PUNCTATE INNER CHOROIDOPATHY FOLLOWING PARS PLANA VITRECTOMY FOR HIGH MYOPIC FULL THICKNESS MACULAR HOLE.

PURPOSE: To describe a case of punctate inner choroidopathy (PIC) and secondary or epiphenomenon multiple evanescent white dot syndrome (EpiMEWDS) following surgery for high myopic full-thickness macular hole (FTMH). METHODS: Case report. RESULTS: A 57-year-old high myopic female was diagnosed with cataract and FTMH in the left eye. Her initial best-corrected visual acuity (BCVA) was 20/20 in her right eye and 20/80 in the left eye. She underwent routine combined phacoemulsification and 25-gauge pars plana vitrectomy (PPV) with the inverted internal limiting membrane (ILM) technique and twice-repeated epiretinal membrane (ERM) and ILM staining in the left eye. Two weeks postoperatively, the patient reported significant visual decline and photopsia in her left eye. BCVA decreased to counting fingers. Anterior segment examination was unremarkable. Ophthalmoscopic examination showed multiple whitish-yellow lesions in the macular region compatible with PIC lesions in the left eye. Optical coherence tomography (OCT), blue-light fundus autofluorescence (BAF), fluorescein angiography, and indocyanine green angiography were performed and confirmed the diagnosis. The patient underwent oral steroid therapy for PIC treatment. One week after treatment initiation, BAF showed the occurrence of EpiMEWDS. After one month, all lesions resolved and BCVA improved to 20/100. CONCLUSIONS: We report a rare case of PIC and EpiMEWDS development following surgery for FTMH. We hypothesize that several causes, including individual susceptibility (high myopia and female gender), post-surgical inflammation, and/or dye toxicity due to repeated staining could have amplified this inflammatory chorioretinal response. Larger studies are needed to better understand the potential triggers of PIC development after surgery.

Small-Incision new generation implantable miniature telescope surgical technique and patient outcomes.

BACKGROUND: Various ocular implants were suggested as a means of enhancing vision in patients with advanced age related macular degeneration. Recently, a new generation of implantable telescopes has been released. The purpose of this study is to report the surgical technique of implantation along with patient outcomes. METHODS: This work focuses on the surgical technique. Crucial surgical steps are carefully reported along with discussion on main drawbacks and limitations. RESULTS: This approach uses a preloaded delivery system with improved features and requires a smaller incision. First patient outcomes are also reported. CONCLUSIONS: Surgical steps to implant this preloaded intraocular telescope are easier than previous versions, however this remains a complex procedure. Initial patient functional outcomes look promising.

Neurotrophic Keratopathy after wide retinal endolaser and postoperative Ketorolac eye drops: A case series.

PURPOSE: We report a series of 5 cases, happened in a period of 5 months, who developed neurotrophic keratopathy (NK) following pars plana vitrectomy (PPV) and retinal endolaser for rhegmatogenous retinal detachment (RRD). In our several decennary experience of surgical center predominantly based on vitreoretinal surgery, we had rare cases of postoperative NK. These recent cases of post-surgical NK happened contextually to our change of postoperative non-steroidal anti-inflammatory drugs (NSAIDs) drops, based on Ketorolac Tromethamine 0.5% eye drops. CASES PRESENTATION: Five patients with a mean age of 61 ± 7.3 years were treated with one or more PPV with intraoperative peripheral endolaser for RRD. Nobody had previous herpetic keratitis, systemic disease like diabetes mellitus or other predisposing factors for NK. In the postoperative period, all patients received Ketorolac Tromethamine 0.5% eye drops for a mean period of 54 ± 25 days. During follow-up visits they developed NK and they were successfully treated with suspension of Ketorolac eye drops, application of therapeutic contact lens or amniotic membrane patch and topical lubricant therapy. CONCLUSIONS: Postoperative Ketorolac eye drops, in patients who underwent PPV with endolaser, may reduce the corneal sensitivity, predispose to epithelial disruption and NK development. Studies are needed to explore the effect of NSAIDs on corneal sensitivity reduction in patient who will undergo PPV and extensive endolaser.

The effect of optical degradation from cataract using a new Deep Learning optical coherence tomography segmentation algorithm.

