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The Infectious Uveitis Treatment Algorithm Network (TITAN) Report 2-global current practice patterns for the management of Cytomegalovirus anterior uveitis. Eye (Lond) 2024; 38:68-75. [PMID: 37419958 PMCID: PMC10764804 DOI: 10.1038/s41433-023-02631-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 07/09/2023] Open
Abstract
AIMS To present current practice patterns in the diagnosis and management of Cytomegalovirus anterior uveitis (CMV AU) by uveitis experts worldwide. METHODS A two-round modified Delphi survey with masking of the study team was performed. Based on experience and expertise, 100 international uveitis specialists from 21 countries were invited to participate in the survey. Variation in the diagnostic approaches and preferred management of CMV AU was captured using an online survey platform. RESULTS Seventy-five experts completed both surveys. Fifty-five of the 75 experts (73.3%) would always perform diagnostic aqueous tap in suspected CMV AU cases. Consensus was achieved for starting topical antiviral treatment (85% of experts). About half of the experts (48%) would only commence systemic antiviral treatment for severe, prolonged, or atypical presentation. The preferred specific route was ganciclovir gel 0.15% for topical treatment (selected by 70% of experts) and oral valganciclovir for systemic treatment (78% of experts). The majority of experts (77%) would commence treatment with topical corticosteroid four times daily for one to two weeks along with antiviral coverage, with subsequent adjustment depending on the clinical response. Prednisolone acetate 1% was the drug of choice (opted by 70% of experts). Long-term maintenance treatment (up to 12 months) can be considered for chronic course of inflammation (88% of experts) and those with at least 2 episodes of CMV AU within a year (75-88% of experts). CONCLUSIONS Preferred management practices for CMV AU vary widely. Further research is necessary to refine diagnosis and management and provide higher-level evidence.
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Epiretinal implant of human amniotic membrane to treat highly myopic macular hole retinal detachments: A novel surgical technique. Eur J Ophthalmol 2024; 34:304-309. [PMID: 37820366 PMCID: PMC11046140 DOI: 10.1177/11206721231206717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/25/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE To describe a new surgical technique involving the use of a human amniotic membrane (hAM) epiretinal patch to treat a primary macular hole retinal detachment (MHRD) in a highly myopic patient. METHODS A 60 years old highly myopic man was referred to our clinic with a diagnosis of MHRD in his right eye. The patient was pseudophakic, with a visual acuity of counting fingers at the baseline evaluation. Pars plana vitrectomy was performed, a small retinotomy was created at the inner margin of the staphyloma, and membrane blue dual was used to obtain an adequate peeling of the inner limiting membrane. Then, a 1.5 mm diameter circular hAM patch was obtained and positioned over the macular hole with the chorion layer settled over the retina. After a complete fluid-air exchange, 20% sulfur hexafluoride gas was used as endotamponade, and the patient was asked to remain face down for three days. RESULTS Four weeks after surgery, optical coherence tomography (OCT) scan showed the hAM patch, visualized as a distinct hyperreflective layer well integrated with the retina. Nine months after surgery, the macular hole was closed, the retina reattached, the hAM patch was adherent to the retina, and the patient presented a best-corrected visual acuity improved to 0.7 logMar. No postoperative adverse events were registered during the follow-up. CONCLUSIONS Epiretinal hAM implant could represent a novel surgical technique, feasible and easier compared to other current techniques used to treat MHRD in highly myopic patients.
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The Infectious Uveitis Treatment Algorithm Network (TITAN) Report 1-global current practice patterns for the management of Herpes Simplex Virus and Varicella Zoster Virus anterior uveitis. Eye (Lond) 2024; 38:61-67. [PMID: 37419957 PMCID: PMC10764303 DOI: 10.1038/s41433-023-02630-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 07/09/2023] Open
Abstract
AIMS To present current expert practice patterns and to formulate a consensus for the management of HSV and VZV AU by uveitis specialists worldwide. METHODS A two-round online modified Delphi survey with masking of the study team was conducted. Responses were collected from 76 international uveitis experts from 21 countries. Current practices in the diagnosis and treatment of HSV and VZV AU were identified. A working group (The Infectious Uveitis Treatment Algorithm Network [TITAN]) developed data into consensus guidelines. Consensus is defined as a particular response towards a specific question meeting ≥75% of agreement or IQR ≤ 1 when a Likert scale is used. RESULTS Unilaterality, increased intraocular pressure (IOP), decreased corneal sensation and diffuse or sectoral iris atrophy are quite specific for HSV or VZV AU from consensus opinion. Sectoral iris atrophy is characteristic of HSV AU. Treatment initiation is highly variable, but most experts preferred valacyclovir owing to simpler dosing. Topical corticosteroids and beta-blockers should be used if necessary. Resolution of inflammation and normalisation of IOP are clinical endpoints. CONCLUSIONS Consensus was reached on several aspects of diagnosis, choice of initial treatment, and treatment endpoints for HSV and VZV AU. Treatment duration and management of recurrences varied between experts.
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Viscoelastics Enable Dissection of Anterior Closed Funnels in Proliferative Vitreoretinopathy: A Retrospective Case Series. Case Rep Ophthalmol 2024; 15:394-398. [PMID: 38665388 PMCID: PMC11045213 DOI: 10.1159/000535795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/05/2023] [Indexed: 04/28/2024] Open
Abstract
Introduction The present study aimed to describe a case series of patients in which a cohesive ophthalmic viscous device (OVD) was used to viscodissect and posteriorly displace the retina in cases of total retinal detachment complicated by proliferative vitreoretinopathy, operated with minimally invasive pars plana vitrectomy. Case Presentations Three patients with a mean age of 67 years were included in the present study. One eye was aphakic, while the others were pseudophakic. OVD injection was performed through the limbus in the aphakic eye and via pars plana in the pseudophakic eyes. In all cases, the OVD injection led to a posterior displacement of the detached retina with a smooth dissection. No complications related to the surgery were observed. At the last follow-up visit, the retina was attached in all cases, with an improvement in visual acuity. Conclusion To conclude, the injection of a cohesive OVD anterior to the detached retina allowed to posteriorize and viscodissect to some extent the retina, facilitating the implant of trocars.
