TANGENTIAL RETINAL DISPLACEMENT INCREASES AFTER MACULAR PUCKER SURGERY: An Apparent Nonsense.

PURPOSE: To measure the tangential retinal displacement and vision before and after macular pucker surgery and study if pars plana vitrectomy with epiretinal membrane peeling allows the reconstitution of previous anatomy or else it results in a different configuration. METHODS: Retrospective series of patients undergoing pars plana vitrectomy for epiretinal membrane, with >6-month follow-up before and after surgery, complete with best-corrected visual acuity, optical coherence tomography, M-Charts, and infrared retinography. Tangential retinal displacement between earliest visit (T E ), time of surgery (T 0 ), and latest available visit (T L ) of the examined retina, concentric circles at 0.5, 1.5, and 4.5 mm radii, and the central horizontal and vertical meridians were measured. Tangential displacement was calculated as the optical flow of consecutive infrared photographs. RESULTS: The study comprised 32 patients: 15 men and 17 women. Average preoperative and postoperative follow-up were 23.4 ± 27.9 months and 19.2 ± 11.8 months, respectively. Best-corrected visual acuity reduced before surgery (0.69 ± 0.16 Snellen to 0.46 ± 0.17; P < 0.001) and increased after (0.866 ± 0.16 Snellen; P < 0.001). Horizontal and vertical metamorphopsia increased between before surgery but only horizontal metamorphopsia significantly reduced after. Average tangential displacement before surgery was 35.6 ± 29.9 µ m versus 56.6 ± 41.3 µ m after ( P = 0.023). Preoperative and postoperative displacement within the fovea was less than over the entire area ( P < 0.001). CONCLUSION: Retinal tangential displacement between diagnosis and surgery (T E - T 0 ) is less than the displacement occurring after surgery (T 0 - T L ). Postoperative displacement does not represent the restoration of the anatomy existing before the disease ensued but rather the resulting equilibrium of newly deployed forces.

RETINAL TECTONICS AFTER MACULAR PUCKER SURGERY: Thickness Changes and En Face Displacement Recovery.

PURPOSE: To study visual function, retinal layer thickness changes, and tangential displacement after pars plana vitrectomy for epiretinal membrane. METHODS: Retrospective series of patients undergoing pars plana vitrectomy for epiretinal membrane, with 6-month follow-up including best-corrected visual acuity, optical coherence tomography, M-charts, epiretinal membrane grading, and infrared fundus photograph at time 0 (T0, preop) at months 1 (T1), 3 (T3), and 6 (T6) postop (±1 week). Retinal layer thickness and tangential ( en face ) retinal displacement between successive times for the entire retinal surface and the central horizontal and vertical meridian were also measured. En face displacement was calculated as optical flow of consecutive images. RESULTS: Average best-corrected visual acuity improved from 0.28 ± 0.08 logarithm of Minimum Angle of Resolution at T0 to 0.16 ± 0.25 at T6 ( P = 0.05), best-corrected visual acuity improvement correlated with best corrected visual acuity (BCVA) at T0 ( P < 0.001). Vertical metamorphopsia decreased from 1.33° ± 0.70° at T0 to 0.82° ± 0.69° at T6 ( P < 0.05). Foveal thickness reduced from 453 ± 53 µ m at T0 to 359 ± 31 µ m at T6 ( P < 0.05) and reduction correlated with best-corrected visual acuity improvement ( P < 0.05). Foveal layers decreased ( P < 0.05) in all cases. The mean en face deformation was 155.82 ± 50.17 µ m and mostly occurred in the first month: T0-T1 displacement was 83.59 ± 30.28 µ m, T1-T3 was 36.28 ± 14.45 µ m, while T3-T6 was 39.11 ± 22.79 µ m ( P < 0.001) on average. Perifoveal and parafoveal deformation correlated with optical coherence tomography foveal thickness reduction at all time intervals (1, 3, and 6 months: P < 0.01). CONCLUSION: Epiretinal membrane peeling affects all retinal layer thickness and results in new force balance across the entire retina and tangential displacement. Both en face and in-depth changes correlate with visual function.

THREE-DIMENSIONAL RETINAL DISPLACEMENT BEFORE AND AFTER MACULAR PUCKER SURGERY.

