Macular hole surgery follow-up with spectral domain-optical coherence tomography-guided facedown posturing.

PURPOSE: The main treatment for macular hole (MH) is pars plana vitrectomy, with or without internal limiting membrane (ILM) peeling, followed by gas tamponade and face-down positioning (FDP). This study aims to present the anatomical and visual outcomes following MH repair with optical coherence tomography (OCT)-guided FDP. METHODS: Thirty-two patients who underwent surgery for idiopathic MH were enrolled. The requirement for the prone position was lifted for those with MH closure observed under gas on postoperative day one OCT. Patients with unclosed MHs were instructed to maintain FDP until the 3rd day. Best-corrected visual acuity at preoperative, postoperative 1st month, and the last visit, closure time post-surgery, duration of prone position, and surgical success rate were recorded. RESULTS: Among the patients, 21 underwent phacovitrectomy + ILM peeling + gas tamponade, while 11 had vitrectomy + ILM peeling + gas tamponade. On postoperative day one, 28 out of 32 MHs closed, with 3 closures on day 3 and one on day 5. There were 18 stage two (56.3%), 13 stage three (40.6%) and 1 stage four (3.1%) MHs. The mean minimum MH diameter was 381.75 ± 68.07 (min 260-max 517) microns. All patients with MH closure time over postoperative day one had non-combined vitrectomy instead of phacovitrectomy. No late complications were observed. CONCLUSIONS: OCT-guided FDP approach yields excellent closure rates with no late complications and ensures good patient comfort.

Choroidal vascularity index changes in different treatments for vitreomacular traction.

INTRODUCTION: The aim of this study was to examine if choroidal vascularity index (CVI) is different in eyes with unilateral vitreomacular traction (VMT) from their healthy fellow eyes; and whether different treatments affect the CVI. METHODS: The baseline and 8-week post treatment CVIs of 56 unilateral VMT patients that underwent spontaneous resolution (n = 30), vitreoretinal surgery (n = 16) or pneumatic vitreolysis (n = 10) were compared with fellow eyes using paired samples t-test. Partial correlation analyses correcting age and gender was used for calculations between treatment groups. P values < 0.05 were considered statistically significant. RESULTS: The mean baseline CVI for VMT and control eyes had no statistically significant difference (p = 0.81, r= -0.38). The post traction release follow-up CVI of VMT eyes and contralateral eyes had no significant difference (p = 0.12, r = 0.49). In spontaneous resolution group, vitreoretinal surgery group and pneumatic vitreolysis group the baseline and follow up CVIs of VMT eyes were statistically similar (p = 0.72, p = 0.32 and p = 0.79 respectively).Spontaneous detachment patients' CVIs showed a 0.57±5.81% increase, vitreoretinal surgery group had a reduction of 1.098±4.76%, and the pneumatic vitreolysis patients showed a CVI reduction of 0.307±4.24%. However, none of these changes was found to be statistically significant when compared between the groups (p = 0.21, r = 0.02). DISCUSSION: Previous studies have argued that vitreomacular traction might have a role on the choroidal changes seen in the vitreoretinal interface disorders. This study has shown that VMT alone does not cause any significant changes in choroidal vascular index pre or post traction release.

Macular Imaging Characteristics in Children with Myelinated Retinal Nerve Fiber and High Myopia Syndrome.

Objectives: To investigate the macular imaging features in patients with unilateral myelinated retinal nerve fiber (MRNF) and high myopia syndrome. Materials and Methods: Six patients with unilateral MRNF and high myopia syndrome and 13 myopic controls were enrolled in this study. Spectral domain (SD) optical coherence tomography (OCT), SD enhanced depth imaging OCT, and OCT angiography (OCTA) imaging results of MRNF-affected eyes were compared with the fellow eyes and myopic controls. Results: All patients had abnormal foveal reflex and/or ectopia. No significant difference in retinal thickness parameters were noted between the groups. In OCT scans, posterior vitreous detachment (PVD) was observed in 4 out of the 6 MRNF-affected eyes. Regarding OCTA parameters, only a significant increase in acircularity index was noted in myelinated eyes (p=0.01). Conclusion: All patients demonstrated normal foveal contours, macular structure, and OCTA features except for a higher acircularity index. The incidence of PVD was notably increased in the myelinated eyes.

