Comparative Outcomes of Primary Vitrectomy Versus Tap and Inject for Endophthalmitis Following Phacoemulsification Cataract Surgery.

PURPOSE: To compare functional and anatomical outcomes, rates of culture positivity and number of procedures in eyes with endophthalmitis following phacoemulsification surgery, treated with either primary vitrectomy and intravitreal antibiotics or vitreous tap and antibiotic injection (T&I). METHODS: Patients developing endophthalmitis after phacoemulsification surgery between 2007 and 2016 were identified, and outcomes were compared between the two treatment groups. RESULTS: 19 patients underwent a primary vitrectomy and 22 underwent a T&I. There was a significant improvement in visual acuity after T&I (p=.003) and primary vitrectomy (p=.00005). The median improvement in visual acuity was significantly greater for the primary vitrectomy group than the T&I group (p=.024). 64% of eyes were culture positive with the initial T&I, and 63% with primary vitrectomy (p=1.00). Two eyes initially culture negative with a T&I, and three eyes that were culture positive with a T&I were subsequently culture positive with a vitrectomy 24-72 hours later. 68% of patients who underwent a T&I required an additional procedure, compared to 26% of the vitrectomy group (p=.01). The T&I group underwent a mean of 2.3 procedures each, and the primary vitrectomy group underwent 1.5 (p=.03). CONCLUSIONS: Eyes with endophthalmitis treated with a primary vitrectomy demonstrated greater visual improvement and needed fewer procedures than those initially treated with a T&I. Viable bacteria were only seen in subsequent procedures in the T&I group, indicating that primary vitrectomy was superior at sterilizing the eye.

INTERNAL DRAINAGE OF SUBRETINAL FLUID DURING CHANDELIER-ASSISTED SCLERAL BUCKLING.

PURPOSE: To describe the surgical technique of internal drainage of subretinal fluid as an adjunct to chandelier-assisted scleral buckling for the repair of rhegmatogenous retinal detachment. METHODS: The technique of internal drainage with a sharp needle or cannula through a trocar is described and shown in a Supplemental Digital Content 1 (see Video, http://links.lww.com/ICB/A87). RESULTS: Three patients (3 eyes) underwent scleral buckling for rhegmatogenous retinal detachment repair. Subretinal fluid was drained using the internal drainage approach in all cases. All three patients had successful reattachment of retina with improvement in visual function. No complications were reported related to vitreous loss, retinal incarceration, or redetachment following primary surgery. CONCLUSION: Internal drainage of subretinal fluid during chandelier-assisted scleral buckling is a useful technique that can be considered for repairing rhegmatogenous retinal detachment.

Better visual outcome associated with early vitrectomy in the management of endophthalmitis.

AIMS: To examine the role of early vitrectomy in the management of endophthalmitis from all causes. METHODS: Retrospective study of 290 consecutive subjects diagnosed with endophthalmitis at Auckland District Health Board between 1 January 2006 and 31 July 2019. Main outcome measure was visual acuity at 9-month follow-up and proportion of subjects with severe vision loss (≤20/200). RESULTS: Median age at presentation was 70.4 years and 151 subjects (52.1%) were women. Cataract surgery was the most common cause of endophthalmitis in 92 subjects (31.7%) followed by intravitreal injection in 57 (19.7%), endogenous endophthalmitis in 48 subjects (16.6%), non-surgical trauma in 42 subjects (14.5%), glaucoma surgery in 24 subjects (8.3%), vitrectomy in 22 subjects (7.6%) and corneal in 5 subjects (1.7%). Culture was positive in 136 (46.9%) with gram-positive organisms most common (76.5%). Early vitrectomy was performed in 82 subjects (28.3%). Median visual acuity at 9 months was 20/100 (IQR 20/30 to light perception), and severe vision loss occurred in 100 (43.5%). Retinal detachment occurred in 35 eyes (12.1%) and 26 eyes were enucleated. On multivariate analysis, younger age, poor presenting visual acuity and culture-positive endophthalmitis were associated with worse outcomes, and early vitrectomy was associated with better outcomes. CONCLUSIONS: Early vitrectomy (within 24 hours) is associated with better visual outcomes at 9 months, while younger age, poor presenting visual acuity and culture-positive endophthalmitis are associated with poorer visual acuity outcomes.