PURPOSE: To measure the coronal and sagittal retinal displacement before and after surgery for epiretinal membranes in InfraRed horizontal foveal sections and optical coherence tomography scans and describe displacement tridimensionality, vision loss, and metamorphopsia. METHODS: Retrospective series with greater than 6-month average follow-up before and after surgery. The record included best-corrected visual acuity, optical coherence tomography, M-charts, and InfraRed retinography. Overall, pre- and postoperative coronal and sagittal retinal displacement across the entire field, concentric circles at 0.5-, 1.5-, and 4.5-mm radii, and the central horizontal and vertical meridian were calculated as the optical flow of consecutive images. RESULTS: This study comprised 10 patients (4 men, 6 women), with 22.7 ± 25.2 months follow-up before surgery and 16.2 ± 7.3 months after. Best-corrected visual acuity reduced before surgery (0.15 ± 0.67 logarithm of minimum angle of resolution to 0.38 ± 0.85 logarithm of minimum angle of resolution; P < 0.05) and increased afterward (0.086 ± 0.61 logarithm of minimum angle of resolution; P = 0.003). Preoperative coronal displacement was 30.1 ± 29.1 µm versus 67.0 ± 23.4 µm after (P = 0.002). Sagittal retinal displacement was 140.9 ± 84.6 µm before surgery, 339.7 ± 172.5 µm after (P = 0.017), and 357.6 ± 320.8 µm across the entire follow-up. Preoperative best-corrected visual acuity decreases correlated with the foveal coronal displacement. Vertical metamorphopsia correlated with the average coronal displacement within a 4.5-mm radius. Pre- and postoperative sagittal displacement correlated with horizontal metamorphopsia (P = 0.006 and P = 0.026). Postoperative sagittal displacement correlated with postoperative best-corrected visual acuity (P = 0.026) and foveal thickness (P = 0.009). CONCLUSION: This study confirms that postoperative displacement is greater than preoperative and that sagittal displacement is greater than coronal and correlates with best-corrected visual acuity and metamorphopsia changes.

TLR2 and TLR4 Are Expressed in Epiretinal Membranes: Possible Links with Vitreous Levels of Complement Fragments and DAMP-Related Proteins.

Previous studies reported the expression of toll-like receptors (TLRs), merely TLR2 and TLR4, and complement fragments (C3a, C5b9) in vitreoretinal disorders. Other than pathogens, TLRs can recognize endogenous products of tissue remodeling as damage-associated molecular pattern (DAMPs). The aim of this study was to confirm the expression of TLR2 and TLR4 in the fibrocellular membranes and vitreal fluids (soluble TLRs) of patients suffering of epiretinal membranes (ERMs) and assess their association with disease severity, complement fragments and inflammatory profiles. Twenty (n = 20) ERMs and twelve (n = 12) vitreous samples were collected at the time of the vitrectomy. Different severity-staged ERMs were processed for: immunolocalization (IF), transcriptomic (RT-PCR) and proteomics (ELISA, IP/WB, Protein Chip Array) analysis. The investigation of targets included TLR2, TLR4, C3a, C5b9, a few selected inflammatory biomarkers (Eotaxin-2, Rantes, Vascular Endothelial Growth Factor (VEGFA), Vascular Endothelial Growth Factor receptor (VEGFR2), Interferon-γ (IFNγ), Interleukin (IL1ß, IL12p40/p70)) and a restricted panel of matrix enzymes (Matrix metalloproteinases (MMPs)/Tissue Inhibitor of Metallo-Proteinases (TIMPs)). A reduced cellularity was observed as function of ERM severity. TLR2, TLR4 and myD88 transcripts/proteins were detected in membranes and decreased upon disease severity. The levels of soluble TLR2 and TLR4, as well as C3a, C5b9, Eotaxin-2, Rantes, VEGFA, VEGFR2, IFNγ, IL1ß, IL12p40/p70, MMP7 and TIMP2 levels were changed in vitreal samples. Significant correlations were observed between TLRs and complement fragments and between TLRs and some inflammatory mediators. Our findings pointed at TLR2 and TLR4 over-expression at early stages of ERM formation, suggesting the participation of the local immune response in the severity of disease. These activations at the early-stage of ERM formation suggest a potential persistence of innate immune response in the early phases of fibrocellular membrane formation.