A variation of foveal morphology in a group of children with hypermetropia.

PURPOSE: During routine eye examinations, we noticed widened and flattened foveal pits with loss of normal V-shaped foveal profile and a pseudohole-like appearance in some otherwise healthy hypermetropic children. Our purpose was to describe clinical significance and multimodal imaging features of this incidental finding. METHODS: Prospectively, 25 eyes of 13 hypermetropic children with these foveal changes and 36 eyes of 19 hypermetropic children with normal foveal appearance were enrolled. The macular thickness measurements and foveal parameters including pit diameter, depth, base, and area obtained by optical coherence tomography (OCT) (Heidelberg Spectralis, Heidelberg Engineering, Heidelberg, Germany), macular superficial and deep vessel density (VD) and foveal avascular zone values obtained by optical coherence tomography angiography (Avanti RTVue­XR; Optovue, Fremont, CA, USA) were noted. The correlations of these parameters with visual function were evaluated. RESULTS: In the study group, significantly widened and flattened pit contours with decreased central foveal thickness (p = 0.01), and increased distance between foveal edges (p < 0.001) were observed. While the whole image superficial macular VD was similar between the groups (p = 0.74), a significant decrease in deep macular VD was observed in the study group (p = 0.01). None of these changes were correlated with visual acuity. CONCLUSION: Wider and flattened foveal pits described here represent a newly defined variation in healthy hypermetropic children. Although a correlation with visual acuity was not evident, these changes in foveal profile are shown to be related with macular microvascular changes in deep capillary plexus. Awareness of these morphologic changes will help clinicians in the differential diagnosis of macular pseudohole.

The correlation of atrophy, traction and neovascularization in myopic choroidal neovascularization according to a novel myopic maculopathy classification system (atrophy (A), traction (T), neovascularization (N): ATN).

PURPOSE: To grade myopic choroidal neovascularization (CNV) patients according to the new myopic maculopathy classification (A: atrophy, T: traction, N: neovascularization-ATN) and analyze the correlation in between atrophy, traction and neovascularization. METHODS: Fifty-one eyes of 41 patients with the diagnosis of pathologic myopia and myopic CNV were included in this clinical practice study. Patients were graded according to the recently described ATN classification. Color fundus photographs were used to grade the atrophy and spectral domain optical coherence tomography scans were used to grade traction and neovascularization. Active myopic CNVs were treated with intravitreal anti-vascular endothelial growth factor (VEGF) injections. Chi-square test was used to test the categorical variants and univariate logistic regression analysis was used to predict the independent risk factors of myopic CNV scar formation. RESULTS: Active myopic CNV was observed most frequently in the group with patchy chorioretinal atrophy. Grade of the atrophy and female gender were significantly associated with myopic CNV scar in the univariate logistic regression tests. Multivariate logistic regression showed that atrophy grading is the independent predictor of myopic CNV scar. CONCLUSION: ATN classification is a practical and comprehensive system to grade myopic CNV. Atrophy is an independent predictor for myopic CNV scar and patchy chorioretinal atrophy requires a more careful examination and close follow-up for the risk of CNV development.

Hedgehog Signal Defect Leading to Familial Exudative Vitreoretinopathy-Like Disease and Gastrointestinal Malformation.

Objectives: The aim of the study was to present a new genetic association presenting with gastrointestinal tract malformations (GTMs) and familial exudative vitreoretinopathy (FEVR)-like disease and review the genetics of Hedgehog signaling. Materials and Methods: Three neonates were diagnosed with FEVR-like retinal vascular disease upon routine ophthalmological examination during hospitalization in the neonatal surgical intensive care unit for GTMs. Genetic analysis of the neonates was performed. Results: Gestational age of the neonates was 39, 38, and 39 weeks and birth weights were 3,500, 3,600, and 3,300 grams, respectively. All six eyes of the three infants were treated by laser photocoagulation. Recurrence was not seen in any of the eyes. Genetical analysis of all the neonates diagnosed with FEVR-like disease revealed defects in the Hedgehog pathway. Conclusion: FEVR is a genetically well-defined retinal vascular disease. The current study is the first to show an association between FEVR-like retinal vascular disease and GTMs. This study demonstrates the importance of the Hedgehog pathway in retinal vascular and gut development.