PURPOSE: To assess the validity of the results of a freely available online Deep Learning segmentation tool and its sensitivity to noise introduced by cataract. METHODS: The OCT images were collected with a Spectralis SD-OCT (Heidelberg Engineering, Heidelberg, Germany) as part of normal clinical practice. Data were segmented using a freely available online tool called Relayer ( https://www.relayer.online/ ), based on a cross-platform Deep Learning segmentation architecture specifically adapted for retinal OCT images. The segmentations were read into MATLAB (The MathWorks, Natick, MA, USA) and analyzed. RESULTS: There was an excellent agreement between the ETDRS measurements obtained from the two algorithms. Upon visual inspection, the segmentation based on Deep Learning obtained with Relayer appeared more accurate except in one case of apparent good quality image showing interrupted segmentations in some of the B-scans. CONCLUSION: A freely available online Deep Learning segmentation tool showed good and promising performance in healthy retinas before and after cataract surgery, proving robust to optical degradation of the image from media opacities.

Phenomenology of spontaneous closure in degenerative and mixed type lamellar macular hole.

PURPOSE: To the describe OCT imaging characteristics of a cohort of patients showing spontaneously closing degenerative or mixed type lamellar macular holes (LMH) and to compare them to the ones of a sex and age matched group showing stable lesions. METHODS: Patients diagnosed with degenerative and mixed type LMHs showing OCT-documented spontaneous anatomical closure were retrospectively selected from 3 specialized retina centres. An equal number of age and sex matching subjects were randomly selected among patients with anatomically stable lesions. RESULTS: Eleven (11) spontaneously closing (SC group) and 11 stable (ST group) degenerative LMH with a mean follow up of 4 years were recruited. Hyperreflective inner border (HIB) and linear hyperreflectivity in the outer plexiform layer (LHOP) at baseline were significantly more prevalent in SC group in processed images (respectively p = 0.007 and p = 0.003). A borderline significance in lamellar hole associated epiretinal proliferation (LHEP) at last follow up was detected (p = 0.085). As for mixed type LMH, 10 patients for SC group and 10 for ST group were recruited. LHOP at baseline in processed images was significantly more prevalent in SC group (p = 0.005). CONCLUSIONS: Spontaneously closing LMHs show higher prevalence of HIB and LHOP at the beginning of the closing process, a difference which is enhanced by image processing. These signs might be a signal of microglial and Muller cells coordinated activation.

How to Set Up Genetic Counselling for Inherited Macular Dystrophies: Focus on Genetic Characterization.

Inherited macular dystrophies refer to a group of degenerative conditions that predominantly affect the macula in the spectrum of inherited retinal dystrophies. Recent trends indicate a clear need for genetic assessment services in tertiary referral hospitals. However, establishing such a service can be a complex task due to the diverse skills required and multiple professionals involved. This review aims to provide comprehensive guidelines to enhance the genetic characterization of patients and improve counselling efficacy by combining updated literature with our own experiences. Through this review, we hope to contribute to the establishment of state-of-the-art genetic counselling services for inherited macular dystrophies.

Trans-Scleral Plugs Fixated FIL SSF IOL: A Review of the Literature and Comparison with Other Secondary IOL Implants.

Purpose. To revise the current literature on FIL SSF (Carlevale) intraocular lens, previously known as Carlevale lens, and to compare their outcomes with those from other secondary IOL implants. Methods. We performed a peer review of the literature regarding FIL SSF IOLs until April 2021 and analyzed the results only of articles with a minimum of 25 cases and a follow-up of at least 6 months. The searches yielded 36 citations, 11 of which were abstracts of meeting presentations that were not included in the analysis because of their limited data. The authors reviewed 25 abstracts and selected six articles of possible clinical relevance to review in full text. Of these, four were considered to be sufficiently clinically relevant. Particularly, we extrapolated data regarding the pre- and postoperative best corrected visual acuities (BCVA) and the complications related to the procedure. The complication rates were then compared with those from a recently published Ophthalmic Technology Assessment by the American Academy of Ophthalmology (AAO) on secondary IOL implants. Results. Four studies with a total of 333 cases were included for results analysis. The BCVA improved in all cases after surgery, as expected. Cystoid macular edema (CME) and increased intraocular pressure were the most common complications, with an incidence of up to 7.4% and 16.5%, respectively. Other IOL types from the AAO report included anterior chamber IOLs, iris fixation IOLs, sutured iris fixation IOLs, sutured scleral fixation IOLs, and sutureless scleral fixation IOLs. There was no statistically significant difference in the rates of postoperative CME (p = 0.20), and vitreous hemorrhage (p = 0.89) between other secondary implants and the FIL SSF IOL, whereas the rate of retinal detachment was significantly less with FIL SSF IOLs (p = 0.04). Conclusion. The results of our study suggest the implantation of FIL SSF IOLs is an effective and safe surgical strategy in cases where there is a lack of capsular support. In fact, their outcomes seem to be comparable to those obtained with the other available secondary IOL implants. According to published literature, the FIL SSF (Carlevale) IOL provides favorable functional results with a low rate of postoperative complications.