Heterozygous COL9A3 variants cause severe peripheral vitreoretinal degeneration and retinal detachment.

The COL9A3 gene encodes one of the three alpha chains of Type IX collagen, with heterozygous variants reported to cause multiple epiphyseal dysplasia, and suggested as contributory in some cases of sensorineural hearing loss. Patients with homozygous variants have midface hypoplasia, myopia, sensorineural hearing loss, epiphyseal changes and carry a diagnosis of Stickler syndrome. Variants in COL9A3 have not previously been reported to cause vitreoretinal degeneration and/or retinal detachments. This report describes two families with autosomal dominant inheritance and predominant features of peripheral vitreoretinal lattice degeneration and retinal detachment. Genomic sequencing revealed a heterozygous splice variant in COL9A3 [NG_016353.1(NM_001853.4):c.1107 + 1G>C, NC_000020.10(NM_001853.4):c.1107 + 1G>C, LRG1253t1] in Family 1, and a heterozygous missense variant [NG_016353.1(NM_001853.4):c.388G>A p.(Gly130Ser)] in Family 2, each segregating with disease. cDNA studies of the splice variant demonstrated an in-frame deletion in the COL2 domain, and the missense variant occurred in the COL3 domain, both indicating the critical role of Type IX collagen in the vitreous base of the eye.

Mortality after endophthalmitis following contemporary phacoemulsification cataract surgery.

IMPORTANCE: To determine if endophthalmitis following cataract surgery is linked to increased mortality. BACKGROUND: Increased mortality has been linked to patients with cataract and cataract surgery. We tested the hypothesis that post-cataract endophthalmitis has a greater risk of death than pseudophakes who do not develop this complication. DESIGN: Case-control study conducted in a tertiary public hospital. PARTICIPANTS: The study group comprised 50 consecutive patients with post-cataract endophthalmitis, and these were matched with selected controls. METHODS: Patients with endophthalmitis following cataract surgery were identified from a prospective electronic surgical database. Subsequently, it was determined if the patient was deceased at the time of sequestration (September 2015), and the date of death was recorded. A previously described population who had undergone cataract surgery in the same facility was selected as a control group, and the population was case-matched in terms age, gender, presence or absence of diabetes and/or hypertension. MAIN OUTCOME MEASURES: The median survival rates were determined for the control group and the patients with post-cataract endophthalmitis. RESULTS: Fifty patients were identified as undergoing endophthalmitis post-cataract surgery, and 48 (n = 48) met inclusion criteria (mean age 72 years ±12 SD with 30:18 F:M); 17% were diabetic, and 50% had systemic hypertension. No statistically significant difference in median survival between the study and control cases was identified (100 months (95% confidence interval 86-114) vs. 106 months (95% confidence interval 66-146), respectively, P = 0.756). CONCLUSIONS AND RELEVANCE: Post-cataract endophthalmitis was not associated with an increased rate of mortality in this study.

Comparative study of femtosecond laser-assisted cataract surgery and conventional phacoemulsification in vitrectomized eyes.

