Unexplained Vision Loss Associated With Intraocular Silicone Oil Tamponade in Rhegmatogenous Retinal Detachment Repair.

Purpose: To evaluate the visual outcomes with unexplained vision loss during or after silicone oil (SO) tamponade. Methods: This multicenter retrospective case series comprised patients with unexplained vision loss associated with SO tamponade or its removal. Eyes with other clear secondary identifiable causes of vision loss were excluded. Results: Twenty-nine eyes of 28 patients (64% male) were identified. The mean age was 50 ± 13 years (range, 13-78 years). The mean duration of SO tamponade was 148 ± 38 days. Eighteen eyes (62%) developed unexplained vision loss while under SO; 11 (38%) had vision loss after SO removal. The most common optical coherence tomography (OCT) finding was ganglion cell layer (GCL) thinning (55%). Eyes with vision loss after SO removal had a mean logMAR best-corrected visual acuity (BCVA) of 0.6 ± 0.7 (Snellen 20/85) before SO tamponade and 1.2 ± 0.4 (20/340) before SO removal. By the last follow-up after SO removal, the BCVA had improved to 1.1 ± 0.4 (20/235). In eyes with vision loss after SO removal, the BCVA before SO removal was 0.7 ± 0.7 (20/104), which deteriorated to 1.4 ± 0.4 (20/458) 1 month after SO removal. By the last follow-up, the BCVA had improved to 1.0 ± 0.5 (20/219). Conclusions: Unexplained vision loss can occur during SO tamponade or after SO removal. Vision loss was associated with 1000-centistoke and 5000-centistoke oil and occurred in macula-off and macula-on retinal detachments. The duration of tamponade was 3 months or longer in the majority of eyes. Most eyes had GCL thinning on OCT. Gradual visual recovery can occur yet is often incomplete.

INTRAOCULAR INFLAMMATION INCIDENCE AFTER INTRAVITREAL BROLUCIZUMAB INJECTION FOR EXUDATIVE AGE-RELATED MACULAR DEGENERATION.

PURPOSE: We evaluated the clinical outcomes of intraocular inflammation (IOI) of eyes with neovascular age-related macular degeneration (AMD) injected with brolucizumab in our tertiary referral center. METHODS: A retrospective case series for which clinical records of all eyes that received intravitreal brolucizumab at Bascom Palmer Eye Institute between December 1, 2019, and April 1, 2021, were reviewed. RESULTS: There were 345 eyes of 278 patients who received 801 brolucizumab injections. IOI was detected in 16 eyes of 13 patients (4.6%). In those patients, baseline Logarithm of Minimu Angle of Resolution (logMAR) best-corrected visual acuity was 0.32 0.2 (20/42), while it was 0.58 0.3 (20/76) at IOI presentation. The mean number of injections among eyes experiencing IOI was 2.4, and the interval between the last brolucizumab injection and IOI presentation was 20 days. There was no known case of retinal vasculitis. Management of IOI included topical steroids in seven eyes (54%), topical and systemic steroids in five eyes (38%), and observation in one eye (8%). Best-corrected visual acuity returned to baseline and inflammation resolved in all eyes by the last follow-up examination. CONCLUSION: Intraocular inflammation after brolucizumab injection for neovascular AMD was not uncommon. Inflammation resolved in all eyes by the last follow-up visit.

Dose-Dependent and Reversible Serous Retinal Detachments in Fibroblast Growth Factor Receptor Inhibitor-Associated Retinopathy.

We report two cases of fibroblast growth factor receptor (FGFR) inhibitor-associated retinopathy, including the first case of Debio 1347 associated retinopathy manifesting with bilateral serous retinal detachments along the superotemporal arcades and a case of erdafitinib associated retinopathy manifesting with classic foveal serous retinal detachments. Both cases demonstrate a clear dose-dependent and reversible class effect likely secondary to downstream effects of FGFR inhibition on the MEK pathway, resulting in retinal pigment epithelial cell dysfunction, and may also involve additional mechanisms of cellular injury through inhibition of the PI3K/AKT/mTOR pathway. FGFR inhibitor-associated retinopathy appears to manifest differently among patients. [Ophthalmic Surg Lasers Imaging Retina 2023;54:368-370.].

Intraocular Lens Exchange: Indications, Comparative Outcomes by Technique, and Complications.

