Complications of Intra-Arterial tPA for Iatrogenic Branch Retinal Artery Occlusion: A Case Report through Multimodal Imaging and Literature Review.

Background and Objectives: To document, through multimodal imaging, the post-procedural clinical course and visual outcome of a patient who received intra-arterial tissue plasminogen activator (tPA) for acute iatrogenic branch retinal artery occlusion (BRAO), and to review the literature and guidelines regarding the use of tPA for retinal arterial occlusions. Methods: A 28-year-old female patient who sustained an iatrogenic BRAO and subsequently received intra-arterial tPA was followed through her post-interventional course of 3 months with serial exams and multimodal imaging, including color fundus photography, visual field testing, spectral domain optical coherence tomography (SD-OCT), and OCT angiography (OCT-A). Results: A patient with history of left internal cerebral artery (ICA) aneurysm and baseline visual acuity (VA) of 20/20 developed an acutely symptomatic BRAO after undergoing a neuroendovascular procedure and was acutely treated with tPA through the left ophthalmic artery. At two weeks follow-up, a central posterior pole hemorrhage was noted although VA was preserved. A superior altitudinal defect was shown on automated perimetry. VA dropped to 20/50 at 7 weeks follow-up and hyperreflective material deep to the attachment between the posterior hyaloid and the internal limiting membrane (ILM) consistent with hemorrhage was noted on SD-OCT. At 11 weeks follow-up, VA returned to 20/20, SD-OCT revealed a membrane bridging the foveal depression, OCT-A showed decreased vascularity in the inferior macula, and the visual field defect was stable by automated perimetry. Conclusions: Intraocular hemorrhage is a possible complication of intra-arterial tPA administration for BRAO, and a careful analysis of risks, benefits, and goals of this procedure must be considered by both provider and patient before such intervention.

Silicone Scaffold Support Using a Bilayer Dermal Regeneration Matrix Template for Correction of Primary or Recurrent Eyelid Retraction.

PURPOSE: To evaluate the efficacy and safety of a bilayer dermal regenerative matrix for primary or complex/recurrent eyelid retraction. METHODS: Retrospective review of patients undergoing eyelid retraction repair using the bilayer dermal regenerative matrix from 2005 to 2019. Nineteen eyelid surgeries from 15 patients were identified. Collected data included patient demographics, symptoms, preoperative/postoperative lower eyelid position, inferior scleral show, lagophthalmos, etiology of retraction, history of prior retraction surgeries, major/minor complications, and follow-up duration (minimum 6 months). Postoperative measurements were taken at a minimum of 1 week, 3-6 weeks, 2-4 months, and 6 months. RESULTS: Postoperatively, 90% of cases had good improvement of lower eyelid retraction (defined as 1 mm or less below the inferior limbus). Postoperative elevation of the lower eyelid ranged 1-3.5 mm compared with preoperative measurements. When used in the upper eyelid for conjunctival scarring, the implant improved the superior fornix depth. Complications were minimal and included transient conjunctival injection, eyelid edema, and foreign body sensation. No patients requested early removal of the silicone layer due to ocular pain. CONCLUSIONS: The bilayer dermal regeneration matrix template may be considered a reasonable alternative to other spacers to reduce the vertical palpebral fissure and eyelid malposition in primary, complex, or recurrent cases. It also worked well for first-line correction of thyroid retraction, which tend to be more challenging due to globe proptosis. Suboptimal results may have occurred due to active cicatrizing conjunctival disease, or residual negative vector of the cheek and orbit. High cost may be a consideration, and the bilayer dermal regeneration matrix template was not studied directly against hard palate and other spacer materials.

Optimization of transversal phacoemulsification settings in peristaltic mode using a new transversal ultrasound machine.

PURPOSE: To determine the optimum bottle height, vacuum, aspiration rate, and power settings in the peristaltic mode of the Whitestar Signature Pro machine with Ellips FX tip action (transversal). SETTING: John A. Moran Eye Center Laboratories, University of Utah, Salt Lake City, Utah, USA. DESIGN: Experimental study. METHODS: Porcine lens nuclei were hardened with formalin and cut into 2.0 mm cubes. Lens cubes were emulsified using transversal and fragment removal time (efficiency), and fragment bounces off the tip (chatter) were measured to determine optimum aspiration rate, bottle height, vacuum, and power settings in the peristaltic mode. RESULTS: Efficiency increased in a linear fashion with increasing bottle height and vacuum. The most efficient aspiration rate was 50 mL/min, with 60 mL/min statistically similar. Increasing power increased efficiency up to 90% with increased chatter at 100%. CONCLUSION: The most efficient values for the settings tested were bottle height at 100 cm, vacuum at 600 mm Hg, aspiration rate of 50 or 60 mL/min, and power at 90%.