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Refractory post-surgical cystoid macular edema managed following suprachoroidal microcatheterization and delivery of triamcinolone. BMC Ophthalmol 2023; 23:367. [PMID: 37670276 PMCID: PMC10478372 DOI: 10.1186/s12886-023-03110-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/22/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Post-surgical macular edema (ME) is a common cause of prolonged visual impairment. Here we report on the feasibility and clinical outcomes from the use of a novel suprachoroidal microcatheter to treat post-surgical chronic ME by the posterior suprachoroidal placement of a triamcinolone acetonide (TA) suspension. METHODS Two patients were catheterized with the Oxulumis suprachoroidal delivery system on two separate occasions starting 5 and 10 mm posterior to the limbus. The catheter only remains in the suprachoroidal space for the time of the drug administration. Visual acuity and spectral domain optical coherence tomography (SD-OCT) changes were followed over several weeks to months to determine the duration of ME resolution. RESULTS Suprachoroidal microcatheterization for posterior delivery of triamcinolone was possible in all attempts using the illuminated Oxulumis catheter. No reflux, scleral or choroidal trauma was observed. There was no intraocular pressure rise during the follow-up period. The triamcinolone deposit was visible on infrared imaging and on SD-OCT a choroidal elevation was visible. Both progressively disappeared over time. A rapid resolution of ME associated with improved vision was observed following each injection for 3 to 7 months with a TA dose of 2.4 mg or 4 mg. CONCLUSIONS In these patients with poorly responsive ME, posterior suprachoroidal TA led to a visible suprachoroidal drug deposit and prolonged visual improvement. The Oxulumis microcatheterization device performed as expected and was not associated with any complications.
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Robot-Assisted Epiretinal Membrane Peeling: A Prospective Assessment of Pre- and Intra-Operative Times and of Surgeons' Subjective Perceptions. J Clin Med 2023; 12:jcm12082768. [PMID: 37109104 PMCID: PMC10141075 DOI: 10.3390/jcm12082768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/02/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
PURPOSE The Preceyes Surgical System (PSS) is a robotic assistive device that may enhance surgical precision. This study assessed pre- and intra-operative times and surgeons' perceptions of robot-assisted epiretinal membrane peeling (RA-MP). METHODS We analyzed the time requirement of three main tasks: the preparation of the PSS (I), patient preparation (II), and surgery (III). Following surgery, the surgeons were asked questions about their experience. RESULTS RA-MP was performed in nine eyes of nine patients. Task I required an average time of 12.3 min, initially taking 15 min but decreasing to 6 min in the last surgery. Task II showed a mean time of 47.2 (range of 36-65) min. Task III had a mean time of 72.4 (range of 57-100) min. A mean time of 27.9 (range of 9-46) min was necessary for RA-MP. The responses to the questionnaire revealed a trend towards increasing ease and reduced stress as familiarity with the PSS increased. CONCLUSIONS A substantial reduction in pre- and intra-operative times, decreasing to a total of 115 min, was demonstrated. RA-MP was positively anticipated by the surgeons and led to no hand or arm strain while being more complex than manual MP.
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Mineralocorticoid receptor antagonists as a potential treatment option in persistent subretinal fluid following the repair of a rhegmatogenous retinal detachment. Am J Ophthalmol Case Rep 2022; 29:101789. [PMID: 36718434 PMCID: PMC9883142 DOI: 10.1016/j.ajoc.2022.101789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/14/2022] [Accepted: 12/25/2022] [Indexed: 01/01/2023] Open
Abstract
Purpose To report the resolution of subretinal fluid persisting more than a year following retinal detachment surgery resolving with a short term course of mineralocorticoid receptor antagonists use. Observations A 41 year-old, highly myopic male presented with a temporal rhegmatogenous retinal detachment involving the macula. The tear was treated with a radial sponge without subretinal fluid (SRF) drainage. Post-operatively, SRF persisted for more than 1 year with only slight improvement in visual acuity. On OCT, slow regression of subretinal fluid was noted. In order to stimulate the RPE pump, a systemic mineralocorticoid receptor antagonist (spironolactone 50 mg) was initiated after discussion with the patient. After one month of therapy, there was a complete resolution of SRF and the visual acuity improved. Two years later, there was no reaccumulation of SRF and the visual acuity remained stable. Conclusions and importance A short term of course of mineralocorticoid receptor antagonist is a potential treatment for persistent subretinal fluid following a successful detachment surgery.
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Tarsier Anterior Chamber Cell Grading: Improving the SUN Grading Scheme with a Visual Analog Scale. Ocul Immunol Inflamm 2022; 30:1686-1691. [PMID: 34232824 DOI: 10.1080/09273948.2021.1934036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To compare an analog visual scale in grading anterior chamber cells (ACC) to a modified Standardization of Uveitis Nomenclature (SUN) ACC scale. METHOD A graphical representation of anterior chamber cells as a reference and a test set was created and shown to two groups of experienced uveitis experts. Group 1 was given the analog scale in written format, while group two was given the reference images for comparison. Each test subject was asked to provide the best approximation for each grade. RESULTS Eleven graders participated in phase 1. Correct grading occurred in 87.4% of cases. Discrepancies were seen at all grades. Only 3 of 11 graders were able to achieve a perfect score. Seven graders participated in phase 2. Agreement was 95.2% with 4/7 graders achieving a perfect score. Discrepancies were seen at higher grades only. CONCLUSIONS ACC grading is improved by a visual grading scale, and interobserver variability is reduced.
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Randomized controlled trial on robot‐assisted vs manual surgery for pucker peeling. Clin Exp Ophthalmol 2022; 50:1057-1064. [DOI: 10.1111/ceo.14174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/28/2022] [Accepted: 09/15/2022] [Indexed: 12/01/2022]
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The Role of Intravitreal Corticosteroids in the Treatment of DME: Predictive OCT Biomarkers. Int J Mol Sci 2022; 23:ijms23147585. [PMID: 35886930 PMCID: PMC9319632 DOI: 10.3390/ijms23147585] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 11/18/2022] Open
Abstract
This work aims to summarize predictive biomarkers to guide treatment choice in DME. Intravitreal anti-VEGF is considered the gold standard treatment for centers involving DME, while intravitreal steroid treatment has been established as a second-line treatment in DME. However, more than 1/3 of the patients do not adequately respond to anti-VEGF treatment despite up to 4-weekly injections. Not surprisingly, insufficient response to anti-VEGF therapy has been linked to low-normal VEGF levels in the serum and aqueous humor. These patients may well benefit from an early switch to intravitreal steroid treatment. In these patients, morphological biomarkers visible in OCT may predict treatment response and guide treatment decisions. Namely, the presence of a large amount of retinal and choroidal hyperreflective foci, disruption of the outer retinal layers and other signs of chronicity such as intraretinal cysts extending into the outer retina and a lower choroidal vascular index are all signs suggestive of a favorable treatment response of steroids compared to anti-VEGF. This paper summarizes predictive biomarkers in DME in order to assist individual treatment decisions in DME. These markers will help to identify DME patients who may benefit from primary dexamethasone treatment or an early switch.