The Short-Term Results of Autologous Platelet-Rich Plasma as an Adjuvant to Re-Intervention in the Treatment of Refractory Full-Thickness Macular Holes.

The purpose of this study was to investigate the short-term efficacy and safety of autologous platelet-rich plasma (a-PRP) as an adjuvant to revisional vitrectomy for refractory full-thickness macular holes (rFTMHs). We conducted a prospective, non-randomized interventional study including patients with rFTMH after a pars plana vitrectomy (PPV) with internal limiting membrane peeling and gas tamponade. We included 28 eyes from 27 patients with rFTMHs: 12 rFTMHs in highly myopic eyes (axial length greater than 26.5 mm or a refractive error greater than -6D or both); 12 large rFTMHs (minimum hole width > 400 µm); and 4 rFTMHs secondary to the optic disc pit. All patients underwent 25-G PPV with a-PRP, a median time of 3.5 ± 1.8 months after the primary repair. At the six-month follow-up, the overall rFTMH closure rate was 92.9%, distributed as follows: 11 out of 12 eyes (91.7%) in the highly myopic group, 11 out of 12 eyes (91.7%) in the large rFTMH group, and 4 out of 4 eyes (100%) in the optic disc pit group. Median best-corrected visual acuity significantly improved in all groups, in particular from 1.00 (interquartile range: 0.85 to 1.30) to 0.70 (0.40 to 0.85) LogMAR in the highly myopic group (p = 0.016), from 0.90 (0.70 to 1.49) to 0.40 (0.35 to 0.70) LogMAR in the large rFTMH group (p = 0.005), and from 0.90 (0.75 to 1.00) to 0.50 (0.28 to 0.65) LogMAR in the optic disc pit group. No intraoperative or postoperative complications were reported. In conclusion, a-PRP can be an effective adjuvant to PPV in the management of rFTMHs.

Pneumatic retinopexy versus scleral buckling for the management of primary rhegmatogenous retinal detachment.

BACKGROUND AND OBJECTIVE: To compare pneumatic retinopexy (PnR) and scleral buckling (SB) for repair of primary rhegmatogenous retinal detachment. MATERIALS AND METHODS: Single-centre retrospective analysis of patients undergoing PnR and SB. Inclusion criteria comprehend phakic patients with a single retinal break or a group of breaks in detached retina in the same quadrant above the 8- and 4-o'clock meridians. A total of 184 patients were included, respectively 106 underwent PnR and 78 SB. Follow-up time was 6 months. RESULTS: Final visual outcome did not differ significantly between the two procedures (P = 0.12). Single-procedure reattachment rate was significantly higher in SB (94%) than in PnR (68%) (P < 0001). Anatomical success rate was not influenced by macular involving. Reattachment rate in repeated PnR was 95% and in these patients visual outcome did not statistically differ compared to those reattached with first attempt (P = 0.196). Total reattachment rate including repeated procedures was 87% in PnR group and 94% in SB group, the difference was not significant (P = 0.06). CONCLUSION: SB has a higher single reattachment rate than PnR. However, final visual outcomes of both procedures are comparable. In selected cases, PnR can be repeated with a high successful rate.

Genetic Aspects of Age-Related Macular Degeneration and Their Therapeutic Potential.