Macular Vessel Density Measurement in Pediatric Renal and Liver Transplant.

OBJECTIVES: Microcirculatory dysfunction is known to be associated with organ failure and increased mortality in transplant patients. Noninvasive monitorization of retinal structures of the eye could be a predictor for systemic microvasculature in these patients. Therefore, in this study we aimed to evaluate the retinal microvascular changes in pediatric patients who had undergone liver or renal transplant surgery, using optical coherence tomography angiography. MATERIALS AND METHODS: The medical records of pediatric patients who had liver or renal transplant in the past 10 years were reviewed. The macular vessel density parameters were obtained by optical coherence tomography angiography (Avanti RTVue XR). The results were compared with the age-matched, sex-matched, and spherical equivalent-matched healthy participants (control group). The IBM SPSS (version 25.0) statistics program was used for data analysis. RESULTS: We included 32 eyes of 16 liver transplant patients, 20 eyes of 10 renal transplant patients, and 64 eyes of 32 healthy participants (control group). Superficial macular whole image, superficial perifoveal, and deep foveal vessel densities were found to be lower in the liver transplant group compared with the healthy control group (P = .02, P = .01, and P = .01, respectively). Superficial foveal, deep macular whole image, deep foveal, and deep perifoveal vessel densities were found to be lower in the renal transplant group compared with the healthy control group (P = .03, P = .04, P = .01, and P = .02, respectively). CONCLUSIONS: Macular vessel density measurements are affected in pediatric renal and liver transplant patients. In those patients, retinal optical coherence tomography and optical coherence tomography angiography measurements may provide a noninvasive window to the microcirculation.

Antiproliferative and Mitochondrial Protective Effects of Apigenin in an Oxygen-Induced Retinopathy In Vivo Mouse Model.

Purpose: To investigate the effects of a common dietary flavonoid apigenin on retinal endothelial cell proliferation, retinal morphological structure, and apoptotic cell death in an oxygen-induced retinopathy (OIR) mouse model to evaluate the possibility of the use of apigenin in the treatment of ocular neovascular diseases (ONDs). Methods: Ninety-six newborn C57BL/6J mice were included. Eight groups were randomized, each including 12 mice. Two negative control groups were kept in room air: the first without any injection and the second received intravitreal (IV) dimethyl sulfoxide (DMSO), which is the solvent we used. The OIR groups were exposed to 75% ± 2% oxygen from postnatal days (PD) 7 to 12. On PD 12, the mice were randomly assigned to 6 groups: 2 OIR control groups (1 received no injection, 1 received IV-DMSO), 2 IV-apigenin groups (10 and 20 µg/mL), and 2 intraperitoneal (IP)-apigenin groups (10 and 20 mg/kg). We quantified retinal endothelial cell proliferation by counting neovascular tufts in cross-sections and examined histological and ultrastructural changes through light and electron microscopy. We evaluated apoptosis by terminal deoxynucleotidyl transferase-mediated nick end-labeling (TUNEL). Results: We detected a significant increase in endothelial cell proliferation in the OIR groups. Groups receiving apigenin, both IP and IV, had significant decreases in endothelial cells, atypical mitochondrion count, and apoptotic cells compared with the groups receiving no injections. None of the apigenin-injected groups revealed cystic degeneration or cell loss. Conclusions: Apigenin suppresses neovascularization, has antiapoptotic and antioxidative effects in an OIR mouse model, and can be considered a promising agent for treating OND. Clinical trial (Project number: DA15/19).

Favorable outcomes in the treatment of aggressive posterior retinopathy of prematurity.