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Robotic Assistance for Intraocular Microsurgery: Challenges and Perspectives. PROCEEDINGS OF THE IEEE. INSTITUTE OF ELECTRICAL AND ELECTRONICS ENGINEERS 2022; 110:893-908. [PMID: 36588782 PMCID: PMC9799958 DOI: 10.1109/jproc.2022.3169466] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Intraocular surgery, one of the most challenging discipline of microsurgery, requires sensory and motor skills at the limits of human physiological capabilities combined with tremendously difficult requirements for accuracy and steadiness. Nowadays, robotics combined with advanced imaging has opened conspicuous and significant directions in advancing the field of intraocular microsurgery. Having patient treatment with greater safety and efficiency as the final goal, similar to other medical applications, robotics has a real potential to fundamentally change microsurgery by combining human strengths with computer and sensor-based technology in an information-driven environment. Still in its early stages, robotic assistance for intraocular microsurgery has been accepted with precaution in the operating room and successfully tested in a limited number of clinical trials. However, owing to its demonstrated capabilities including hand tremor reduction, haptic feedback, steadiness, enhanced dexterity, micrometer-scale accuracy, and others, microsurgery robotics has evolved as a very promising trend in advancing retinal surgery. This paper will analyze the advances in retinal robotic microsurgery, its current drawbacks and limitations, as well as the possible new directions to expand retinal microsurgery to techniques currently beyond human boundaries or infeasible without robotics.
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First-in-Human Robot-Assisted Subretinal Drug Delivery Under Local Anesthesia. Am J Ophthalmol 2022; 237:104-113. [PMID: 34788592 DOI: 10.1016/j.ajo.2021.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE To report the results of a first-in-human study using a robotic device to assist subretinal drug delivery in patients undergoing vitreoretinal surgery for macular hemorrhage. DESIGN Double-armed, randomized controlled surgical trial (ClinicalTrials.gov identifier: NCT03052881). METHODS The study was performed at the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom. In total, 12 participants were recruited-6 in the robot-assisted and 6 in the control manual surgery arm according to the prespecified inclusion and exclusion criteria. All subjects presented with acute loss of vision owing to a subfoveal hemorrhage secondary to neovascular age-related macular degeneration. After standard vitrectomy, intraoperative optical coherence tomography-guided subretinal injection of tissue plasminogen activator (TPA) was performed by either robot-assisted or conventional manual technique under local anesthesia. The robotic part of the procedure involved advancement of a cannula through the retina and stabilizing it during foot-controlled injection of up to 100 µL of TPA solution. We assessed surgical success, duration of surgery, adverse events, and tolerability of surgery under local anesthesia. RESULTS The procedure was well tolerated by all participants and safely performed in all cases. Total duration of surgery, time taken to complete the injection, and retinal microtrauma were similar between the groups and not clinically significant. Subretinal hemorrhage was successfully displaced at 1 month postintervention, except for 1 control subject, and the median gain in visual acuity was similar in both arms. CONCLUSIONS This first-in-human study demonstrates the feasibility and safety of high-precision robot-assisted subretinal drug delivery as part of the surgical management of submacular hemorrhage, simulating its potential future application in gene or cell therapy.
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Subretinal Therapy: Technological Solutions to Surgical and Immunological Challenges. Front Med (Lausanne) 2022; 9:846782. [PMID: 35402424 PMCID: PMC8985755 DOI: 10.3389/fmed.2022.846782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022] Open
Abstract
Recent advances in ocular gene and cellular therapy rely on precisely controlled subretinal delivery. Due to its inherent limitations, manual delivery can lead to iatrogenic damage to the retina, the retinal pigment epithelium, favor reflux into the vitreous cavity. In addition, it suffers from lack of standardization, variability in delivery and the need to maintain proficiency. With or without surgical damage, an eye challenged with an exogenous viral vector or transplanted cells will illicit an immune response. Understanding how such a response manifests itself and to what extent immune privilege protects the eye from a reaction can help in anticipating short- and long-term consequences. Avoidance of spillover from areas of immune privilege to areas which either lack or have less protection should be part of any mitigation strategy. In that regard, robotic technology can provide reproducible, standardized delivery which is not dependent on speed of injection. The advantages of microprecision medical robotic technology for precise targeted deliveries are discussed.
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Abstract
The COVID-19 pandemic has galvanized the global response towards the development of new vaccines based on novel technologies at an unprecedented pace. Since the widespread implementation of vaccination campaigns, case reports on vaccines' systemic side effects, including ocular manifestations, have emerged. Since administered vaccines are generally not able to cause the disease in the recipient, or induce an immune response against the pathogen, we hypothesize that the development of ocular phenomena post-COVID-19 vaccination may occur via an immune response elicited by the vaccine. Of many, the most common ocular adverse events include facial nerve palsy, central venous sinus thrombosis and acute anterior uveitis. These COVID-19 vaccine-induced ocular (CVIO) adverse events could resemble the ocular findings in some of the COVID-19 patients. This review will provide a comprehensive overview of published ocular side effects potentially associated with COVID-19 vaccination and serve as a springboard for further research into CVIO adverse events.
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Clinical Evaluation of an Instrument-Integrated OCT-Based Distance Sensor for Robotic Vitreoretinal Surgery. OPHTHALMOLOGY SCIENCE 2021; 1:100085. [PMID: 36246942 PMCID: PMC9560530 DOI: 10.1016/j.xops.2021.100085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 10/11/2021] [Accepted: 11/08/2021] [Indexed: 04/29/2023]
Abstract
PURPOSE To assess the efficacy of an instrument-integrated OCT (iiOCT)-based distance sensor during robotic vitreoretinal surgery using the Preceyes Surgical System (PSS; Preceyes B.V.). DESIGN Single-center interventional study. PARTICIPANTS Patients requiring vitreoretinal surgery. METHODS Five patients were enrolled. Standard preoperative OCT images were obtained. After vitrectomy, a predefined set of actions was performed using the iiOCT-based sensor. Images then were processed to assess the signal-to-noise ratio (SNR) at various angles to the retina and at different distances between the instrument tip and the retinal surface. Preoperative and intraoperative OCT images were compared qualitatively and quantitatively. MAIN OUTCOMES MEASURES The feasibility in performing surgical tasks using the iiOCT-based sensor during vitreoretinal surgery, the SNR when imaging the retina, differences among intraoperative and preoperative OCT images, and characteristics of intraoperative retinal movements detected with the iiOCT-based probe. RESULTS Surgeons were able to perform all the tasks but one. The PSS was able to maintain a fixed distance. The SNR of the iiOCT-based sensor signal was adequate to determine the distance to the retina and to control the PSS. Analysis of iiOCT-based sensor A-scans identified 3 clearly distinguishable retinal layers, including the inner retinal boundary and the interface at the retinal pigment epithelium-Bruch's membrane. Thickness values differed by less than 5% from that measured by preoperative OCT, indicating its accuracy. The Fourier analysis of iiOCT-based sensor recordings identified anteroposterior retinal movements attributed to heartbeat and respiration. CONCLUSIONS This iiOCT-based sensor was tested successfully and promises reliable use during robot-assisted surgery. An iiOCT-based sensor is a promising step toward OCT-guided robotic retinal surgery.