THE PROPHYLAXIS OF FELLOW-EYE RETINAL DETACHMENT IN STICKLER SYNDROME: A RETROSPECTIVE SERIES.

PURPOSE: To evaluate retrospectively if scleral buckling combined or not to cryopexy reduces fellow-eye retinal detachment (RD) in Stickler syndrome patients who lost their first eye due to RD. METHODS: Retrospective review of 52 Stickler syndrome patients who received a 6-mm wide, 360° encircling scleral buckling. Thirty-nine (75%; Cryo + Group) also received cryo treatment, whereas the reminder 13/52 (25% Cryo - Group) did not. RESULTS: Average follow-up was 15.6 ± 2.41 years. Five patients (5/52; 9.6%) developed a retinal detachment 2.6 ± 0.55 years after prophylactic treatment, respectively, 0/39 patients in the Cryo + Group and 5/13 in the Cryo - Group (P < 0.001). All five RD eyes were successfully reattached through revised episcleral surgery and adjunctive cryo treatment. Postop refraction changed an average -1.9 ± 0.74 diopters and best corrected visual acuity at the end of follow-up was 20/25 (0.1 ± 0.07 logarithm of the minimum angle of resolution), not significantly different from the rest of sample population who did not develop RD in their fellow eye. CONCLUSION: Cryopexy significantly reduced the risk of RD in Stickler syndrome patients undergoing scleral buckling. If RD ensues, the presence of scleral buckling may ease surgical repair and improve final outcome.

Branch retinal artery occlusion caught in the act by an optical coherence tomography angiography image: case report.

BACKGROUND: Retinal artery occlusion is a vascular entity caused by the temporary blockage of retinal arterioles. CASE PRESENTATION: We present the case of a 57-year-old woman a partial visual loss in the right eye due to a cilioretinal artery occlusion. Ophthalmoscopy revealed a focal area of retinal whitening superior to the optic nerve in the right eye, while the left eye was within the limit. Retinal imaging, in particular optical coherence tomography angiography (OCTA), showed a capillary drop out of the superficial capillary plexus and the corresponding b-scan showed a round hyporeflective grey dot (optical empty) corresponding to the dark grey spot on the enface view at the level of the retinal whitening area. CONCLUSION: Although the images did not allow the differentiation between vasospasm or retinal emboli, the OCTA imaging might help to identify and to caught in the act the specific region causing the retinal impairment. Also, the possible formation of small microcavity should be considered in case with branch retinal artery occlusion. The use of this new imaging technology might help to evaluate the efficacy of the therapy in vivo.

Phacoemulsification and nucleic acid-enriched aerosol: considerations from an eye model of cataract simulation.

PURPOSE: The purpose of this study is to investigate whether phacoemulsification can generate aerosolized single-stranded RNA (ssRNA) and retain sequence integrity using an artificial eye model for experimental cataract surgery. METHODS: A simulation of cataract surgery was performed using an anterior chamber eye model filled with an ssRNA probe at different scalar dilutions (kanamycin positive control ssRNA). A plastic conical cage was built over the artificial eye surface of the mock-up. A total of 24 tests (twice reproduced) were performed, and five nitrocellulose strips were placed 15 cm from the artificial surface of the mock-up and used to collect aerosol particles, from each experiment. Phaco-activity was mimicked using a phacoemulsification equipped with a 2.75-mm tip, and strips were removed at the end of the procedure. RNA extraction, reverse transcription, and agarose gel electrophoresis were performed and compared. RESULTS: Strips collected aerosol droplets enriched with ssRNA, mainly at the higher concentrations tested, compared to related untouched standard solutions. Complementary DNA (cDNA) synthesis confirmed the presence of intact ssRNA fragments. As observed from densitometric analysis of resolved RNA in extracted samples and cDNA bands after retro-transcription, lower concentrations of ssRNA were also detected. CONCLUSIONS: As the main output of the study, the phaco-generated aerosol can deliver an intact ssRNA sequence. Since the aerosol can potentially reach the operator's face, any biological agent (virus/bacteria) potentially inside the anterior chamber of a patient undergoing cataract surgery, eventually escaping from biomolecular checks, can be potentially infective for operators. The data reported herein suggest that collective versus individual protective countermeasures should always be encouraged in ocular surgery and should not be restricted to coronavirus disease emergencies.

