Deformation of Aflibercept and Ranibizumab Syringes Causes Variation in Intravitreal Injection Volume and Risks Retinal Tear Formation.

Purpose: The intravitreal injection volume is known to vary with plunger alignment and the speed of injection. We investigated the role that syringe stopper deformation plays in allowing excess volumes to be injected into the eye and the potential for the vitreous humor to become incarcerated when excess force is released within the eye. Design: Experimental study. Methods: Aflibercept prefilled syringes (PFSs), ranibizumab PFSs, and 1-ml tuberculin (TB) syringes were subjected to increasing injection force to assess the extent to which each design allowed for excess volumes to be expelled after the stopper reached the bottom of the syringe barrel (i.e., after the 50-µl dose was expelled). Main Outcome Measures: Additional volume expelled with stopper deformation. Results: Syringe stoppers are capable of deformation into the dead space when additional force is applied. This allows for progressively greater medication doses to be administered. At an additional force of 3.92 N after the syringe stopper came in contact with the bottom of the syringe barrel, the aflibercept PFSs, ranibizumab PFSs, and 1-ml TB syringes dispensed an additional 17.2%, 11.4%, and 0.8% higher volume than the intended volume of 50 µl, respectively. Upon release of this force, a proportional volume was observed to be drawn back into the needle. Conclusions: The intravitreal injection volume varies with the force applied to fully depressed syringes because of syringe stopper deformation. We advise that performing forceful intravitreal injections be avoided to prevent excessive dosing of medication. We also caution that pressure applied to the plunger during intravitreal injections not be released while the needle is in the vitreous cavity to guard against vitreous incarceration, which could lead to retinal tear formation or detachment.

Outcomes of Rhegmatogenous Retinal Detachment Repair When Comparing Surgeon Continuity in a Team-Based Practice.

BACKGROUND AND OBJECTIVE: To facilitate timely surgery and efficient use of operating room time, our practice uses a team-based approach so patients may undergo primary rhegmatogenous retinal detachment (RRD) surgery with a different surgeon instead of the diagnosing surgeon. PATIENTS AND METHODS: This was a retrospective cohort study of 331 eyes that underwent RRD surgery. Patients were divided into two groups: RRD surgery performed by the diagnosing surgon, and RRD surgery performed by a different surgeon. RESULTS: Of 331 eyes, 200 eyes (60.4%) were repaired by the diagnosing surgeon and 131 eyes (39.6%) were repaired by a different surgeon. Primary anatomic success (PAS) rates at 3 months postoperatively were equivalent between the two groups (87.0% and 87.8% in the diagnosing surgeon and different surgeon groups, respectively [P = .83]). There was no significant difference in preoperative (P = .08) or final (P = .28) visual acuity between the groups. Time between diagnosis and RRD repair was shorter in the different surgeon group (median of 1.5 days [IQR: 1.0-3.6] in the surgeon group versus 2.2 days [IQR: 0.8-5.7] in the diagnosing surgeon group) (P = .03). Logistic regression analysis gave no evidence to suggest that PAS rates depended on day of week, time of day surgery was performed, group, or the interaction between those factors (P = .93). CONCLUSIONS: Visual and anatomic success in RRD repair are equivalent when surgery is performed by either the diagnosing surgeon or a surgical colleague because time to surgery is reduced. Neither time of day nor day of the week had any influence on the outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:560-566.].

MOSAICISM AS A PROPOSED MECHANISM FOR ASYMMETRIC RETINAL TESSELLATIONS.

BACKGROUND/PURPOSE: Report a case of markedly asymmetric retinal tessellations and propose mosaicism as a mechanism. METHODS AND RESULTS: A 59-year-old pseudophakic woman presented with uncorrected 20/20 vision and was found to have markedly different retinal tessellation appearances in both eyes. The axial lengths were 25.66 mm and 25.88 mm in the right and left eyes, respectively, and no significant asymmetrical choroidal thinning was seen on optical coherence tomography or optical coherence tomography angiography. Fluorescein angiogram showed significant hyperfluorescence, representing the underlying choroid, which correlated with the tessellation patterns in the left eye. She had no other ocular or systemic findings such as stripes or whorled skin. CONCLUSION: This is the first reported case of markedly asymmetric retinal tessellation patterns that are not due to asymmetric axial myopia or choroidal thinning. We propose that mosaicism is a possible mechanism causing this finding.

Autoimmune retinopathy: findings and limitations from optical coherence tomography angiography.