Age-related macular degeneration (AMD) is a complex and multifactorial disease, resulting from the interaction of environmental and genetic factors. The continuous discovery of associations between genetic polymorphisms and AMD gives reason for the pivotal role attributed to the genetic component to its development. In that light, genetic tests and polygenic scores have been created to predict the risk of development and response to therapy. Still, none of them have yet been validated. Furthermore, there is no evidence from a clinical trial that the determination of the individual genetic structure can improve treatment outcomes. In this comprehensive review, we summarize the polymorphisms of the main pathogenetic ways involved in AMD development to identify which of them constitutes a potential therapeutic target. As complement overactivation plays a major role, the modulation of targeted complement proteins seems to be a promising therapeutic approach. Herein, we summarize the complement-modulating molecules now undergoing clinical trials, enlightening those in an advanced phase of trial. Gene therapy is a potential innovative one-time treatment, and its relevance is quickly evolving in the field of retinal diseases. We describe the state of the art of gene therapies now undergoing clinical trials both in the field of complement-suppressors and that of anti-VEGF.

OCT Analysis of Retinal Pigment Epithelium in Myopic Choroidal Neovascularization: Correlation Analysis with Different Treatments.

Objective: The objective of this study was to analyze the status of the retinal pigment epithelium (RPE) by means of the spectral domain optical coherence tomography (SD-OCT) overlying the myopic neovascular lesions in the involutive phase, looking for any correlations between the status of the RPE and the size of the lesions and the type and duration of the treatment. Methods: SD-OCT examinations of 83 consecutive patients with myopic choroidal neovascularization (CNV) were reviewed and divided into two groups: group A, patients with CNV characterized by uniformity of the overlying RPE, and group B, patients with CNV characterized by non-uniformity of the overlying RPE. Results: The median lesion area, major diameter, and minimum diameter were, respectively, 0.42 mm2 (0.30−1.01 mm2), 0.76 mm2 (0.54−1.28 mm2), and 0.47 mm2 (0.63−0.77 mm2) in group A, and 1.60 mm2 (0.72−2.67 mm2), 1.76 mm2 (1.13−2.23 mm2), and 0.98 mm2 (0.65−1.33 mm2) in group B. These values were lower in group A than in group B (p < 0.001). The number of treatments with a period free of disease recurrence for at least 6 months was greater (p < 0.010) in group B (6.54 ± 2.82) than in group A (3.67 ± 2.08), and treatments include intravitreal anti-vascular endothelial growth factor injection, photodynamic therapy, or both. Conclusions: Our results showed that the size of myopic neovascular lesion influences the development of a uniform RPE above the lesion and therefore the disease prognosis. The presence of uniform RPE was found to be extremely important in the follow-up of patients with myopic CNV, as it influences the duration of the disease and the number of treatments required.

Curcumin in Retinal Diseases: A Comprehensive Review from Bench to Bedside.

Recent evidence in basic science is leading to a growing interest in the possible role of curcumin in treating retinal diseases. Curcumin has been demonstrated to be able to modulate gene transcription and reduce ganglion cell apoptosis, downgrade VEGF, modulate glucose levels and decrease vascular dysfunction. So far, the use of curcumin has been limited by poor bioavailability; to overcome this issue, different types of carriers have been used. Multiple recent studies disclosed the efficacy of using curcumin in treating different retinal conditions. The aim of this review is to comprehensively review and discuss the role of curcumin in retinal diseases from bench to bedside.

Efficacy and tolerability of polyvinylpyrrolidone-iodine 0.6% treatment in adenoviral keratoconjunctivitis: a Prospective Randomized Controlled Study.