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A review of robotic surgical training: establishing a curriculum and credentialing process in ophthalmology. Eye (Lond) 2021; 35:3192-3201. [PMID: 34117390 PMCID: PMC8602368 DOI: 10.1038/s41433-021-01599-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/04/2021] [Accepted: 05/07/2021] [Indexed: 12/21/2022] Open
Abstract
Ophthalmic surgery requires a highly dexterous and precise surgical approach to work within the small confines of the eye, and the use of robotics offers numerous potential advantages to current surgical techniques. However, there is a lag in the development of a comprehensive training and credentialing system for robotic eye surgery, and certification of robotic skills proficiency relies heavily on industry leadership. We conducted a literature review on the curricular elements of established robotics training programs as well as privileging guidelines from various institutions to outline key components in training and credentialing robotic surgeons for ophthalmic surgeries. Based on our literature review and informal discussions between the authors and other robotic ophthalmic experts, we recommend that the overall training framework for robotic ophthalmic trainees proceeds in a stepwise, competency-based manner from didactic learning, to simulation exercises, to finally operative experiences. Nontechnical skills such as device troubleshooting and interprofessional teamwork should also be formally taught and evaluated. In addition, we have developed an assessment tool based on validated global rating scales for surgical skills that may be used to monitor the progress of trainees. Finally, we propose a graduating model for granting privileges to robotic surgeons. Further work will need to be undertaken to assess the feasibility, efficacy and integrity of the training curriculum and credentialing practices for robotic ophthalmic surgery.
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Methodical bias, incorrect use of the RADNER Reading Charts and - avoiding misleading reporting in Visual Acuity Measurements Kortuem C, Marx T, Altpeter E, Trauzettel-Klosinski S, Kuester-Gruber S. Comparing reading speeds for reading standardized single sentences and paragraphs in patients with maculopathy. Ophthalmic Res. 2021;64(3):512-522. Ophthalmic Res 2021; 65:239-243. [PMID: 34614500 DOI: 10.1159/000520029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 09/24/2021] [Indexed: 11/19/2022]
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Ocular Adverse Events After COVID-19 Vaccination. Ocul Immunol Inflamm 2021; 29:1216-1224. [PMID: 34559576 PMCID: PMC8477588 DOI: 10.1080/09273948.2021.1976221] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/24/2021] [Accepted: 08/29/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE The COVID-19 pandemic has galvanized the development of new vaccines at an unprecedented pace. Since the widespread implementation of vaccination campaigns, reports of ocular adverse effects after COVID-19 vaccinations have emerged. This review summarizes ocular adverse effects possibly associated with COVID-19 vaccination, and discusses their clinical characteristics and management. METHODS Narrative Literature Review. RESULTS Ocular adverse effects of COVID-19 vaccinations include facial nerve palsy, abducens nerve palsy, acute macular neuroretinopathy, central serous retinopathy, thrombosis, uveitis, multiple evanescent white dot syndrome, Vogt-Koyanagi-Harada disease reactivation, and new-onset Graves' Disease. Studies in current literature are primarily retrospective case series or isolated case reports - these are inherently weak in establishing association or causality. Nevertheless, the described presentations resemble the reported ocular manifestations of the COVID-19 disease itself. Hence, we hypothesize that the human body's immune response to COVID-19 vaccinations may be involved in the pathogenesis of the ocular adverse effects post-COVID-19 vaccination. CONCLUSION Ophthalmologists and generalists should be aware of the possible, albeit rare, ocular adverse effects after COVID-19 vaccination.
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Advantages of robotic assistance over a manual approach in simulated subretinal injections and its relevance for gene therapy. Gene Ther 2021; 30:264-270. [PMID: 34002047 PMCID: PMC10113148 DOI: 10.1038/s41434-021-00262-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 04/01/2021] [Accepted: 04/22/2021] [Indexed: 11/09/2022]
Abstract
Subretinal injection is a method for gene delivery to treat genetic diseases of the photoreceptors and retinal pigment epithelium. A reflux-free subretinal injection is important to allow effective, safe, and cost-effective gene therapy to the retina. We report on a comparison between manual and robotic assistance in simulated subretinal injections using an artificial retina model. Nine surgeons carried out the procedure with and without the Preceyes Surgical System, using an OPMI Lumera 700 Zeiss surgical microscope equipped with intra-operative optical coherence tomography. Success in creating a bleb without reflux, injection duration, drift, tremor, and increase in the diameter of the puncture hole were analyzed. Robotic assistance improved drift (median 16 vs 212 µm), tremor (median 1 vs 18 µm), enlargement of the retinal hole, and allowed for prolonged injection times (median 52 vs 29 sec). Robotic assistance allowed higher rate of bleb formation (8/9 vs 4/9 attempts) with a moderate reduction in reflux (7/9 vs 8/9 attempts) in this artificial model. Robotic assistance can significantly contribute to subretinal injections and provide quantifiable parameters in assessing surgical and clinical success of novel retinal gene therapies.