OBJECTIVES: To report the results of intravitreal ranibizumab injection as primary therapy in aggressive posterior retinopathy of prematurity, the process of the disease, and the additive treatments performed. METHODS: This retrospective case review included 15 eyes of 8 premature babies with aggressive posterior retinopathy of prematurity who were initially treated with intravitreal ranibizumab injection. The documented data were gestational age, birth weight, gender, postmenstrual age at intravitreal ranibizumab injection, zone of retinopathy of prematurity, reactivation time of disease, iris neovascularization, retinal hemorrhage, anatomical outcome, and additional treatment. RESULTS: Median gestational age at birth was 26 (range, 23-27) weeks, birth weight was 730 (range, 550-970) g, and postconceptional age at aggressive posterior retinopathy of prematurity diagnosis and intravitreal ranibizumab injection was 35 (range, 33-35) weeks. Intravitreal ranibizumab injection was performed as primary treatment. Two eyes necessitated a second intravitreal ranibizumab injection. The reactivation of retinopathy of prematurity was 5 (range, 3-7) weeks after intravitreal ranibizumab injection. Recurrence of the disease in Zone II was treated with laser photocoagulation. A favorable outcome was obtained in all eyes (100%). CONCLUSION: Aggressive posterior retinopathy of prematurity is a serious, rapidly progressing form of retinopathy of prematurity that requires quick and proper management. This study indicates that primary treatment with ranibizumab and laser photocoagulation on recurrence provide favorable anatomical outcomes.

Effect of breast milk and sucrose on pain and perfusion index during examination for retinopathy of prematurity.

OBJECTIVE: The objective of this study is to investigate the effect of breast milk and sucrose on pain scores and perfusion index (PI) and to evaluate the alteration in pain and PI during retinopathy of prematurity (ROP) examination. METHODS: This prospective randomized controlled study was conducted with preterm infants who were born in our hospital, hospitalized in the neonatal intensive care unit and whose gestational week was <32 weeks and birth weight was <1500 g. The preterm infants who would undergo ROP examination were allocated to three groups according to simple randomization method as follows: group 1: only local anesthetic eye drops, proparacaine HCl ophthalmic solution 0.5%, group 2: proparacaine HCl ophthalmic solution 0.5% plus breast milk, and group 3: proparacaine HCl ophthalmic solution 0.5% plus sucrose 24%. Postductal PI, transcutaneous oxygen saturation and heart rate (HR) values were measured before the eye examination (0), at the 30th, 60th, and 90th seconds (s) of the eye examination and 30 s after lasting of the examination in all infants. Pain was evaluated using Neonatal Infant Pain Scale (NIPS) during the examination. RESULTS: Fifty-one preterm neonates were prospectively enrolled into the study. The HR was higher during and after the examination in all infants according to before the examination (p < .001). Transcutaneous oxygen saturation values significantly decreased during the examination in breast milk and sucrose groups (p = .001 and <.001, respectively). While PI was found to be lower at the 60th s compared to the 30th s of the examination in the proparacaine HCl group, no difference was found between the values before and after the examination. Perfusion index was found to significantly decrease during and after the examination compared to the values before the examination in the breast milk group. Perfusion index values were determined to significantly decrease at the 30th and 60th s of the examination in the sucrose group. The NIPS scores during the examination were determined to be higher compared to the NIPS scores before the examination in all groups (p< .001). In the intergroup comparisons, the NIPS scores were found to be higher in the sucrose group compared to the proparacaine HCl group at the 60th s of the examination and higher than that in the breast milk group at the 90th s of the examination (p = .02 and p = .01, respectively). CONCLUSIONS: The present study indicates that alterations may be seen in PI during the ROP examination; in other words, peripheral tissue perfusion could be affected. We consider that eye examination is a very painful procedure, and administering breast milk, sucrose or local anesthetic is not sufficient for reducing pain.

Choroidal Thickness After Dexamethasone Implant or Aflibercept in Patients with Diabetic Macular Edema Persistent to Ranibizumab.

Purpose: This study aims to compare subfoveal choroidal thicknesses (SFCTs) after intravitreal dexamethasone (IVD) or intravitreal aflibercept (IVA) treatment in patients with persistent diabetic macular edema (DME) unresponsive to intravitreal ranibizumab (IVR). Methods: The study consisted of patients with DME unresponsive to IVR treatment in which 37 were administered 1 dose IVD (group A) and 34 patients who were administered 3 doses of IVA (group B), as well as 35 healthy individuals (group C). Detailed ophthalmological examination and optical coherence tomography parameters of group A and group B, including central retinal thickness and SFCT, were retrospectively evaluated before and after treatment. Results from preinjection, and 1, 2, and 3 months after injection were analyzed. Results of group A and group B were compared within themselves and also compared with group C. Results: SFCT measurements were compared within group A and group B (1 = preinjection; 2 = 1 month postinjection; 3 = 2 months postinjection; 4 = 3 months postinjection). There was significant thinning in SFCT between 1-2, 1-3, 1-4, 2-3, 2-4, and 3-4 time intervals within both group A and group B (both P < 0.001). Comparison of SFCT measurements showed preinjection, 1-, and 2-month values of group A were significantly thicker than those of group C (P < 0.001), whereas there was no significant difference between 3-month values (P = 0.09). Preinjection, 1-, and 2-month values of group B were significantly thicker than those of group C (P < 0.001), whereas there was no significant difference between 3-month values (P = 0.06). Conclusions: Three month follow-up showed thinning in SFCT measurements in patients with persistent DME unresponsive to IVR who were applied IVD or IVA treatment.