A novel intraocular lens designed for sutureless scleral fixation: surgical series.

PURPOSE: To report a retrospective series of patients implanted with a novel hydrophilic acrylic single-piece intraocular lens (IOL) designed for sutureless scleral fixation (FIL-SSF Carlevale lens, Soleko, Italy) injectable through a 2.2-mm incision. METHODS: Seventy-eight patients with minimum 6-month follow-up were divided into 6 groups: dropped nucleus, luxated IOL, trauma, aphakia, IOL exchange, and Marfan's syndrome. Surgery included peritomy and scleral flap creation at 3 and 9 o'clock position. The IOL was then injected and grasped with 25G forceps through a hole created 2 mm posterior to the limbus underneath the sculped scleral flap. RESULTS: The study included 78 patients (mean age 71.9 ± 12.6 years) and average follow-up 10.2 ± 4.2 months. Average surgery duration was 69.4 ± 26.1 min and vision significantly improved from 0.86 ± 0.56 logMAR to 0.38 ± 0.42 logMAR at 6 months post-operative (p < 0.001). Intraoperative complications included corneal edema, retinal tears, and vitreous bleeding each in 2/78 patients (2.5%); 1/78 (1.3%) localized retinal detachment and 1/78 (1.3%) rupture of one T-shaped IOL harpoon. Post-operative complications included 4/78 (5.1%) cystoid macular edemas, 2/78 retinal tears, 2/78 retinal detachments, 2/78 developed ocular hypertension, and 1/78 corneal decompensation requiring DSAEK. CONCLUSION: The Carlevale lens is designed for sutureless intrascleral fixation and can be successfully used in a variety of indications including difficult trauma cases with good rehabilitation. An implant requires experience and delicate manipulation.

Osteopontin in vitreous and idiopathic epiretinal membranes.

PURPOSE: To investigate osteopontin (OPN) expression in vitreous and in related idiopathic epiretinal membranes (ERMs), with respect to VEGF-A, IL8, MIP1α, IL6, and IL33, and correlate OPN expression with disease staging. METHODS: Fifteen (15) vitreous and allied ERMs were collected at the time of therapeutic vitreoretinal surgery. Additional 5 vitreous and 10 ERMs (historical collection) were used. Biochemical and molecular analysis of OPN was performed in clear vitreous, vitreal pelleted cells, and ERMs. Double-immunofluorescence analysis (OPN - GFAP and OPN - αSMA) was performed on paraffin and whole-mounted ERMs. Vitreal OPN levels were correlated to those of VEGF-A, IL8, MIP1α, IL6, and IL33. RESULTS: High OPN levels were observed in vitreal samples, and OPN transcripts were amplified in vitreal cells and related ERMs. OPN immunoreactivity was found in ERMs, mainly in GFAP-bearing (Muller cells) and to a less extend in αSMA-expressing (myofibroblasts) cells. OPN levels were highest at early stages of ERM formation and positively correlated to VEGF-A and MIP1α. CONCLUSIONS: High OPN levels in vitreous, OPN transcripts in vitreal cells/ERMs, OPN immunoreactivity in activated Müller cells and contractile myofibroblasts, as well as the correlation with VEGF-A and MIP1α fulfill the potential involvement of OPN in both inflammation and tissue remodeling that takes part in vitreoretinal interface disorders. The highest OPN levels at early stages of ERM formation would prospect OPN as a potential biomarker for disease severity.

Macular hole closure patterns: an updated classification.