IMPORTANCE: To compare the safety and outcomes of femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification in post-vitrectomy eyes. BACKGROUND: To compare visual outcomes and adverse outcomes of FLACS and conventional phacoemulsification in vitrectomized eyes. DESIGN: Single surgeon, retrospective study set in a private clinic in Auckland, New Zealand. Patients selected in a chronological manner, without masking or randomization. PARTICIPANTS: Only patients undergoing cataract extraction following vitrectomy were included. METHODS: The last 25 surgeries performed prior to acquisition of the femtosecond laser and the first 25 surgeries performed following acquisition of the femtosecond laser were included. Patient demographic data, preoperative and postoperative visual acuities were collected. Intraoperative and postoperative complications were compared. Follow-up ranged from 1 to 74 months. MAIN OUTCOME MEASURES: The main outcome measures are postoperative visual outcomes and intra- and postoperative complications for both groups. RESULTS: Results of FLACS compared to conventional phacoemulsification are as follows: preoperative logMAR best corrected visual acuity (BCVA) (0.63 vs. 0.69), postoperative logMAR BCVA (0.17 vs. 0.19), posterior capsule complications (0% vs. 12%, P = 0.235), cystoid macular oedema (CMO) (12% vs. 20%, P = 0.705) and postoperative neodymium-doped yttrium aluminium garnet (Nd:YAG) capsulotomy (16% vs. 48%, P = 0.032). CONCLUSIONS AND RELEVANCE: FLACS demonstrates comparable visual outcomes to conventional phacoemulsification. Whilst outcomes measured were not statistically significant, except postoperative YAG capsulotomy, FLACS showed a trend towards a better intraoperative and postoperative safety profile. Femtosecond laser offers a theoretical advantage in reducing complication rates in post-vitrectomy eyes, further larger studies are needed.

Optic Nerve Head Hemorrhages Associated With Posterior Vitreous Detachment.

PURPOSE: To report and evaluate the clinical and optical coherence tomography (OCT) features of optic nerve hemorrhages (ONH) associated with spontaneous posterior vitreous detachment (PVD). DESIGN: A prospective case series conducted at a private ophthalmic practice in Auckland, New Zealand. METHODS: A consecutive series of patients presenting at a private multispecialty practice in Auckland, New Zealand, with symptoms of PVD with ONH underwent imaging of the optic nerve with digital retinal photography and OCT. The number and location of each hemorrhage were recorded, together with relevant ophthalmic and demographic data. RESULTS: Twenty of 30 eyes with ONH had evidence of persistent vitreopapillary adhesion. Three patterns of adhesion were identified: central, peripheral, and combined. In all, 52 hemorrhages were identified, of which the majority were flame-shaped, although other types were seen including dot and blot hemorrhages. One subretinal hemorrhage occurred in a patient with a central vitreopapillary adhesion. CONCLUSIONS: ONH hemorrhages associated with PVD are commonly found with persistent vitreopapillary adhesions as evidenced on OCT. The clinical features of ONH together with OCT imaging may help to distinguish ONH associated with PVD from other hemorrhages found on or adjacent to the optic nerve.

Removal of subfoveal perfluorocarbon liquid: Report of 3 cases.

PURPOSE: To report removal of retained subfoveal perfluorocarbon liquid (PFCL) after vitrectomy for retinal detachment. METHODS: Three patients underwent 3-port 23-gauge vitrectomy in an attempt to remove retained subfoveal PFCL bubble secondary to retinal detachment surgery. In two patients, removal was achieved via a 23-G needle whereas the third patient with multiple small subfoveal droplets, multiple punctures were required and in that case a small 40-G needle was used.We assessed best corrected visual acuity (BCVA), fundus imaging, and spectral domain optical coherence tomography (SD-OCT) of all patients before and after surgery. RESULTS: The subfoveal PFCL was successfully removed in all 3 eyes and although a functional improvement was documented, outer retinal atrophy and photoreceptor loss was observed in all our cases. CONCLUSIONS: SD-OCT allows early recognition of retained subfoveal PFCL. Surgical removal may lead to retinal morphologic restoration and functional improvement. While we achieved complete removal of PFCL with both 23-G and 40-G instrumentation, we believe the versatility and ease justifies the universal usage of 40-G retinotomy needles.

Epiretinal membrane: a treatable cause of visual disability in myotonic dystrophy type 1.