Impact of Platelet Count in Retinopathy of Prematurity.

Objectives: The aim of the study was to investigate the risk factors for retinopathy of prematurity (ROP), including platelet count. Materials and Methods: This retrospective study analyzed 137 infants in 3 subgroups: no ROP; mild ROP, and severe ROP requiring laser treatment (type 1 ROP). A retrospective review of records was performed and statistical analysis of possible risk factors for ROP including platelet count was evaluated by using logistic regression. Results: Birth weight (BW), gestational age (GA), and low platelet count in the first week after birth were significant risk factors for developing ROP (p=0.038, 0.02, and 0.004, respectively). BW, GA, ventilation, and lower platelet count were associated with progression to type 1 ROP (p=0.004; 0.027, and 0.021, respectively). Conclusion: Lower platelet count in the first week after birth is a risk factor for ROP development in addition to the previously established factors of ventilation need, low BW, and low GA.

A diagnostic dilemma in a patient with delayed onset endophthalmitis.

We report a case of nonpainful uveitis nine months after an uncomplicated phacoemulsification cataract surgery. Chronic postoperative endophthalmitis was suspected. Diagnostic vitrectomy and partial capsular bag removal was performed, but the specimens cultured in microbiology laboratory showed no pathogens. Systemic workup came positive for skin Tuberculosis test, and presumed intraocular tuberculosis treatment was started accordingly. Inflammation persisted, so a repeat vitrectomy was performed with removal of the lens implant with the capsule, and this time bedside culture inoculation was performed in operating room, revealing Pseudomonas infection. Delayed-onset postoperative endophthalmitis typically progresses slowly and therefore can be confused with uveitis and treated with steroid and immunosuppressant treatment regimes. Our case confirms both the value of immediate bacterial inoculation and the necessity of aggressive surgical treatment in chronic postoperative endophthalmitis cases.

Antiproliferative and anti-apoptotic effect of astaxanthin in an oxygen-induced retinopathy mouse model.

OBJECTIVE: To evaluate the impact of intravitreal (IV) and intraperitoneal (IP) astaxanthin (AST) injections on neovascular development (ND), retinal morphology, and apoptotic activity in a C57BL/6J mouse model with hyperoxia-induced retinopathy (HIR). DESIGN: C57BL/6J mouse model. METHODS: Two negative control groups (n = 6 each; one of which received IV sterile dimethyl sulfoxide [DMSO]) of C57BL/6J-type mice were exposed to room air. The HIR groups included 36 C57BL/6J-type mice exposed to 75% ± 2% oxygen from postnatal day (PD) 7 to PD 12. On PD 12, these mice were randomized into 6 groups (n = 6 each): 2 HIR control groups (one of which received IV-DMSO), 2 IV-AST groups (10 and 100 µg/mL), and 2 IP-AST groups (0.5 and 5 mg/kg). We measured ND by counting neovascular tufts in cross sections and examined histological, ultrastructural changes via light and electron microscopy. Apoptosis was detected using terminal deoxynucleotidyl transferase-mediated nick end-labeling. RESULTS: No ND was detected in the negative control groups. ND levels were not significantly different between high- and low-dose AST for either means of administration. However, ND levels were significantly lower in the AST groups, regardless of delivery, compared to the control groups. The means of delivery (IP versus IV) also yielded significant differences in ND. The incidence of mitochondrial dysmorphology and apoptosis were lower in groups receiving AST. CONCLUSIONS: AST seems to suppress ND and has anti-apoptotic activity in the HIR mouse model.

Bilateral Asymmetric Rhegmatogenous Retinal Detachment in a Patient with Stickler Syndrome.