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Standardisation of optical coherence tomography angiography nomenclature in uveitis: first survey results. Br J Ophthalmol 2020; 105:941-947. [DOI: 10.1136/bjophthalmol-2020-316881] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/12/2020] [Accepted: 06/25/2020] [Indexed: 12/24/2022]
Abstract
AimTo standardise the nomenclature for reporting optical coherence angiography (OCT-A) findings in the field of uveitis.MethodsMembers of the International Uveitis Study Group, of the American Uveitis Society and of the Sociedad Panamericana de Infermedades Oculares that choose to participate responded to an online questionnaire about their preferred terminology when reporting on OCT-A findings in uveitis. The response of individuals with several publications on OCT-A (experts) was compared with uveitis specialists (users) who have less than five publications on the field of uveitis and OCT-A.ResultsA total of 108 uveitis specialists who participated in the survey were included in the analysis. Of those, 23 were considered OCT-A ‘experts’. There was an agreement in both groups for the definition of wide-field (WF)-OCT-A, and definition of neovascularisation in uveitis. Moreover, there was a difference in the responses in other areas, such as quantification of ischaemia, definition of ‘large’ areas of ischaemia or terms to describe decreased OCT-A signal from different causes. There was an unanimous need of ‘users’ and ‘experts’ to distinguish size of decreased OCT-A signal in uveitis, to implement a quantitative measurement of decreased flow specifically for WF-OCT-A and to use different terms for different causes of decreased OCT-A signal.ConclusionsWhile there was considerable agreement in the terminology used by all uveitis experts, significant differences in terminology were noted between ‘users’ and ‘experts’. These differences indicate the need for standardisation of nomenclature among all uveitis specialists both for the purpose of reporting and in clinical use.
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Expert opinion on the management and follow-up of uveitis patients during SARS-CoV-2 outbreak. Expert Rev Clin Immunol 2020; 16:651-657. [PMID: 32615046 DOI: 10.1080/1744666x.2020.1791086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Routine medical and ophthalmic care is being drastically curtailed in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Uveitis patients require particular attention because of their theoretical risk of viral infection, in the context of therapeutic immunosuppression. AREAS COVERED This collaborative work proposes practical management and follow-up criteria for uveitis patients in the context of the ongoing SARS-CoV-2 pandemic. EXPERT OPINION Management should proceed as usual when access to health care possible in patients who do not belong to a group at high risk of severe SARS-CoV-2 infection, and in uncontrolled uveitis cases. In case of reduced access to eye clinics or high risk of SARS-CoV-2 infection, patients' management should be stratified based on their clinical presentation. In non-severe uveitis cases, the use of systemic steroids should be avoided, and local steroids preferred whenever possible. In uncontrolled situations where there is real risk of permanent visual loss, high-dose intravenous steroids and/or systemic immunosuppressants and/or biotherapies can be administered depending on the severity of eye disease. Immunosuppressive therapy should not be withheld, unless the patient develops SARS-CoV2 infection.
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Collaborative Ocular Tuberculosis Study Consensus Guidelines on the Management of Tubercular Uveitis-Report 2: Guidelines for Initiating Antitubercular Therapy in Anterior Uveitis, Intermediate Uveitis, Panuveitis, and Retinal Vasculitis. Ophthalmology 2020; 128:277-287. [PMID: 32603726 DOI: 10.1016/j.ophtha.2020.06.052] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/03/2020] [Accepted: 06/22/2020] [Indexed: 10/24/2022] Open
Abstract
TOPIC The Collaborative Ocular Tuberculosis Study (COTS), supported by the International Ocular Inflammation Society, International Uveitis Study Group, and Foster Ocular Immunological Society, set up an international, expert-led consensus project to develop evidence- and experience-based guidelines for the management of tubercular uveitis (TBU). CLINICAL RELEVANCE The absence of international agreement on the use of antitubercular therapy (ATT) in patients with TBU contributes to a significant heterogeneity in the approach to the management of this condition. METHODS Consensus statements for the initiation of ATT in TBU were generated using a 2-step modified Delphi technique. In Delphi step 1, a smart web-based survey based on background evidence from published literature was prepared to collect the opinion of 81 international experts on the use of ATT in different clinical scenarios. The survey included 324 questions related to tubercular anterior uveitis (TAU), tubercular intermediate uveitis (TIU), tubercular panuveitis (TPU), and tubercular retinal vasculitis (TRV) administered by the experts, after which the COTS group met in November 2019 for a systematic and critical discussion of the statements in accordance with the second round of the modified Delphi process. RESULTS Forty-four consensus statements on the initiation of ATT in TAU, TIU, TPU, and TRV were obtained, based on ocular phenotypes suggestive of TBU and corroborative evidence of tuberculosis, provided by several combinations of immunologic and radiologic test results. Experts agreed on initiating ATT in recurrent TAU, TIU, TPU, and active TRV depending on the TB endemicity. In the presence of positive results for any 1 of the immunologic tests along with radiologic features suggestive of past evidence of tuberculosis infection. In patients with a first episode of TAU, consensus to initiate ATT was reached only if both immunologic and radiologic test results were positive. DISCUSSION The COTS consensus guidelines were generated based on the evidence from published literature, specialists' opinions, and logic construction to address the initiation of ATT in TBU. The guidelines also should inform public policy by adding specific types of TBU to the list of conditions that should be treated as tuberculosis.
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Minimally interface vitrectomy for rhegmatogenous retinal detachment with a single break in young patients. Am J Ophthalmol Case Rep 2020; 19:100739. [PMID: 32551398 PMCID: PMC7287242 DOI: 10.1016/j.ajoc.2020.100739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/29/2020] [Accepted: 05/06/2020] [Indexed: 12/19/2022] Open
Abstract
Purpose This study evaluates a new surgical technique consisting of minimal vitreous removal under air (minimal interface vitrectomy; MIV) to reduce postoperative complications while preserving the ability to address surgical factors at the retinal break. Methods This retrospective analysis examined the outcomes of minimal interface vitrectomies in consecutive cases, with a minimum 12-month follow-up period, of primary rhegmatogenous retinal detachment (RRD), recurrent RRD after pars plana vitrectomy (PPV), or failed surgery after primary scleral buckling surgery (SBS). Results Twelve eyes of 12 patients with RRD underwent MIV. The total surgical duration was 190–300 s (mean, 245.25 s). Eight (66.7%) eyes were treated with cryotherapy, and 4 (33.3%) with endolaser to seal the retinal break. Successful, complete retinal reattachment was achieved in all eyes and maintained during follow-up. No intra- or postoperative complications occurred and no patients developed inflammation or cataract during follow-up. Conclusion and Importance We effectively removed traction and subretinal fluid and treated breaks with endolaser or cryotherapy by using a novel minimal interface vitrectomy technique in this selected population.