Purpose: To describe the indications, outcomes, and complications associated with intraocular lens (IOL) exchange. Patients and Methods: To determine the relative frequency of postoperative complications between techniques for all patients undergoing IOL exchange from May 1, 2014 through August 31, 2020. Results: IOL exchange was performed in 511 eyes of 489 patients (59.7% men; mean age: 67.0 ± 13.9 years, median time from cataract procedure to IOL exchange: 47.5 months). Mean uncorrected visual acuity significantly improved from 20/192 Snellen equivalent (logMAR 0.981) preoperatively to 20/61 (logMAR 0.487) at last follow-up (P < 0.001). Overall, 384 eyes (78.7%) met their desired refractive outcome within ±1.0 diopter (D). The most frequent complication was cystoid macular edema (CME) (n=39, 7.6%). Iris-sutured technique was associated with significantly greater frequency of subsequent IOL dislocation (10.3%) than 4-point scleral sutured (0%, P = 0.002), anterior chamber IOL (ACIOL, 1.5%, P = 0.01), and 2-point scleral sutured (0%, P = 0.03) techniques. Yamane scleral-fixation technique was associated with significantly greater frequency of developing IOL tilt (11.8%) than ACIOL (0%, P = 0.002), 4-point scleral sutured (1.1%, P = 0.01), 2-point scleral sutured (0%, P = 0.04), and iris-sutured (0%, P = 0.04) techniques. Conclusion: IOL exchange significantly improved uncorrected visual acuity and more than three-quarters of eyes met the refractive goal. Certain techniques were associated with complications, including subsequent dislocation associated with iris-sutured technique and IOL tilt associated with Yamane scleral-fixation technique. This information may help guide surgeons in deciding between procedural techniques for individual patients during IOL exchange preoperative planning.

VALSALVA RETINOPATHY: Clinical Features and Treatment Outcomes.

PURPOSE: To report the clinical presentation and outcomes in patients with Valsalva retinopathy. METHODS: This was a retrospective case series of patients diagnosed with Valsalva retinopathy between June 1, 2010, and May 31, 2020. Clinical notes, operative reports, fundus photography, and optical coherence tomography images were reviewed. RESULTS: This study comprised 58 eyes of 58 patients. The most common causes were lifting (34.4%), vomiting (20.6%), straining (20.6%), and coughing (17.2%). Mean best-corrected visual acuity at diagnosis was 20/163. The most frequently involved vitreoretinal compartment was the subhyaloid space (42.3%) followed by the intraretinal (32.7%), intravitreal (23.1%), and subretinal (13.4%) spaces. Mean best-corrected visual acuity of all patients was 20/59 at 3 months, 20/48 at 6 months, and 20/22 at 1 year. Mean time to clearance of hemorrhage on clinical examination was 99.0 ± 18.7 days in patients who underwent observation and 4.5 ± 3.5 days after surgery in patients who received pars plana vitrectomy. CONCLUSION: Valsalva retinopathy is generally associated with a favorable visual prognosis. Most eyes perform well with observation although pars plana vitrectomy may be indicated in patients requiring rapid resolution of hemorrhage.

Outcomes of Pars Plana Vitrectomy with Panretinal Photocoagulation for Treatment of Proliferative Diabetic Retinopathy Without Retinal Detachment: A Seven-Year Retrospective Study.

Objective: To review clinical outcomes of patients with proliferative diabetic retinopathy (PDR) and vitreous hemorrhage (VH) who underwent pars plana vitrectomy (PPV) with endolaser panretinal photocoagulation (PRP) without retinal detachment (RD) repair. Methods: Retrospective chart review of the rate of postoperative clinical findings and visual acuity in patients with PDR from May 2014 to August 2021. Results: Pars plana vitrectomy with endolaser PRP was performed in 81 eyes of 81 patients (mean age of 62.1 ± 10.5 years). At a median follow-up of 18 months, mean Snellen best-corrected visual acuity (BCVA) significantly improved from 20/774 preoperatively to 20/53 at last follow-up (P < 0.001). Postoperative complications and clinical findings included VH (12.3%), diabetic macular edema (DME) (12.3%), ocular hypertension (8.6%), RD (4.9%), and need for additional PPV (6.2%). Eyes with PRP performed within 6 months before surgery had a lower frequency of developing postoperative VH (5.3%) compared to eyes that received PRP more than 6 months before surgery (27.3%, P = 0.04). Eyes that received preoperative anti-vascular endothelial growth factor (VEGF) treatment (2.0%) had a lower frequency of postoperative VH compared to eyes that did not receive anti-VEGF treatment (14.3%, P = 0.04). Eyes that received intraoperative sub-tenon triamcinolone acetonide developed postoperative DME (4.0%) less frequently than eyes that did not receive sub-tenon triamcinolone acetonide (26.7%, P = 0.04). Conclusion: In patients with PDR and VH, PPV with PRP yielded significant improvements in visual acuity and resulted in overall low rates of recurrent postoperative VH. Preoperative anti-VEGF and PRP laser treatment were associated with lower rates of postoperative VH. Furthermore, intraoperative use of sub-tenon triamcinolone acetonide was associated with a lower rate of postoperative DME. Pars plana vitrectomy with endolaser PRP in conjunction with the aforementioned pre- and intraoperative therapies is an effective treatment for patients with PDR and VH.

