Choriocapillaris: Fundamentals and advancements.

The choriocapillaris is the innermost structure of the choroid that directly nourishes the retinal pigment epithelium and photoreceptors. This article provides an overview of its hemovasculogenesis development to achieve its final architecture as a lobular vasculature, and also summarizes the current histological and molecular knowledge about choriocapillaris and its dysfunction. After describing the existing state-of-the-art tools to image the choriocapillaris, we report the findings in the choriocapillaris encountered in the most frequent retinochoroidal diseases including vascular diseases, inflammatory diseases, myopia, pachychoroid disease spectrum disorders, and glaucoma. The final section focuses on the development of imaging technology to optimize visualization of the choriocapillaris as well as current treatments of retinochoroidal disorders that specifically target the choriocapillaris. We conclude the article with pertinent unanswered questions and future directions in research for the choriocapillaris.

Presumed Natural History of Combined Hamartoma of the Retina and Retinal Pigment Epithelium.

PURPOSE: To correlate structural changes of combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) with patient age. DESIGN: Retrospective study. PARTICIPANTS: Fifty eyes of 49 patients (age range, 1-74 years) with CHRRPE studied at 9 tertiary vitreoretinal institutions. METHODS: We analyzed the clinical findings with respect to lesion topography and pigmentation as well as investigated the OCT findings regarding the thickness, vitreoretinal interface, outer plexiform layer distortion, ellipsoid zone disruption, and retinal pigment epithelium-Bruch's membrane complex involvement of CHRRPE. MAIN OUTCOME MEASURES: Clinical and imaging findings of CHRRPE at different ages. RESULTS: Analysis of 50 CHRRPE patients revealed that younger patients were more likely to demonstrate partial thickness involvement of the retina (P = 0.009) with predominantly inner retinal layer involvement (P = 0.04). The inverse was true for older patients with CHRRPE. In addition, older patients more commonly showed pigmentary changes. Eyes with CHRRPE were more likely to show an increase in central macular thickness independently of tumor location. CONCLUSIONS: Based on these findings, we believe that CHRRPE typically begins in the inner retina and continues toward the outer retina over time, with increase in central macular thickness, despite the location of the tumor.

One year outcomes of eyes with polypoidal choroidal vasculopathy with ≥20/40 visual acuity treated with anti-vascular endothelial growth factor agents.

PURPOSE: To report the 12 months outcomes of treatment naïve polypoidal choroidal vasculopathy (PCV) in patients with ≥20/40 Snellen's best-corrected visual acuity (BCVA). METHODS: This was a retrospective study including eyes treated with monotherapy of anti-vascular endothelial growth factors (VEGF) agents (bevacizumab, ranibizumab, aflibercept, and ziv-aflibercept) on a pro-re-nata (PRN) protocol. Photodynamic therapy using verteporfin (vPDT) was used as rescue therapy. The primary study objective was change in BCVA at 12 months. Secondary objectives included change in optical coherence tomography parameters: central macular thickness (CMT) and pigment epithelial detachment (PED) height, the mean number of injections, and treatment-free interval at 12 months. RESULTS: A total of 18 eyes of 18 patients (7 males, 11 females) were included. The mean age was 58.0 ± 12.0 years. BCVA at baseline and 12 months were 0.16 ± 0.08 (Snellen equivalent 20/30) and 0.15 ± 0.15 logarithm of the minimum angle of resolution (20/30), respectively. Twelve (66.6%) eyes either improved or maintained BCVA. Mean (±standard deviation [SD]) CMT at baseline and 12 months were 188.2 ± 61.1 µ and 161.7 ± 47.4 µ (P = 0.15), respectively. PED height improved to 236.4 ± 208.7 µ at 12 months (P = 0.05). The mean (±SD) number of injections was 3.28 ± 1.96 with a treatment-free period of 6.83 ± 3.63 months. Three eyes required vPDT (4 treatment sessions; mean: 1.33) as a rescue therapy through 12 months. CONCLUSION: PRN anti-VEGF monotherapy in real-life situations for the treatment of naïve PCV eyes with good visual acuity (≥20/40) achieves maintenance or improvement of visual acuity through 12 months follow-up.