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Retinal relaxation following membrane peeling: Effect on vision, central macular thickness, and vector analysis of motion. J Clin Transl Res 2020; 5:236-242. [PMID: 33029566 PMCID: PMC7534668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/09/2020] [Accepted: 04/09/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Epiretinal membranes (ERM) form as a result of an inward displacement of retinal structures. Removal of an ERM leads to the outward displacement of retinal vessels and visual improvement. PURPOSE The aim of the study was to evaluate the direction and extent of displacement of retinal/superficial vascular structures after a membrane peeling procedure by means of image comparison and in selected cases, a vector analysis of displacement. METHODOLOGY Scanning laser ophthalmoscope images of the retina of eyes undergoing ERM peeling were compared before and 6 months after surgery. Stratification was made between prominent and limited displacement, with assessment of visual acuity (VA), and central macular thickness (CMT). In three cases, using the optic nerve as reference, 50 landmarks were chosen within the posterior pole along large and small vascular structures allowing the construction of a vector map of displacement over 1 year. RESULTS Nine eyes with prominent and six with limited displacement were assessed. Improvement in VA was similar for both groups, while CMT drop was greatest for the worst group. Vector analysis showed that most vascular movement occurs over the first 6 months, covers most of the posterior retina, is centered around distinct nodes, and may lead to several hundred micrometers of displacement. CONCLUSIONS Superficial retinal relaxation has no direct implication on visual recovery. It originates in nodes of retinal contraction. Its extent can be significant, covering most of the posterior pole. RELEVANCE FOR PATIENTS A better understanding of retinal relaxation following the peeling of ERM may help better understand when intervention is required and which part of the membrane is critical to surgical success.
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Abstract
After the outbreak of the disease COVID-19, it has reached pandemic proportions within a very short time. It is mainly transmitted human-to-human through direct contact with secretions from an infected person or through inhalation of droplets containing SARS-CoV-2. It is controversial whether the virus may be transmitted via tears. Exposed ocular surface can serve as a gateway in transmission and acquiring respiratory diseases. Considering the reported cases on healthcare workers indicating nosocomial transmission and the anatomical and physiological aspects it is perceived that ophthalmic healthcare professionals are at higher risk of contracting the virus by virtue of their job. In this narrative review we discuss current evidence around detection of SARS-CoV-2 in human tears and forms of transmissions reported to date. We also provide a comprehensive approach that may be implemented in an ophthalmic care facility to protect healthcare personnel, as well as patients, from contracting the virus.
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Erratum: Sicherheit, Effektivität und protektive Wirkung einer Parazentese bei intravitrealen Injektionen: „Eine Lanze für die Parazentese brechen“. Klin Monbl Augenheilkd 2020; 237:e1. [DOI: 10.1055/a-1185-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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[Safety, Efficacy and Protective Aspects of an Add-on Paracentesis during Intravitreal Injections]. Klin Monbl Augenheilkd 2019; 237:90-94. [PMID: 31770791 DOI: 10.1055/a-0972-9747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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First-line treatment algorithm and guidelines in center-involving diabetic macular edema. Eur J Ophthalmol 2019; 29:573-584. [DOI: 10.1177/1120672119857511] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Management of center-involving diabetic macular edema represents a real therapeutic challenge. Diabetic macular edema is the leading cause of visual acuity impairment in diabetic patients. Since the advent of intravitreal drugs, management of diabetic macular edema has significantly evolved. The historical grid laser photocoagulation is no longer recommended as first-line treatment of diabetic macular edema owing to the findings of the pivotal randomized controlled trials, and anti-vascular endothelial growth factor therapy has emerged as first-line therapy. Steroids also represent a valid treatment option in the management of naïve diabetic macular edema and their efficacy has also been confirmed in several studies. The optimal treatment for diabetic macular edema should consider both general and ophthalmological comorbidities. Patient compliance and motivation should also be carefully evaluated as some treatments require monthly follow-up. Based on recent literature evidence, the present review provides clinicians with a first-line treatment algorithm for center-involving diabetic macular edema tailored to the patient’s individual characteristics.
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Efficacy and Safety of Sarilumab for the Treatment of Posterior Segment Noninfectious Uveitis (SARIL-NIU):: The Phase 2 SATURN Study. Ophthalmology 2018; 126:428-437. [PMID: 30316888 DOI: 10.1016/j.ophtha.2018.09.044] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 08/17/2018] [Accepted: 09/20/2018] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To assess efficacy and safety of sarilumab, a human anti-interleukin-6 receptor antibody, for treatment of posterior segment noninfectious uveitis (NIU). DESIGN Randomized, double-masked, placebo-controlled, phase 2 study. PARTICIPANTS Fifty-eight patients (eyes) with noninfectious intermediate, posterior, or panuveitis. METHODS Eyes received treatment every 2 weeks for 16 weeks with subcutaneous sarilumab 200 mg or placebo. MAIN OUTCOME MEASURES The primary end point was the proportion of patients with ≥2-step reduction in vitreous haze (VH) on the Miami scale or with a reduction of systemic corticosteroids (prednisolone or equivalent) to a dose of <10 mg/day at week 16. Primary end point was based on VH evaluation by a central reading center. Investigator evaluation of VH was a prespecified, planned secondary analysis. RESULTS At week 16, proportion of patients taking sarilumab or placebo with ≥2-step reduction in VH or corticosteroid dose <10 mg/day was 46.1% vs. 30.0% (P = 0.2354) based on central reading center assessment of VH and 64.0% vs. 35.0% (P = 0.0372) based on investigator assessment of VH, respectively. In the subgroup of eyes with VH grade ≥2 at baseline, the mean VH reduction from baseline to week 16 was significantly greater with sarilumab vs. placebo regardless of assessment by the central reading center (-2.1 [n = 11] vs. -1.7 [n = 3], respectively; P = 0.0255) or investigator (-2.5 [n = 19] vs. -1.2 [n = 11], respectively; P = 0.0170). The mean best-corrected visual acuity gain from baseline to week 16 was greater with sarilumab vs. placebo in the overall population (8.9 vs. 3.6 letters, respectively; P = 0.0333) and in the subgroup of eyes with central subfield thickness (CST) ≥300 μm at baseline (12.2 [n = 13] vs. 2.1 [n = 7] letters, respectively; P = 0.0517). Corresponding changes in CST were -46.8 vs. +2.6 μm (P = 0.0683) in the overall population and -112.5 [n = 13] vs. -1.8 [n = 6] μm (P = 0.1317) in the subgroup of eyes with CST ≥300 μm at baseline, respectively. The most common ocular adverse events were worsening of uveitis (0 [placebo] and 3 [sarilumab] patients) and retinal infiltrates (1 [placebo] and 2 [sarilumab] patients). CONCLUSIONS Subcutaneous sarilumab may provide clinical benefits in the management of NIU of the posterior segment, especially in eyes with uveitic macular edema.