Haptic Erosion Following Sutureless Scleral-fixated Intraocular Lens Placement.

PURPOSE: To describe the clinical features and visual outcomes of eyes with conjunctival haptic erosion after sutureless intrascleral (SIS) fixated intraocular lens (IOL) placement. DESIGN: Retrospective case series. SUBJECTS: Patients experiencing haptic erosion after SIS fixation between January 1, 2013, and March 1, 2022. METHODS: A multicenter, multisurgeon, retrospective review. MAIN OUTCOME MEASURES: Clinical features, visual outcomes, and treatment options following haptic erosions after SIS fixation. RESULTS: Nineteen eyes with haptic erosion were identified. The mean age at initial SIS fixation was 64 ± 12 years (range, 38-81 years). There were 5 (26%) eyes with a history of conjunctiva involving ocular surgery, including scleral buckle surgery and tube shunt surgery. Trocar-assisted fixation was performed in 15 (79%) eyes, whereas needle fixation was used in 4 (21%) eyes. Eighteen (95%) sets of haptics were flanged with a low temperature cautery. Seventeen (90%) sets of haptics were externalized superiorly and inferiorly, and 2 (10%) sets of haptics were externalized nasally and temporally. Haptics were covered by conjunctiva in 14 (74%) eyes and by scleral flap in 5 (26%) eyes. All patients experienced a single haptic erosion, of which 8 (43%) were located superiorly, 9 (47%) inferiorly, and 2 (10%) temporally. The mean interval between the initial SIS fixation and haptic erosion was 278 ± 437 days. After correction of the erosion, 18 (95%) eyes had a stable IOL at the last follow-up, with no recurrence of haptic erosion. In this series, there were no cases of endophthalmitis. CONCLUSIONS: Haptic erosion is a notable complication after SIS fixated IOL surgery but may be repaired with favorable visual outcomes. Careful evaluation of the conjunctiva should be considered before the surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Trends in Sports-Related Ocular Trauma in United States Emergency Departments from 2010 to 2019: Multi-Center Cross-Sectional Study.

IMPORTANCE: Traumatic eye injury is one of the leading causes of visual impairment in the United States, but there is limited information available in the literature about ocular trauma related to sports. OBJECTIVE: To evaluate the primary ocular diagnosis, type of sport, seasonal prevalence, and injury severity following ocular sports-related trauma. DESIGN: Cross-sectional study. SETTING: United States (US) hospital emergency departments (ED). PARTICIPANTS: Patients with sports-related ocular injuries in the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP) database from January 1, 2010 to December 31, 2019. MAIN OUTCOME AND MEASURE: To identify and compare the type of sport, primary diagnosis of ocular injury, and injury severity. RESULTS: For 4,671 sports-related ocular injuries identified, the mean age of injury was 19.4±15.2 years (median: 15.0 years, 79% male). The largest proportion of injuries occurred in the 12-17 years of age cohort (38.6%), occurring during summer months (P< .001). The most common sports associated with eye injury were basketball (37.8%), baseball (13.8%),, and football (12.3%). There were 3,214 injuries (68.8%) deemed 'minor' anterior segment injuries, 359 injuries (7.7%) deemed 'major' anterior segment injuries, 31 injuries (0.7%) deemed 'minor' posterior segment injuries, 77 injuries (1.7%) deemed 'major' posterior segment injuries, and 990 injuries (21.2%) of unknown severity. Basketball-related ocular trauma had a greater frequency of corneal/scleral abrasions than baseball (P < .001), soccer (P < .001), tennis (P = .03), softball (P = .001), and paintball (P = .02). Baseball-related ocular trauma had a greater frequency of contusions than basketball (P < .001), football (P < .001), soccer (P < .001), volleyball (P< .001). Paintball and soccer were more associated with 'major' anterior and posterior ocular injuries than basketball (P < .001, for both). CONCLUSION AND RELEVANCE: Sports-related trauma remains a highly prevalent cause of eye-related visits to the emergency room, particularly in young male adolescents in the spring and summertime. While most diagnoses were deemed 'minor' injuries with basketball associated with corneal/scleral abrasions and baseball with contusions, paintball, and soccer were more significantly associated with 'major' anterior and posterior ocular injuries.