Regression in polypoidal choroidal vasculopathy treated with ziv-aflibercept monotherapy - short term study.

PURPOSE: The aim of this study was to evaluate the effectiveness of intravitreal ziv-aflibercept (IVZ) in the treatment of polypoidal choroidal vasculopathy (PCV) and its efficacy in regard to polyp regression using optical coherence tomography (OCT) and indocyanine green angiography (ICGA). METHODS: This was a retrospective study of eight eyes of eight patients with treatment-naïve PCV. Patients received IVZ on pro re nata protocol. OCT and ICGA parameters were assessed at baseline and subsequent visits with a minimum follow-up of 6 months. ICGA was repeated at 3-6 months to determine the disease activity and quantify the changes in branching vascular network (BVN) polyps. Quantifiable OCT parameters included central macular thickness, pigment epithelial detachment (PED) height, and subfoveal choroidal thickness. RESULTS: The mean age of the study cohort was 62.3 ± 7.7 years, with a mean follow-up of 7.1 ± 1.2 months. The baseline best-corrected visual acuity improved from 0.70 ± 0.36 logarithm of the minimum angle of resolution (Snellen's equivalent 20/100) to 0.63 ± 0.34 (20/80) at last follow-up which was statistically insignificant (P = 0.5). Post IVZ injections (mean ± standard deviation: 2.6 ± 0.7), the total number of polyps reduced significantly from 3 ± 3.5 to 1 ± 1.7 (P = 0.03) along with a reduction in BVN size (3.9 ± 4.8 to 2.7 ± 3.8mm2; P = 0.07). OCT analysis revealed a significant reduction in PED height from 462.5 ± 353.8 µ to 169.9 ± 127.2 µ (P = 0.02). CONCLUSION: IVZ leads to significant morphological changes on ICGA and OCT in terms of polyp regression and reduction of PED height, respectively, with a limited change in visual acuity. IVZ may serve as a cost-effective alternative to treat eyes with PCV.

REPLACEMENT OF LIDOCAINE GEL WITH TOPICAL PROPARACAINE ANESTHESIA FOR ROUTINE INTRAVITREAL INJECTIONS: A Comparative Study.

PURPOSE: Lidocaine gel was suggested to be highly effective in providing anesthesia for intravitreal injections but adverse effects include a possibility of making sterilization of the conjunctiva difficult. Hence, we wished to determine the effect of using 0.5% proparacaine drops alone over the use of 3.5% lidocaine hydrochloride gel anesthesia during office-based intravitreal injections. METHODOLOGY: This was a case-control study in patients who came routinely to the clinic for antivascular endothelial growth factor injections. Eyes were treated with one of two anesthesia modalities. A total of 216 injections in 120 patients were reviewed. One group (N = 107) underwent anesthesia with 0.5% proparacaine drops, and the control group (N = 109) received 3.5% lidocaine gel. The pain perceived after injection was graded using the numerical rating scale, and score was immediately recorded by the "masked" injecting physician. RESULTS: The mean pain score (±SD) for the proparacaine-only group versus gel group was 1.97 (±1.17) versus 1.76 (±0.92), P value = 0.3174. There was no statistical difference between the 2 groups. CONCLUSION: 3.5% lidocaine gel is not superior to 0.5% proparacaine drops as patients attained good pain control and excellent rates of overall satisfaction with proparacaine drops alone.

Optical coherence tomography analysis of surgical outcomes of combined hamartoma of retina and retinal pigment epithelium.

