterior chamber intraocular lens (PCIOL). Retinal redetachments occurred on average at 1.5 and 9 months after the initial surgery. Significant best-corrected visual acuity improvement was associated with SOAS (P < 0.0001).

CONCLUSIONS

Scleral buckling plus PPV resulted in greater SOAS outcomes than PPV alone for primary RRD repair. Phakic eyes achieved greater surgical success with SB+PPV, whereas eyes with a PCIOL achieved similar results with both methods. Most retinal redetachments occurred within the initial postoperative 3-month period. Single-operation anatomic success was associated with statistically significant visual improvement.

Rhegmatogenous Retinal Detachment after Intravitreal Injection

PURPOSE

To describe the clinical features and outcomes in patients with rhegmatogenous retinal detachment (RRD) after intravitreal injection of pharmacologic agents.

DESIGN

Retrospecitve case series.

PARTICIPANTS

Patients diagnosed with rhegmatogenous retinal detachment within 3 months of receiving an intravitreal injection of a pharmacologic agent for treatment of macular disease.

METHODS

Retrospective case series of reported cases of RRD in patients with prior intravitreal injection who underwent subsequent surgical repair at a university referral center.

MAIN OUTCOME MEASURES

Visual acuity (VA), single surgery anatomic success rate (SSAS) and retinal reattachment at last follow-up.

RESULTS

Thirteen patients were identified to have RRD within 3 months of intravitreal injection. Injection was performed in the inferotemporal quadrant in 12 of 13 eyes (92%) with a 31- or 32-gauge needle. Additional risk factors for RRD other than intravitreal injection were present in 5 of 13 eyes (38%), including prior pars plana vitrectomy (3 eyes), history of retinal tear (1 eye), and history of RRD in the fellow eye (1 eye). Average duration from time of injection to diagnosis of RRD was 27 days (range, 5-43 days). Retinal reattachment was achieved in 12 of 13 eyes (92%). Visual acuity returned to baseline in only 3 of 13 eyes (23%) at the last follow-up visit.

CONCLUSIONS

Although RRD after intravitreal injection is rare, prior retinal surgery and alternate risk factors for RRD may predispose to RRD after intravitreal injection. Surgical outcomes were generally favorable, but VA outcomes were limited by the high rate of macula-off RRD and the underlying macular disease.

Postoperative Endophthalmitis Caused by Cutibacterium (Formerly Propionibacterium) Acnes: Case Series and Review

We report the clinical features, treatment strategies and outcomes in a series of patients with infectious endophthalmitis after cataract surgery caused by Cutibacterium acnes (C. acnes), formerly known as Propionibacterium acnes (P. acnes). This retrospective case series includes six eyes of six patients with chronic postoperative endophthalmitis caused by culture-proven C. acnesfrom December 2010 to July 2019 at a University referral center. All patients underwent prior cataract extraction with intraocular lens (CE/IOL) implantation. The mean time between cataract surgery and the microbiologic diagnosis of endophthalmitis was 7.4 ± 5.2 months (range 1.5–17 months). The average time from obtaining the specimen to culture positivity was 7.7 ± 4.4 days (range 3–15 days). Three eyes (50%) presented with hypopyon and three eyes (50%) presented with prominent keratic precipitates without hypopyon. Presenting visual acuity ranged from 20/25 to 2/200. Initial treatments included intravitreal antibiotics alone (n = 2), pars plana vitrectomy (PPV) with partial capsulectomy and intravitreal antibiotics (n = 3), and pars plana vitrectomy with IOL removal and intravitreal antibiotics (n = 1). Follow-up treatments included IOL removal (n = 2), intravitreal antibiotics (n = 1), and topical antibiotics (n = 1). The best-corrected visual acuity at last follow-up was 20/70 or better in all patients. In a literature review, the clinical features and treatment outcomes for all case series of delayed-onset postoperative endophthalmitis caused by C. acnes(n = 120) are listed. A definitive cure (the absence of recurrent inflammation) was achieved in 100% of patients that underwent IOL removal, in 77% of those that underwent PPV/partial capsulectomy and intravitreal antibiotics, and in 18% of cases treated with intravitreal antibiotics alone. Endophthalmitis after CE/IOL caused by C. acnesis characterized by slowly progressive intraocular inflammation and has a protracted course from surgery to microbiologic diagnosis. Visual outcomes are generally favorable, but IOL explantation may be necessary for definitive cure.

Refractive Outcomes of Four-Point Scleral Fixation of Akreos AO60 Intraocular Lens Using Gore-Tex Suture

Background/Objective

To determine the refractive outcomes after 4-point scleral fixation of the Akreos AO60 intraocular lens with Gore-Tex suture.

Methods

This was a single referral center, multi-surgeon, retrospective consecutive case series. A total of 63 eyes met the inclusion criteria for having received surgical implantation of the Akreos AO60 intraocular lens with Gore-Tex suture from August 2014 to December 2018. Exclusion criteria included all ocular pathology that precluded an accurate refraction, concurrent ocular surgery, poor corrected pre-operative visual potential, among other factors. Main outcome measures included post-operative uncorrected visual acuity (VA), best-corrected VA, and spherical equivalent deviation from target.

Results

Mean pre-operative BCVA was 0.67 ± 0.64 LogMAR (20/93 Snellen). Mean final post-operative BCVA was 0.17 ± 0.18 (20/28 Snellen) and mean final post-operative UCVA was 0.31 ± 0.22 (20/41 Snellen). Mean post-operative spherical equivalent was −0.57 D. Mean post-operative astigmatism was 0.85 D.

Conclusion

Refractive outcomes after secondary implantation with Akreos AO60 are favorable in eyes with good visual potential.