Atypical Location of Diffuse Large B-cell Lymphoma in the Nasal Septum.

Diffuse large B-cell lymphoma (DLBCL) is the most prevalent subtype of non-Hodgkin's lymphoma (NHL). This subtype can be present in various extranodal sites, including the brain, bones, intestines, kidneys, adrenal glands, and other soft tissues. As demonstrated in this case, one rare site of DLBCL is the nasal septum, which presents as a rapidly enlarging mass resistant to antibiotics and steroids. The definitive diagnosis for this case involved biopsy, but further workup, such as computed tomography (CT) and fluorescence in situ hybridization (FISH), helped support the diagnosis of DLBCL. While determining the stage of the lymphoma, treatment with R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) was initiated immediately. This case demonstrates a rare presentation of DLBCL in the nasal septum and describes the significance of urgent examination as well as treatment.

Contractual considerations in the private equity era.

Private equity (PE) has grown rapidly in medicine. The reintroduction of PE in ophthalmology has necessitated a greater understanding of the potential contractual relationships with PE firms from both a practice owner and an employee physician perspective. There are contractual obligations that need to be met as PE agreements are designed to ensure clear investment patterns and abide by legal mandates. A practice owner entering into a PE contract needs to consider how the practice is being valued, what their obligations are to the PE entity after the sale has been completed to attain full compensation and understand their new role at the practice. On the other hand, employee ophthalmologists must carefully evaluate the compensation package being offered in terms of the type of equity, vesting of shares, obligations to the PE firm under the agreement such as a noncompete clause, and what occurs under a subsequent sale of the practice. Overall, contractual considerations in the private equity era need to be carefully evaluated in order to ensure the agreement is in the best interest for the clinician, practice, and their patients.

An Isolated Radiographic Finding of Spontaneous Vertebral Osteomyelitis.

Vertebral osteomyelitis (VO) is an infection of the vertebral body, most often arising secondary to hematogenous spread or contiguous spread from local soft tissue infection. Establishing a diagnosis of VO requires a high index of suspicion as patients often present with nonspecific symptoms such as pain of the affected vertebral segments along with leukocytosis and elevated inflammatory markers. Magnetic resonance imaging (MRI) has high sensitivity and specificity for detecting VO, even in the early phases of infection. Diagnosis is generally confirmed with blood cultures or vertebral biopsy demonstrating a culprit organism and treatment is tailored to the identified organism. However, some patients may have culture-negative VO that still necessitates antimicrobial treatment. Imaging alone may be an acceptable form of diagnosis that can allow for prompt empiric antibiotic therapy, reducing the need for invasive diagnostic measures. We present a case of a 46-year-old male with a past medical history of type 2 diabetes mellitus, hyperlipidemia, and prior transient ischemic attack (TIA). The patient presented with signs and symptoms of another TIA as well as new-onset neck and upper back pain. MRI in the neurologic workup demonstrated findings consistent with osteomyelitis of the C5 and C6 cervical vertebrae. Previous imaging showed no evidence of vertebral dysfunction. This patient presented with new-onset VO in the absence of systemic symptoms or elevation of inflammatory markers and no identified source of infection. Based on imaging and clinical presentation, empiric antibiotic treatment was initiated resulting in clinical improvement and resolution of VO on imaging. This case demonstrates an atypical presentation of VO and describes the benefit of MRI in recognizing infection in the absence of concurrent typical findings, which allowed for the initiation of empiric therapy.

Mechanical Property Comparison of 23-, 25-, and 27-Gauge Vitrectors across Vitrectomy Systems.