A wide range of ocular abnormalities have been documented to occur in patients with myotonic dystrophy type 1. The objectives of this study were to investigate the macular and optic nerve morphology using optical coherence tomography in patients with myotonic dystrophy type 1. A total of 30 myotonic dystrophy type 1 patients and 28 controls were recruited for participation. All participants underwent a thorough ophthalmologic examination, including spectral-domain optical coherence tomography of the macula and retinal nerve fibre layer. Images were reviewed by a retinal specialist ophthalmologist, masked to the diagnosis of the participants. Average macular thickness was significantly greater in the myotonic dystrophy group compared to controls [327.3 µm vs. 308.5 µm (p < 0.001)]. Macular thickness was significantly greater (p < 0.005) in five of the nine macular regions. The increase in macular thickness was due to the increased prevalence of epiretinal membranes in the myotonic dystrophy patient group (p = 0.0002): 48.2 % of myotonic dystrophy patient eyes had evidence of epiretinal membrane, compared with 12.5 % of control eyes. Examination revealed that 56.7 % of myotonic dystrophy patients had an epiretinal membrane in at least one eye. Visual acuity was reduced due to the presence of epiretinal membrane in six patient eyes and none of the control eyes. The presence of an epiretinal membrane was significantly correlated with increasing age in the patient group. We report an increased prevalence of epiretinal membrane in the myotonic dystrophy type 1 group. This may be a previously under-recognised form of visual impairment in this group. Epiretinal membranes can be treated surgically. We suggest that, in addition to a comprehensive clinical examination, optical coherence tomography examination is implemented as part of an ophthalmological assessment for the myotonic dystrophy type 1 patient with reduced visual acuity.

A Study Investigating a Possible Link Between Lens Protein in the Vitreous Fluid of Eyes After Uncomplicated Cataract Surgery and Chronic Cystoid Macular Edema.

PURPOSE: This study aimed to determine if the lens protein aquaporin 0 (AQP0) is present in the vitreous of pseudophakic eyes of patients presenting with chronic cystoid macular edema (CME). DESIGN: A case-control study was conducted. METHODS: Ten patients undergoing therapeutic vitrectomy for chronic CME after uncomplicated cataract surgery were enrolled in this study. Fourteen patients with pseudophakia undergoing vitrectomy surgery for indications other than CME acted as the comparison group.The vitreous fluid from the 2 groups was analyzed for the presence of the lens protein AQP0 and type II collagen (used as a positive control). RESULTS: Type II collagen was detected in all the vitreous samples, whereas AQP0 was documented in 50% of eyes with chronic CME but was not found in the vitreous of any eyes without a documented history of CME. CONCLUSIONS: Aquaporin 0 is found in some eyes with chronic CME after uncomplicated cataract surgery, suggesting contamination of the vitreous by lens protein may have a role in the pathogenesis of this disorder.

Amino acid immunoreactivity in normal human retina and after brachytherapy.

We localised amino acids in the mid-peripheral aged human retina and a retina that had undergone radiation treatment 10 years earlier. The distribution pattern of glutamate, γ-amino butyric acid (GABA), glycine, glutamine and taurine, reflected patterns established in the primate retina. The retina that had undergone radiation exposure displayed both anatomical and neurochemical remodelling. The proximal retina comprised around 40 to 45 per cent of the total retina and neuronal kinesis and aberrant neuronal projections were also present. Amino acid neurochemistry was strikingly different with Müller cells displaying GABA loading, glycinergic neurons displaced and displaying a very high level of glycine labelling. We conclude that radiation exposure triggered these changes in the human retina and likely reflects general remodelling of structure and function following ischaemic damage to endothelial cells.

Creatine transporter immunolocalization in aged human and detached retinas.