BACKGROUND: The classification of macular hole closure patterns (MHCPs) currently relies on time domain OCT allowing only "open" and "closed" statuses or is based on inner foveal contour shape. Both classification types give no information on retinal layer reconstitution. Novel sophisticated surgical techniques lead to previously unknown MHCPs, outdating existing classifications and urging new ones. The purpose of the present study is to introduce a new classification allowing proper description of all MHCPs resulting from newer surgeries and based on the restoration of retinal layers. METHODS: Retrospective analysis of patients undergoing MH surgery with five different surgical techniques was performed. MHCPs were classified according to spectral domain optical coherence tomography (SD-OCT). Type 0: open MH (0A: flat margin, 0B: elevated, 0C: oedematous); type 1: closed MHs (1A: reconstitution all retinal layers; 1B interruption of the external layers; 1C interruption of internal layers); type 2: MH closed with autologous or heterologous filling tissue interrupting the normal foveal layered anatomy (2A: filling tissue through all layers; 2B reconstitution of normal inner retinal layers; 2C reconstitution of normal outer retinal layers; 2D H-shaped bridging of filling tissue). RESULTS: Closure rate was 95.2% (241/253). Surgical technique and vision correlated to closure pattern (p < 0.001). Type 1 MHCPs had the best post-operative visual acuity (VA) compared with type 2 and type 0 (p < 0.001). MHCPs 1A and 1C performed better than all others. MHCP at months 1 and 3 changed in 42/254 (16.5%) and remained stable in 212/254 (83.5%). Improvement in vision was higher in eyes with shifting closure pattern (0.57 ± 0.33 vs 0.51 ± 0.48 logMAR; p 0.021). CONCLUSION: MHCP classification based on retinal layer restoration properly comprises post-operative anatomic morphologies. MHCPs correlate the surgical technique and post-operative visual outcomes.

ALTERATIONS OF MACULAR BLOOD FLOW IN SUPERFICIAL AND DEEP CAPILLARY PLEXUSES IN THE FELLOW AND AFFECTED EYES OF PATIENTS WITH UNILATERAL IDIOPATHIC EPIRETINAL MEMBRANE.

PURPOSE: Previous research suggests that proliferation of the idiopathic epiretinal membrane (IERM) is related to microbreaks in the inner limiting membrane, which are caused by posterior vitreous detachment. In this study, we used optical coherence tomography angiography to determine whether a vascular defect in the inner retina is present before the mechanical damage caused by posterior vitreous detachment. METHODS: For patients with unilateral IERM (N = 23), optical coherence tomography angiography with blood flow measurement was performed in both eyes at the superficial capillary plexuses (SCP) and deep capillary plexuses (DCP) with 6 mm × 6-mm scans and ETDRS grids centered on the fixation point. These values were then compared with 45 healthy control eyes (CEs). RESULTS: The optical coherence tomography angiography data showed that blood flow was lower in the fellow eyes of IERM patients than in CEs when the whole enface macula (SCP: P = 0.031, DCP: P = 0.004) and extramacular area (SCP: P = 0.048, DCP: P = 0.026) were compared between groups. The blood flow was also lower in the affected eyes compared with CEs in both whole en face macula (SCP: P < 0.001, DCP: P < 0.001) and extramacular areas (SCP: P = 0.011, DCP: P < 0.001). CONCLUSION: Data from this study revealed that blood flow is significantly reduced in the fellow eyes of patients with unilateral IERM when compared with CEs. Overall, the data suggest that a vascular retinal defect could produce changes in the inner retina, preceding and influencing the formation of microbreaks occurring at the time of posterior vitreous detachment in the inner limiting membrane. Understanding the upstream mechanism of inner limiting membrane microbreaks may provide a therapeutic target aimed to ultimately prevent Mu[Combining Diaeresis]ller cells, astrocyte, and fibroblast migration, which cause IERM proliferation.

Folding the internal limiting membrane flap under perfluorocarbon liquid in large, chronic and myopic macular holes.