Here we present the long-term anatomical and visual outcomes of bilateral asymmetric rhegmatogenous retinal detachment repair in a patient with Stickler syndrome. A 17-year-old girl presented with decreased visual acuity in both eyes for more than one year. Her best-corrected visual acuity (BCVA) was 0.1 in the right eye and 0.05 in the left eye. Slit-lamp anterior segment examination revealed subcapsular cataract in both eyes. Fundus examination showed bilateral rhegmatogenous retinal detachment, chronic retinal detachment accompanied by multiple retinal holes, tears and membranous fibrillary vitreous in the peripheral retina. Grade C2 proliferative vitreoretinopathy was observed in the left eye. Scleral buckling surgery was performed initially for both eyes. After the primary surgical procedure, retinal reattachment was achieved in the right eye and the left eye underwent phacoemulsification, intraocular lens implantation, pars plana vitrectomy (PPV), and silicone oil injection. After these surgical procedures retinal reattachment was achieved in the left eye. Silicone oil removal was performed six months after PPV surgery. After surgical treatment, BCVA was 0.6 in the right eye at the end of the 3.5-year follow-up period. After silicone oil removal, BCVA reached 0.2 in the left eye after 36 months of follow-up and retinal reattachment was achieved in both eyes. Scleral buckling surgery and PPV are effective and confidential methods for the treatment of chronic retinal detachment cases in Stickler syndrome.

Relationship between white matter hyperintensities and retinal nerve fiber layer, choroid, and ganglion cell layer thickness in migraine patients.

Aim To compare the relationship between white matter hyperintensities (WMH) on brain magnetic resonance imaging and retinal nerve fiber layer (RNFL), choroid, and ganglion cell layer (GCL) thicknesses in migraine patients and healthy subjects. We also assessed the role of cerebral hypoperfusion in the formation of these WMH lesions. Methods We enrolled 35 migraine patients without WMH, 37 migraine patients with WMH, and 37 healthy control subjects examined in the Neurology outpatient clinic of our tertiary center from May to December 2015. RFNL, choroid, and GCL thicknesses were measured by optic coherence tomography. Results There were no differences in the RFNL, choroid, or GCL thicknesses between migraine patients with and without WMH ( p > 0.05). Choroid layer thicknesses were significantly lower in migraine patients compared to control subjects ( p < 0.05), while there were no differences in RFNL and GCL thicknesses ( p > 0.05). Conclusions The 'only cerebral hypoperfusion' theory was insufficient to explain the pathophysiology of WMH lesions in migraine patients. In addition, the thinning of the choroid thicknesses in migraine patients suggests a potential causative role for cerebral hypoperfusion and decreased perfusion pressure of the choroid layer.

Refractive outcome comparison between vitreomacular interface disorders after phacovitrectomy.

PURPOSE: To compare the refractive accuracy of intraocular lens (IOL) power calculations between patients with vitreomacular interface disorders who had phacovitrectomy for vitreomacular traction (VMT), epiretinal membranes (ERM), and macular holes. SETTING: Baskent University Department of Ophthalmology, Ankara, Turkey. DESIGN: Retrospective case series. METHODS: Refraction results 8 weeks postoperatively were compared between phacovitrectomy (3 study groups comprising eyes with VMT with intrafoveal pseudocysts, ERM, or medium-to-large macular holes) and phacoemulsification (control group comprising eyes having phacoemulsification only). The IOLMaster 700 partial coherence interferometry (PCI) device and Haigis formula were used for all calculations. RESULTS: This study included 100 eyes (100 patients), 25 in each of the 4 groups. There was no statistically significant difference in axial length (AL) between the groups (P = .305). Differences in the preoperative macular thickness were statistically significant between all groups except between the macular hole and VMT groups. Most eyes (92%) in the VMT and macular hole groups and all eyes in the VMT and phacoemulsification groups achieved a final refraction within ±1.00 diopter of the refractive aim. The mean prediction error and the mean absolute error did not differ significantly between the groups. In all groups, there was no significant correlation between prediction error and age, AL, preoperative refractive error, or preoperative or postoperative macular thickness (P > .05). CONCLUSIONS: The IOL power calculation with PCI yielded no difference in postoperative refraction errors between the vitreomacular interface disorders. There was no correlation with preoperative refraction, age, or preoperative or postoperative macular thickness.