OBJECTIVE: To investigate the mechanical properties of 23-, 25-, and 27-gauge vitrectomy vitrectors across 3 different vitrectomy systems to inform surgical techniques. DESIGN: An experimental study that did not involve any human subjects. METHODS: Nine vitrectors (3 each of 23-, 25-, and 27 gauge) from Alcon, Dutch Ophthalmic Research Center (DORC), and Bausch & Lomb (B/L) were measured. Measurements were performed using electroforce displacement at the tip and 15 mm from the tip. Five measurements were performed at each location, and fully elastic deformation was ensured. MAIN OUTCOME MEASURES: The main parameter being measured was the force in grams (gf) necessary to deflect the vitrectors vertically downward by 1 mm, either at the tip of the vitrector or 15 mm from the tip. RESULTS: A total of 90 measurements were performed. Across brands, B/L demonstrated the least stiffness at both the tip and at the 15-mm point for 23-gauge (8.0±0.3gf, 67.3±1.0gf), 25-gauge (6.8±0.3gf, 60.5±0.4gf), and 27-gauge (3.3±0.1gf, 33.9±0.5gf) vitrectors. Although there was only a small decrease in the stiffness in the 25-gauge vitrector compared with the 23-gauge vitrector at the 15-mm point, this difference was statistically significant for Alcon (P < 0.001), DORC (P < 0.001), and B/L (P < 0.001). CONCLUSIONS: Based on this study, 25-gauge vitrectors, although larger than the 27-gauge vitrectors and less stiff than the 23-gauge vitrectors, may offer favorable compromise between stiffness and gauge size. However, surgeon experience, preference, and the type of surgery being performed should be paramount when making the final vitrector selection. Knowledge of these mechanical properties may aid surgeons in choosing between gauge size and vitrectomy system to optimize their comfort and efficiency.

Idiopathic Vitreomacular Traction Managed with Initial Observation: Clinical Course and Outcomes.

OBJECTIVE: To review the clinical course and outcomes of patients with idiopathic vitreomacular traction (VMT) managed initially by observation. DESIGN: Retrospective chart review including patients with idiopathic VMT based on clinical symptoms and findings on OCT between January 1, 2015, and February 15, 2021. SUBJECTS: The study included 436 eyes of 317 patients with a mean age of 72.2 years ± 8.9 at initial visit and mean follow-up time of 34 months ± 19.2. METHODS: Vitreomacular traction severity grade was ascribed to each patient using previously published grading criteria. Grade 1 denoted incomplete cortical vitreous separation with attachment at the fovea and visible distortion of the foveal surface. Grade 2 included intraretinal cysts or clefts along with grade 1 findings. Grade 3 included subfoveal fluid along with grade 2 traits. MAIN OUTCOME MEASURES: The rate of spontaneous release, grade at baseline compared with grade at final follow-up, and outcomes of interventions, if performed. RESULTS: At baseline, mean best corrected visual acuity (BCVA) was 20/40. Baseline OCT demonstrated grade 1 VMT in 212 eyes (48.6%), grade 2 VMT in 172 eyes (39.4%), and grade 3 VMT in 52 eyes (11.9%). Among eyes that were initially grade 1, 25.0% had spontaneous release of VMT (median, 290.0 days; mean, 404.5 days ± 323.9), 50.9% remained stable, and 10.4% worsened. Among eyes that were initially grade 2, 14.5% had spontaneous release of VMT (median, 570.0 days; mean, 692.9 days ± 477.5), 55.2% remained stable, 4.7% improved, and 2.3% worsened. Among eyes that were initially grade 3, 5.8% had spontaneous release of VMT (median, 790.0 days; mean, 839.3 days ± 246.7), 28.8% remained stable, and 5.8% improved. Of the 436 eyes, macular hole development occurred in 42 eyes (9.6%). Pars plana vitrectomy was performed in 94 of 436 eyes (21.6%) with mean BCVA before pars plana vitrectomy of 20/78 and final follow-up BCVA of 20/55. CONCLUSION: This study demonstrates the generally stable clinical course of VMT when managed initially by observation. Stable VMT grade was the most frequent outcome, and eyes with grade 1 VMT were more likely to undergo spontaneous release than eyes with grade 2 or 3.

Milk-Alkali Syndrome as a Cause of Hypercalcemia in a Gentleman With Acute Kidney Injury and Excessive Antacid Intake.

Among the pertinent differentials for hypercalcemia, milk-alkali syndrome remains a diagnosis of exclusion following a thorough workup of other severe causes. However, several key signs may increase a clinician's index of suspicion for possible milk-alkali syndrome, including a prolonged history of antacid ingestion. Milk-alkali syndrome commonly presents with a classic triad: hypercalcemia, metabolic alkalosis, and acute kidney injury. The diagnostic workup should include evaluation of both serum and urine calcium levels, serum phosphate levels, and other hormones (parathyroid hormone, vitamin D). In the case of a confirmed diagnosis of milk-alkali syndrome, rapid correction of calcium levels is of utmost importance. We present the case and workup of an individual presenting to the emergency room with hypercalcemia, acute kidney injury, and several key systemic symptoms. Given a significant history of antacid overuse, and a thorough diagnostic workup, a diagnosis of milk-alkali syndrome was made and the patient was treated accordingly, making a full recovery. We review this rare case and important clinical pearls regarding milk-alkali syndrome.