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Retinal vasculopathy with cerebral leukoencephalopathy and systemic manifestations. Brain 2018; 139:2909-2922. [PMID: 27604306 DOI: 10.1093/brain/aww217] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 07/11/2016] [Indexed: 02/02/2023] Open
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Re: van Bree et al.: Straylight as an Indicator for Cataract Extraction in Patients with Retinal Dystrophy. Ophthalmol Retina 2018; 2:e9. [PMID: 31047544 DOI: 10.1016/j.oret.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 02/27/2018] [Accepted: 03/29/2018] [Indexed: 06/09/2023]
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A Subretinal Cell Delivery Method via Suprachoroidal Access in Minipigs: Safety and Surgical Outcomes. ACTA ACUST UNITED AC 2018; 59:311-320. [DOI: 10.1167/iovs.17-22233] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
New technological progress in robotics has brought many beneficial clinical applications. Currently, computer integrated robotic surgery has gained clinical acceptance for several surgical procedures. Robotically assisted eye surgery is envisaged as a promising solution to overcome the shortcomings inherent to conventional surgical procedures as in vitreoretinal surgeries. Robotics by its high precision and fine mechanical control can improve dexterity, cancel tremor, and allow highly precise remote surgical capability, delicate vitreoretinal manipulation capabilities. Combined with magnified three-dimensional imaging of the surgical site, it can enhance surgical precision. Tele-manipulation can provide the ability for tele-surgery or haptic feedback of forces generated by the manipulation of intraocular tissues. It presents new solutions for some sight-threatening conditions such as retinal vein cannulation where, due to physiological limitations of the surgeon's hand, the procedure cannot be adequately performed. In this paper, we provide an overview of the research and advances in robotically assisted vitreoretinal eye surgery. Additionally the barriers to the integration of this method in the field of ocular surgery are summarized. Finally, we discuss the possible applications of the method in the area of vitreoretinal surgery.
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Insights into the Physiopathology of Inflammatory Macular Edema. MACULAR EDEMA 2017; 58:168-177. [DOI: 10.1159/000455279] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Release of experimental retinal vein occlusions by direct intraluminal injection of ocriplasmin. Br J Ophthalmol 2016; 100:1742-1746. [PMID: 27688592 PMCID: PMC5256413 DOI: 10.1136/bjophthalmol-2016-309190] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/25/2016] [Accepted: 09/03/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE Retinal vein occlusions (RVO) are a major cause of vision loss in people aged 50 years and older. Current therapeutic options limit the consequences of RVO but do not eliminate the cause. Cannulation of the involved vessel and removal of the clot may provide a more permanent solution with a less demanding follow-up. However, cannulation of smaller retinal veins remains challenging. This paper explores the use of ocriplasmin (recombinant plasmin without its kringles) to clear RVO, using a robotic micromanipulator. METHODS Branch RVO were induced in a porcine model with rose bengal followed by 532 nm endolaser to the superior venous branch of the optic nerve. The vein was cannulated proximal to the occlusion or beyond the first branching vessel from the obstruction. The vein was infused with a physiologic citric acid buffer solution (CAM) or CAM/ocriplasmin. The time of cannulation, number of attempts, and the ability to release the thrombus were recorded. RESULTS Cannulation and infusion was possible in all the cases. The use of a micromanipulator allowed for a consistent cannulation of the retinal vein and positional stability allowed the vein to remain cannulated for up to 20 min. In none of the attempts (5/5) with CAM did the thrombus dissolve, despite repeat infusion/relaxation cycles. In 7/7 injections of CAM/ocriplasmin near to the point of obstruction, the clot started to dissolve within a few minutes of injection. An infusion, attempted beyond the first venous branch point proximal to the clot, was unsuccessful in 2/3 attempts. CONCLUSIONS Ocriplasmin is effective in resolving RVO if injected close to the site of occlusion with the use of a micromanipulator.
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Abstract
PURPOSE To develop a methodology for cannulating porcine retinal venules using a robotic assistive arm after inducing a retinal vein occlusion using the photosensitizer rose bengal. METHODOLOGY Retinal vein occlusions proximal to the first vascular branch point were induced following intravenous injection of rose bengal by exposure to 532nm laser light delivered by slit-lamp or endolaser probe. Retinal veins were cannulated by positioning a glass catheter tip using a robotically controlled micromanipulator above venules with an outer diameter of 80μm or more and performing a preset piercing maneuver, controlled robotically. The ability of a balanced salt (BSS) solution to remove an occlusion by repeat distention of the retinal vein was also assessed. RESULTS Cannulation using the preset piercing program was successful in 9 of 9 eyes. Piercing using the micromanipulator under manual control was successful in only 24 of 52 attempts, with several attempts leading to double piercing. The best location for cannulation was directly proximal to the occlusion. Infusion of BSS did not result in the resolution of the occlusion. CONCLUSION Cannulation of venules using a robotic microassistive arm can be achieved with consistency, provided the piercing is robotically driven. The model appears robust enough to allow testing of therapeutic strategies aimed at eliminating a retinal vein thrombus and its evolution over time.
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T-shaped macular buckling combined with 25G pars plana vitrectomy for macular hole, macular schisis, and macular detachment in highly myopic eyes. Br J Ophthalmol 2016; 101:383-388. [PMID: 27234876 DOI: 10.1136/bjophthalmol-2015-308124] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 04/04/2016] [Accepted: 05/09/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To report our experience using the T-shaped macular buckle (MB) with or without pars plana vitrectomy (PPV) as primary surgery or with a previous failed surgical approach in patients affected by high myopia and macular hole (MH) with or without macular detachment and with or without macular schisis. The primary goal was to evaluate complete closure of the MH and reattachment of the retina. DESIGN Retrospective case series of 21 consecutive patients who underwent T-shaped MB implant alone or combined with PPV at the Academic Medical Center in Amsterdam, The Netherlands, between January 2013 and November 2014. The mean axial length was 31.22 mm. The mean follow-up period was 7 months. RESULTS Retinal reattachment was achieved in 100% of cases while MH closure was achieved in 90.5%. No major perioperative complications were observed. Best corrected visual acuity improved in 71.4% of patients. CONCLUSIONS MB combined with PPV should be considered as the preferred surgical approach both in primary and recurrent retinal detachment secondary to MH in high myopic eyes.