BACKGROUND AND OBJECTIVE: To report novel findings and limitations from optical coherence tomography angiography (OCTA) in the evaluation of autoimmune retinopathy (AIR). STUDY DESIGN: We retrospectively reviewed features of five patients diagnosed with AIR and five controls. OCTA scans were obtained and manually segmented to provide accurate measurements of foveal avascular zone (FAZ), vessel density, and retinal thickness at different levels. RESULTS: The total retina and superficial vessel density throughout the whole scan were similar between AIR and controls (p = 0.14 and p = 0.11), whereas deep vessel density was decreased in AIR compared controls (p = 0.02). Decreased vessel density was most pronounced in the parafoveal and perifoveal areas (p = 0.01 and p = 0.01). AIR patients also had reduction of total retinal thickness in the perifoveal zone (p = 0.03), corresponding to outer retinal thinning (p = 0.001). CONCLUSION: This small series shows that AIR patients have reduced deep vessel density, particularly in the parafoveal and perifoveal regions and a decrease in macular thickness. These findings show correlation with the classic "flying saucer" sign seen on OCT.

Pseudotumor cerebri syndrome causing a terson like syndrome.

PURPOSE: Terson syndrome presents with retinal and vitreous hemorrhages in patients with a subarachnoid hemorrhage or after acutely elevated intracranial pressure. The source of this hemorrhage has been debated and may originate either from direct extension of intracranial hemorrhage or more likely from the peripapillary retinal vessels. OBSERVATIONS: A 39-year-old woman presenting with nausea, vomiting, floaters and papilledema with normal neuroimaging was diagnosed ultimately with pseudotumor cerebri syndrome. She had a right vitreous hemorrhage and bilateral subretinal and intraretinal hemorrhages which were consistent with Terson like syndrome. Her symptoms resolved with acetazolamide over one month and the retinal and vitreous hemorrhages significantly improved over two months. CONCLUSIONS AND IMPORTANCE: This case with initial presentation of pseudotumor cerebri syndrome causing a Terson like syndrome may help elucidate the mechanism behind the etiology of these hemorrhages from leaking peripapillary vessels.

Eyelid retraction discomfort with cotton-tipped applicator, unimanual and speculum intravitreal injection techniques: Eyelid retraction technique randomized comparison trial (Eyelid RETRACT).

Purpose: The aim of this study was to test the discomfort experienced during intravitreal injections with eyelid retraction between an eyelid speculum, cotton-tipped applicator (CTA), and unimanual eyelid retraction techniques. Methods: In total, 99 patients receiving intravitreal bevacizumab were enrolled into this prospective study. Participants were randomized to one of the three methods, given subconjunctival 2% lidocaine and then injected in the superior temporal quadrant. Immediately after the procedure, each patient was given a visual analog scale (VAS) to rate their discomfort. Results: The mean pain scores for eyelid retraction with unimanual, CTA, and speculum groups were 0.788 (standard deviation [SD] 0.70, 95% confidence interval [CI] 0.448-1.128), 0.945 (SD 1.28, 95% CI 0.600-1.291), and 1.561 (SD 1.28, 95% CI 1.210-1.912), respectively. A one-way analysis of variance (ANOVA) test revealed a significant difference between the groups (P = 0.006). Post hoc analysis also revealed a difference in mean pain scores between the speculum and both the CTA and the unimanual methods. Conclusion: Our study shows that the unimanual and CTA methods for eyelid retraction are significantly less painful for patients compared to the speculum method. Patient comfort is of the utmost importance as intravitreal injections are performed millions of times a year with most patients requiring multiple injections.

Retinal Toxicity in a Patient on Pentosan Polysulfate Sodium.

Pentosan Polysulfate Sodium (PPS) is commonly used in the treatment of interstitial cystitis/bladder pain syndrome. Recently there have been reported cases of retinal toxicity associated with long-term PPS use. We present a case of a 42-year-old female taking PPS for the last 10 years who was found to have signs of retinal toxicity, but was completely asymptomatic. PPS was discontinued after these retinal findings were discovered.

Post-cataract surgery hyperreflective lesions within corneal incisions suspected to be silicone oil from disposable blades.