OBJECTIVES: To analyze the effect of the employment of polyvinylpyrrolidone-iodine (PVP-I) 0.6% eye drop on the clinical course of patients affected by Adenoviral Keratoconjunctivitis (AKC). METHODS: Consecutive patients with clinical signs of AKC and positive results of AdenoPlus test were enrolled from four Italian Centres. Patients were randomized to receive: PVP-I 0.6% eye drops four times/daily for 20 days (Group A) or hyaluronate-based tear substitutes four times/daily for 20 days (Group B). Best-corrected visual acuity (BCVA), optical coherence tomography (OCT) Optovue iVue pachymetry map; corneal haze; conjunctival injection and chemosis; subepithelial corneal infiltrates (SEIs); corneal and conjunctival staining and corneal densitometry were recorded at diagnosis and at every follow-up visit. The primary outcome was the resolution time of AKC. RESULTS: Overall, 59 AKC patients (34 for Group A and 25 for Group B) completed the study. Patients of Group A showed a significantly shorter resolution time and lower incidence of SEIs compared to patients of Group B. In particular, SEIs were present at the last visit in 3/34 (8.82%) patients of the Group A vs 11/25 (44%) of the Group B (p = 0.005). Patients of Group A showed a significantly lower incidence of corneal haze compared to patients of Group B (0/34 vs 3/25; p = 0.038). No side effects were reported for both groups. CONCLUSIONS: Although further clinical evaluations are needed, according to our data the use of PVP-I 0.6% eye drop in the setting of AKC reduces the risk of SEIs as well as the resolution time of the disease.

Short-Term Outcomes After COVID-19-Related Treatment Interruption Among Patients with Neovascular Age-Related Macular Degeneration Receiving Intravitreal Bevacizumab.

PURPOSE: To assess outcomes and recovery strategy of patients undergoing intravitreal injections for exudative age-related macular degeneration who experienced COVID-19 related interruption in treatment during complete lockdown. METHODS: This was a retrospective, observational case study. We used a mixed effect model with random intercepts to evaluate best corrected visual acuity (BCVA) accounting for measured central macular thickness (CMT) and individual variability of each eye. Furthermore, we analysed measures of the pigmented epithelium detachment as well as presence of subretinal fluid and intraretinal cysts. RESULTS: We included 39 patients and we found a significant reduction in the BCVA between the pre- and post-lockdown controlling for CMT. There was no significant difference in pigmented epithelium detachment and in presence of subretinal fluid and intraretinal cysts. CONCLUSION: We detected a significant loss in visual function. The magnitude of the average loss was, however, limited suggesting good efficacy of the recovery strategy.

Macular Microvascular Modifications in Progressive Lamellar Macular Holes.

Lamellar macular holes (LMHs) may show morphological and functional deterioration over time, yet no definite prognostic factor for progression has been identified. Since neurovascular retinal unit impairment may take part in neurodegeneration, we compare progressive LMHs to stable ones in optical coherence tomography (OCT) angiography parameters. METHODS: OCT B scans of eyes with LMH were analyzed to detect the presence of tissue loss (TL) over time, allowing us to identify a TL group and a stable (ST) group (14 patients each). The best corrected visual acuity (BCVA) at each considered imaging time point was collected. Lastly, patients underwent macular OCT angiography. RESULTS: BCVA at last follow up was significantly reduced in the TL group compared to both the ST group and TL group baseline assessment. SCP foveal vessel density (VD), SCP and deep capillary plexus (DCP) perfusion density (PD) and parafoveal PD were lower in the TL group. Linear correlations between quantitative TL over time and parafoveal PD in SCP and between the speed of TL and BCVA variation during follow up were also detected. CONCLUSIONS: TL in LMHs is associated with both OCT angiography modifications and BCVA deterioration over time. We suggest these findings to be a manifestation of foveal Muller cell impairment in progressive LMHs.

Vitreoretinal Surgery in the Prevention and Treatment of Toxic Tumour Syndrome in Uveal Melanoma: A Systematic Review.

Toxic tumour syndrome (TTS) is a particularly aggressive form of secondary vasculopathy occurring after radiation therapy of uveal melanoma due to the persistence of the necrotic tumour mass inside the eye. The development of TTS confers a particularly unfavourable functional and anatomical ocular prognosis, ultimately requiring enucleation in most cases if untreated. Vitreoretinal (VR) surgery has been successfully applied for treatment and prevention of TTS using both resecting and non-resecting techniques. In this systematic review, we aim to define characteristics of uveal melanomas benefiting the most from secondary VR surgery and to outline the optimal type and timing of VR intervention in such cases. Analysis of the literature reveals that endoresection should be performed within 3 months after radiotherapy to tumours thicker than 7 mm and with a largest basal diameter between 8 mm and 15 mm with post-equatorial location, especially after proton beam treatment. Alternatively, endodrainage remains a valid therapeutic option in eyes with macula-off retinal detachment, tumour diameter larger than 15 mm or ciliary body involvement. VR surgery can be successful in the management of TTS following radiotherapy for uveal melanoma when timing and indication are appropriately evaluated.