PURPOSE: To evaluate the surgical outcomes in combined hamartoma of retina and retinal pigment epithelium (CHRRPE) using optical coherence tomography (OCT). METHODS: This was a retrospective interventional study, in which medical records of 12 eyes with CHRRPE that underwent vitrectomy and membrane peeling at three tertiary vitreoretinal institutes were reviewed. Preoperative and postoperative color fundus photographs and OCT were reviewed for each follow-up visit. RESULTS: Five out of 12 eyes had a good visual outcome (equal or more than 2 lines gain in visual acuity), four had stable visual outcome (<2 line gain), and three had poor visual outcome (loss of visual acuity). Preretinal fibrosis preoperatively was seen in 80% of cases with good outcomes as compared to 50% and 0% of cases in the cohorts with stable and poor outcomes, respectively. Preoperatively all 5 cases with good visual outcome had Grade 4 epiretinal membrane (ERM), while only 1 case with stable and poor visual outcome had grade 4 ERM and the rest had Grade 3 ERM. Maxi peaks were seen in 80%, 50%, and 0% of cases preoperatively in the three cohorts, respectively. Hyperreflectivity of inner retinal layers preoperatively was evident in all cases having good visual outcomes, in 75% of cases with stable visual outcomes, and in 33% of cases with poor outcomes. CONCLUSION: Surgical intervention in CHRRPE with preretinal fibrosis seems to be beneficial. The visual recovery as defined by conventional predictors in cases of surgical removal of ERM fails to explain the visual outcome in CHRRPE.

Fibrin glue for treatment of optic disc maculopathy.

We describe clinical and anatomical outcomes of optic disc maculopathy using internal limiting membrane (ILM) peeling and fibrin glue application over the optic nerve in this retrospective, interventional case series of five eyes. Extent of neurosensory detachment and foveoschisis along with foveal thickness at baseline and follow-up were evaluated. The mean age was 29 ± 10.6 years. The most common location of disc pit was temporal (3 eyes). All eyes underwent peripapillary laser with 532 nm green laser before surgery with a mean interval of 4.9 ± 1.9 months. The mean baseline and final vision was 0.68 ± 0.23 and 0.61 ± 0.33 logMAR, respectively, with a mean follow-up of 7.2 ± 3.5 months. Three eyes showed complete resorption of serous detachment, while the remaining two had reduction in schisis and subretinal fluid. None of the eyes had any complications. Glue application in addition to ILM peeling improves the visual prognosis in optic disc pit maculopathy with restoration of macular anatomy.

Functional and morphological evaluation of autologous retinal graft in large traumatic macular hole.

A 7-year-old boy presented with history of blunt trauma 1 month back. Best corrected visual acuity (BCVA) was 20/200 with optical coherence tomography (OCT) showing a large macular hole. Spontaneous closure of the macular hole seemed unlikely following a month of observation. Pars plana vitrectomy along with autologous retinal graft was performed. At subsequent follow up, hole appeared closed with nasal shrinkage of graft and BCVA improved to 20/100. OCT showed mechanical integration of the graft with adjoining retina. Autologous retinal graft is a feasible option in cases where conventional internal limiting membrane peeling shows lower anatomical success.

SURGICAL OUTCOMES AFTER INVERTED INTERNAL LIMITING MEMBRANE FLAP VERSUS CONVENTIONAL PEELING FOR VERY LARGE MACULAR HOLES.

PURPOSE: To evaluate the anatomical and visual outcomes of inverted flap technique of peeling of internal limiting membrane (ILM) versus standard peeling of ILM for macular holes of basal diameter more than 800 µm. METHODS: Patients with very large idiopathic macular holes more than 800 µm in basal diameter (ranging from 243 µm to 840 µm in minimum diameter) were retrospectively included in the study. In Group A, 18 eyes of 18 patients underwent ILM peeling using the inverted flap technique. In Group B, 18 eyes of 18 patients underwent conventional ILM peeling. The primary endpoint was the rate of hole closure at 6 months after surgery. The secondary outcome measure was the change in best-corrected visual acuity at 6 months after surgery. RESULTS: There were no significant differences in ocular characteristics of the study groups at baseline except for the age distribution. Mean macular hole diameter was 1,162.8 ± 206.0 µm and 1,229.6 ± 228.1 µm in Group A and Group B, respectively. The hole closure rate was 88.9% (16/18) in Group A and 77.8% (14/18) in Group B (P = 0.66). The mean gain in best-corrected visual acuity was higher in Group A than in Group B (P = 0.12) at 6 months, but this was not statistically significant. There were no severe ocular adverse events in either group. CONCLUSION: In this multicenter series, inverted ILM flap technique did not lead to significantly higher anatomical closure rates than conventional ILM peeling in large macular holes more than 800 µm in diameter.