PURPOSE: To investigate hyperreflective lesions within the paracentesis and main wound incisions after cataract surgery performed with disposable blades. SETTING: Kings County Hospital, Brooklyn, New York, USA. DESIGN: Retrospective study. METHODS: This is a retrospective study of 14 patients after cataract surgery with disposable corneal incision blades for the paracentesis and main wound. Anterior segment photographs were reviewed from preoperative and postoperative evaluations. Anterior segment optical coherence tomography (OCT) of the paracentesis and main wounds was included. RESULTS: Fourteen eyes from 14 patients were included in this study. Eleven patients had anterior segment photographs and 2 patients had anterior segment OCT showing hyperreflective lesions within the main wound and paracentesis. One patient had intraoperative photographs showing these hyperreflective lesions appearing immediately after wound construction. No patients had complications related to these findings. Cleaned disposable keratome blades had silicone oil applied to them, and then, main wounds were constructed on pig eyes that showed similar hyperreflective corneal lesions as the 11 patients presented. CONCLUSIONS: To the authors' knowledge, this was the first study to show hyperreflective lesions within corneal incisions after anterior segment surgery. The hypothesis was that trace amounts of silicone oil on the disposable blades was the etiology; this did not seem to have any negative consequences for the patients.

Intravenous Drug Use-Associated Scopulariopsis Endophthalmitis Treated with Systemic and Intravitreal Voriconazole.

PURPOSE: To report a case of intravenous (i.v.) heroin use-associated endogenous endophthalmitis caused by Scopulariopsis fungal species, and its response to intravitreal and oral voriconazole treatments. PATIENT: A 21-year-old-female with chronic hepatitis C and i.v. heroin use presented with subacute decreased vision to hand motion in her left eye. RESULTS: Endogenous fungal endophthalmitis caused by Scopulariopsis was confirmed by vitreous biopsy. The patient improved clinically after vitrectomy with intravitreal voriconazole and 3 weeks of oral voriconazole. The final vision was 20/60 after 6 months. CONCLUSIONS: Scopulariopsis is a rare cause of endophthalmitis, and is often difficult to treat due to its resistance to commonly used antifungals. This case is the first report of Scopulariopsis endophthalmitis secondary to i.v. drug use.

Pediatric Bilateral Blue Laser Pointer-Induced Maculopathy.

BACKGROUND: We report the first case of pediatric bilateral blue laser pointer maculopathy with complete resolution of visual symptoms. CASE: A 12-year-old boy presented with bilateral decreased visual acuity and central scotomata after blue laser pointer exposure. He was treated with a Medrol Dosepak and topical nonsteroidal anti-inflammatory drug (NSAID), with gradual visual acuity improved from 20/40 OU to 20/20 OU over 22 weeks, but with persistent evidence of outer retinal layer disruption from the external limiting membrane to the interdigitation zone. CONCLUSION: Oral steroids and topical NSAIDs may be effective in improving visual outcomes in laser pointer maculopathy in the pediatric population.

Treatment outcomes and spectral-domain optical coherence tomography findings of eyes with symptomatic vitreomacular adhesion treated with intravitreal ocriplasmin.

PURPOSE: To determine treatment outcomes of intravitreal ocriplasmin in symptomatic vitreomacular adhesion. DESIGN: Retrospective interventional case series. METHODS: setting: Private practice. study population: Thirty-five eyes (35 subjects) with symptomatic vitreomacular adhesion. intervention/observation: Intravitreal ocriplasmin injection from February to November 2013. main outcome measure: Vitreomacular adhesion resolution rate. Secondary endpoints included postinjection visual acuity and rates of outer retinal attenuation and full-thickness macular hole (MH) closure. RESULTS: The 35 subjects included were of mean age 69 years, 66% female, and 71% phakic. Eleven subjects (31%) had macular comorbidities. Average adhesion diameter was 571 µm, with mean 7.9 months duration of symptoms. Nine subjects (26%) had epiretinal membrane and 6 (17%) had MH (mean diameter 186 µm). Mean preinjection logarithm of the minimal angle of resolution visual acuity was 0.46, and improved to 0.33 at final follow-up. Fifteen eyes (43%) achieved adhesion release at mean 10 days post injection. One of 6 MH (17%) closed. Transient outer retinal attenuation occurred in 10 of 35 cases (29%), with 8 of 10 (80%) achieving adhesion release. One subject (3%) developed a retinal detachment. Adhesion resolution was more likely in patients with younger age (P = .04), absence of comorbidities (P = .02), small adhesion diameter (P = .005), short adhesion duration (P = .03), and transient outer retinal attenuation (P = .008). CONCLUSIONS: Intravitreal ocriplasmin efficacy in the private practice setting, while including patients with macular comorbidities, is similar to that of previous studies. Transient toxicity to the outer retina occurs frequently-typically with adhesion resolution-necessitating careful postinjection spectral-domain optical coherence tomography monitoring.