Systematic and Random Mapping Errors in Structure - Function Analysis of the Macula.

Purpose: Quantify the spatial error in mapping perimetric stimuli for structure-function analysis resulting from the choice of mapping scheme and eye movements. Methods: We analyzed data from 17 healthy and 30 glaucomatous participants. Structural data of the macula were collected with a spectral-domain optical coherence tomography. We extracted eye movement data and projection locations from a fundus tracking perimeter and quantified the retinal location mapping error (distance between the actual and the intended stimulus location in degrees from the fovea) for non-tracked perimetry in a 10-2 grid. First, we evaluated whether rotating the 10-2 grid to match the fovea-disc axis improved mapping accuracy. Second, we analyzed the effect of eccentric fixation, random eye movements, and gaze attraction from seen stimuli on projection accuracy and spread of fixation, measured with the 95% bivariate contour ellipse area (95% BCEA). We used generalized linear mixed models for our statistical analyses. Results: Rotating the 10-2 grid to match the fovea-disc axis significantly increased the mapping error (P < 0.001). Eye movements evoked by seen stimuli significantly increased the projection error during the test (P < 0.001). Removing such eye movements significantly reduced the 95% BCEA (P < 0.001). Eccentric fixation also significantly contributed to the projection error (P < 0.001), and its effect was larger in glaucoma patients (P < 0.001). Conclusions: Rotating the perimetric grid to match the fovea-disc axis is not recommended. Fixation eccentricity and instability should be taken into account for structure-function analyses. Translational Relevance: Accounting for fixation can improve structure-function mapping in glaucoma.

Curcuma-Based Nutritional Supplement in Patients with Neovascular Age-Related Macular Degeneration.

To investigate effectiveness and safety of a curcumin-based nutritional supplement in neovascular age-related macular degeneration (AMD). We conducted a controlled retrospective study, reviewing the medical records of patients referred to the Eye Center, Humanitas Hospital, Bergamo due to neovascular AMD and treated with antivascular endothelial growth factor (VEGF) intravitreal injections (IVIs) and oral administration of a curcumin-based nutritional supplement vehiculated by enterosoma-I®. We retrospectively collected data of 18 naive patients who received IVI and daily oral nutritional supplement and 24 naive age-matched controls with the same diagnosis undergoing only IVI. All patients underwent a loading-phase of one-per-month IVI for 3 months and then received IVI pro re nata. Median best-corrected visual acuity was significantly improved in treated patients compared with controls (P < .05), while there was no statistical difference in central macular thickness between groups (P > .05). The total number of injections (tIVI) was significantly (P < .05) reduced in the treated group compared with controls. The tIVI in treated group ranged from 3 to 5 with a median of 4 while control group received a tIVI that ranged between 6 and 7 with a median of 7. Treatment with curcumin-based nutritional supplement was safe and effective. Curcumin is a promising adjuvant of anti-VEGF treatment, improves functional outcomes, and prolongs duration.

A novel quantitative analysis method for idiopathic epiretinal membrane.

PURPOSE: To introduce a novel method to quantitively analyse in three dimensions traction forces in a vast area of the ocular posterior pole. METHODS: Retrospective analysis of 14 eyes who underwent peeling surgery for idiopathic, symptomatic and progressive epiretinal membrane. The technique measures the shift in position of vascular crossings after surgery from a fixed point, which is the retinal pigmented epithelium. This shift is defined as the relaxation index (RI) and represents a measure of the postoperative movement of the retina due to released traction after surgery. RESULTS: Best-corrected visual acuity was significantly better than baseline at all follow ups while the RI had its maximum value at baseline. Moreover, we found a significant correlation between best-corrected visual acuity at 6 months and RI at baseline. CONCLUSION: While all previous published methods focused on bi-dimensional changes observed in a small region, this study introduces a three-dimensional assessment of tractional forces. Future integration of RI into built-in processing software will allow systematic three-dimensional measurement of intraretinal traction.