PURPOSE: To identify the distribution of creatine transporter (CRT) in the aged human retina and how this expression pattern is modified after retinal detachment. METHODS: An affinity-purified antibody raised against the CRT was used in the immunohistochemical investigation. The anti-CRT antibody was colocalized with neuronal markers (calbindin, parvalbumin, Islet-1, calretinin, GAD67, Go-alpha), glia markers (glutamine synthetase, glial fibrillary acid protein), and a blood vessel basal membrane marker (laminin). Confocal microscopy was used to visualize the labeling patterns in retinal sections. The level of CRT expression was determined in the retina using a semiquantification method. RESULTS: Immunohistochemical assessment of CRT expression in the normal aged retina revealed strong labeling in photoreceptor synaptic terminals and in inner and outer segments. Labeling was also observed on subpopulations of amacrine cells and ganglion cells as well as in the outer and inner plexiform layers. CRT labeling was observed in blood vessels, although was absent in glial cells. In retinal detachment, the CRT labeling pattern was maintained, although there was an apparent decrease in labeling in inner retina and an increase in CRT expression in photoreceptors. CONCLUSIONS: CRT is expressed in areas of intense metabolic activity, such as photoreceptors, selected cells in the inner retina, and sites of creatine transport into the retina (inner retinal blood vessels and retinal pigment epithelium). The absence of CRT to Müller cells harmonizes with the concept that glial cells are a biosynthetic source of creatine but not a source of creatine to other retinal neurons. The increased immunolabeling of CRT localized to the outer retina in retinal detachment suggests a regional metabolic remodeling occurring in photoreceptor cells.

Functional and anatomical remodeling in human retinal detachment.

Rhegmatogenous retinal detachment is by far the most common indication for retinal surgery and a major cause of severe vision loss. Increased levels of glutamate found in the vitreous of human patients and persistent remodeling, even after reattachment, suggest substantial neurochemical, functional and anatomical changes have occurred in the detached retina. Therefore, this study was designed to characterize the morphological changes and glutamate receptor functionality in human rhegmatogenous retinal detachment. A cation channel permeating probe, agmatine (1-amino-4-guanidobutane; AGB), was employed to track endogenous and kainate (KA) driven channel functionality combined with immunocytochemical characterization of cellular remodeling. In the detached retina increased AGB permeability was identified in the outer retina while there was a decrease in the inner retina in basal conditions. KA receptors exhibited increased AGB permeability in ON bipolar cells and decreased permeability in calbindin labeled inner retinal cells. All retinal detachment samples demonstrated ectopic synaptic protein expression, photoreceptor processes extending toward the inner retina, and other remodeling features of retinal degeneration. These anatomical changes have been demonstrated in animal studies and are novel features unreported in primary cases of human retinal detachment. We conclude that deafferentation in retinal detachment leads to alteration of the glutamatergic pathway.

Functional activation of glutamate ionotropic receptors in the human peripheral retina.

Glutamate is the major neurotransmitter in the vertebrate retina. Neurons involved in the glutamate pathway express α-amino-3-hydroxyl-5-methylisoxazole-4-propionic acid (AMPA), kainic acid (KA) and N-methyl-D-aspartate (NMDA) receptors. Functional characterization of these ionotropic glutamate receptors can be achieved by using a cation channel permeating probe named agmatine (1-amino-4-guanidobutane; AGB). Retinal mapping using this guanidinium analog has certain advantages including the immunocytochemical identification of a whole population of neurons expressing functional glutamate gated receptor channels. We have extended AGB studies into the functionality of ionotropic receptors in peripheral aged human retina to serve as a comparison for functional analysis of retinopathies such as retinal detachment. We probed the human retina with AGB after activation with AMPA, KA and NMDA. The results showed patterns of AGB entry into neurons consistent with those previously observed in subunit localization studies in adult mammalian retinae including primates. Application of 30 µM AMPA activated receptors in virtually all calretinin immunoreactive AII amacrine cells in the mid-peripheral human retina. About half of the AII amacrine cells showed AGB permeation after incubation with 50 µM KA. Some bipolar cells including DB3 OFF bipolar cells displayed functional KA receptors. Colocalization of AGB with parvalbumin labeled horizontal cells revealed functional KA and AMPA receptors with no responsiveness to NMDA activation. NMDA activation resulted in AGB labeling of ganglion cells and amacrine cells. The present study provides a description of functional ionotropic glutamate receptors in the aged mid-peripheral human retina.