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Use of a new intra-ocular spectral domain optical coherence tomography in vitreoretinal surgery. Acta Ophthalmol 2016; 94:246-52. [PMID: 26842922 DOI: 10.1111/aos.12961] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/24/2015] [Indexed: 01/08/2023]
Abstract
PURPOSE To describe the use of a novel intra-ocular side-scanning probe enabling the acquisition of spectral-domain optical coherence tomography (SD-OCT) images during surgery in a series of patients with complex forms of retinal detachment. METHODS A 23-gauge, side-scanning SD-OCT probe (C7 System; LightLab Imaging, Inc/St Jude Medical, St. Paul, MN, USA) in a 20-gauge catheter, was used to acquire the intra-operative OCT images in seven patients with vitreoretinal diseases. Twenty-five gauge pars plana vitrectomy (PPV) was performed in every patient in a standard fashion. After enlarging the temporal sclerotomy to a 20-gauge port, all the patients were scanned with intra-ocular side-scanning SD-OCT, during different steps of the surgery based on surgeon needs. Scans were recorded real time and directly evaluated on a screen during surgery. Optical coherence tomography (OCT) scans were judged beneficial when they would recognize structures otherwise not seen on biomicroscopy. RESULTS The intra-ocular SD-OCT has been helpful in acquiring extra information during vitreoretinal surgery such as the detection of the presence of otherwise invisible membranes (epiretinal membrane, subretinal membrane), the location of small tears and the identification of the retinal plane under suboptimal conditions for visualization. CONCLUSION The use of an intra-ocular SD-OCT can expand upon visual cues during surgery, helping in the decision-making process and allowing additional deliberate surgical manoeuvres aimed at improving surgical outcomes.
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Incorrect use and presentation of the RADNER Reading Charts: comment on measurement of reading speed with standardized texts: a comparison of single sentences and paragraphs, by Altpeter E, Marx T, Nguyen N, Naumann A, Trauzettel-Klosinski S. Graefes Arch Clin Exp Ophthalmol 2016; 254:813-5. [PMID: 26464177 PMCID: PMC4799789 DOI: 10.1007/s00417-015-3183-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/30/2015] [Indexed: 11/28/2022] Open
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Abstract
PURPOSE To evaluate the effect of vitreous floaters on intraocular straylight. METHODS Records of bilaterally phakic patients with unilateral complaint of floaters as the main symptom were identified from an electronic database. Patients who underwent straylight measurements on both affected and unaffected eyes using a C-Quant straylight meter were selected. Data were collected on age, sex, visual acuity, straylight measurements, and optical coherence tomography. The unaffected eye served as a control. RESULTS Fifteen cases were included (7 women and 8 men; mean age, 54.3 years; age range, 24-71 years). Visual acuity was not correlated with the complaint of floaters. Average straylight value in eyes with floaters was 1.426 log(s) (±0.23 SD) with a median value of 1.52 log(s). The mean value for fellow eyes was 1.275 (±0.23 SD) with a median of 1.25 log(s). The differences between both groups using a Wilcoxon matched-pair signed-rank test was statistically significant at P = 0.0009. On optical coherence tomography, most patients had a confirmed or probable posterior vitreous detachment. However, in four patients, a posterior vitreous detachment was absent in the affected eyes. Vitreous floaters were inconsistently imaged by optical coherence tomography, with only a few patients presenting appreciable condensations close to the retinal surface. These were present in both affected and unaffected eyes. CONCLUSION Intraocular straylight is significantly increased in eyes affected by floaters. No correlation was seen with vision or optical coherence tomography appearance. Straylight is an independent objective measure of visual perception that seems to be closely correlated to complaints expressed by patients experiencing floaters.
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Surgical management of severe complications arising from uveitis in juvenile idiopathic arthritis. Ophthalmologica 2014; 232:179-86. [PMID: 25342480 DOI: 10.1159/000365230] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 06/12/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE Evaluate outcomes from severe ocular complications of juvenile idiopathic arthritis following surgery. METHODS Eleven eyes of 7 patients underwent complete vitrectomy and peeling of the inner limiting membrane. Inclusion criteria were: anteroposterior segment involvement, hypotony, inflammation control of less than 3 months, compliance issues, rapidly progressive disease. Phacoemulsification was allowed if the patient was >6 years old and inflammation free >3 months. The alternative was a complete lensectomy. RESULTS Visual acuity improved from a logMAR of 1.48 to 0.37 (p < 0.0001), and 0.20 at 6 and 12 months (p < 0.0001). No flare-up was observed within the first 6 months. Five eyes developed inflammation between 7 and 19 months. Glaucoma developed in 5 eyes at a median of 16 months. No patient developed cystoid macular edema. CONCLUSION Extensive pars plana vitrectomy and cataract extraction can lead to significant improvement in visual acuity. Patients continue to require long-term immunosuppression and adequate follow-up.
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Abstract
PURPOSE Microplasmin is known to alter the structure of the vitreous gel. The current experiments were designed to assess its ability to enhance clearance of an experimentally induced vitreous haemorrhage, and to compare it to ovine hyaluronidase. METHODS Twenty-five rabbits were used for this experiment, divided into five groups; groups 1-3 are microplasmin-treated eyes with 25, 75 and 125 μg, respectively. Group 4 treated with 55 IU of hyaluronidase, while group 5 was treated with normal saline (control). Eyes were injected in the mid-vitreous with 0.05 ml of autologous blood obtained from the marginal ear vein. One week later, all the groups were injected with the test solution injected in mid-vitreous as stated above. Clearance of the vitreous haemorrhage was assessed weekly indirect ophthalmoscopy for 8 weeks. RESULTS Microplasmin-treated eyes showed a significant clearance of the vitreous haemorrhage in a dose-dependent fashion, where group 3 (125 μg) had the highest clearance rate in comparison with control eyes. Hyaluronidase-treated eyes showed a similar clearance rate as group 3. In addition, group 3 showed a complete posterior vitreous detachment, which did not develop in hyaluronidase-treated eyes. CONCLUSION Microplasmin may be a useful agent to accelerate the clearance of vitreous haemorrhage.
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Image diagnostic agreement in uveitis: a picture is worth a thousand words but is it sufficient to diagnose? Can J Ophthalmol 2013; 48:223-5. [PMID: 23931457 DOI: 10.1016/j.jcjo.2013.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
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Management of Combined Inflammatory and Rhegmatogenous Retinal Detachment. Retina 2013. [DOI: 10.1016/b978-1-4557-0737-9.00112-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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48
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Contributors. Retina 2013. [DOI: 10.1016/b978-1-4557-0737-9.00159-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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49
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The Vitreous, the Retinal Interface in Ocular Health and Disease. Ophthalmologica 2013; 230:165-78. [DOI: 10.1159/000353447] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 04/02/2013] [Indexed: 11/19/2022]
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50
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