PURPOSE: The purpose of the present paper is to describe a surgical technique aimed at creating multiple layers of Internal Limiting Membrane (ILM) using Perfluorocarbon Liquid (PFCL) in order to favour the closure of large, chronic and myopic Macular Holes (MH). METHODS: Thirty patients belonging to 3 subgroups: large (> 500 µm), chronic (> 12 months) and myopic (> - 9 diopters), MHs, underwent surgery and completed 6 months follow-up. The ILM was engaged and peeled 360° around the MH, hinged to the rim and folded over the hole. A PFCL bubble spanning the vascular arcades was then injected and the ILM is grasped repeatedly to fold the distal edge towards the MH centre, creating multiple ILM layers over the MH. RESULTS: MH closed in 26/30 cases (86.6%) with no significant difference among subgroups. Vision improved 2.57 ± 1.56 Snellen lines from LogMAR 1.50 ± 1.19 to 1.19 ± 1.32 (p < 0.01). Ellipsoid Zone (EZ) interruption width reduced from 1129 ± 439 µm to 258 ± 507 µm (p < 0.001) and correlated to pattern of MH closure, post-BCVA and line improvement (p < 0.001 in all cases). DISCUSSION: The use PFCL allows multiple ILM layers and resulted in a high closure rate. Pattern of MH closure differs from those previously described leaving a plug of ILM tissue that interrupts retinal architecture often only in the inner layers. PFCL gravity and hydrophobicity displace aqueous while the intensely polar opposite faces of the ILM attract each other. The folded ILM plugs MH and bridges the gap and may help glial cell proliferation and migration.

CORRELATION BETWEEN OUTER RETINAL THICKENING AND RETINAL FUNCTION IMPAIRMENT IN PATIENTS WITH IDIOPATHIC EPIRETINAL MEMBRANES.

PURPOSE: To examine the relationship between retinal layer thickness, retinal sensitivity, and visual function in patients with idiopathic epiretinal membrane using spectral domain optical coherence tomography automated segmentation algorithm. METHODS: Twenty-four eyes with epiretinal membrane and 12 control eyes were enrolled. Ophthalmic evaluations included best-corrected visual acuity, mean retinal sensitivity (MRS) of radial 10° and 4° areas tested with microperimetry, and measurements of 4 retinal layer thicknesses by means spectral domain optical coherence tomography. Relations between retinal layer thickness, MRS, and best-corrected visual acuity values were explored. RESULTS: Compared with controls, MRS (P < 0.001) and best-corrected visual acuity (P < 0.001) values were reduced. In the epiretinal membrane group, MRS of the central 4° values was associated with thickening of the outer nuclear layer (P < 0.05). Furthermore, a correlation was found between the inner nuclear layer thickening and the MRS of the central 4° limited to the inferior quadrant (P < 0.05). The decreased best-corrected visual acuity values were correlated with the thickening of three of four quadrant of the inner nuclear layer, inferior and temporal quadrants of the outer plexiform layer, and finally outer nuclear layer nasal quadrant. CONCLUSION: We found a meaningful correlation between MRS impairment of the central 4° and outer nuclear layer thickness and showed which intraretinal layers mainly contributes to visual acuity loss.

Does the Bursa Pre-Macularis protect the fovea from shear stress? A possible mechanical role.

Purpose of present study is to evaluate whether the Pre-Macular Bursa (PMB) modifies Wall Shear Stress (WSS) at the retinal surface during saccadic movements. We created a mathematical model consisting of 25,000 grid cells and simulated a horizontal saccade spanning 50° in 0.17s, both in absence and in presence of the PMB. Wall Shear Stress SS was computed throughout the retinal surface and the posterior pole was divided into 3 Zones comprising 400 nodes each: Zone 1 (radius 3.5 mm; 0°-17°) corresponding to the PMB area; Zone 2 (concentric annular area 5 mm in radius; 22°) and Zone 3 (concentric annular area 5.5 mm; 28°). The PMB reduced WSS significantly at the macula and increased it in the immediate surroundings. Average WSS in Zone 1 was 1.53 ±â€¯1.01 (max 4.23 Pa) with PMB Vs 6.94 ±â€¯9.23 (max 35.83 Pa) without. Zone 2 WSS was 9.39 ±â€¯10.33 (max 48.36 Pa) with PMB Vs 6.95 ±â€¯9.40 (max 38.60 Pa) without Zone 3 WSS was 8.41 ±â€¯10.03 (max 43.16 Pa) with PMB Vs 6.88 ±â€¯9.42 (max 39.43 Pa) without (p < 0.001 in all cases). The PMB significantly reduces WSS over the retinal surface underlying the bursa region; conversely, WSS slightly increases it in the immediate neighboring areas.

RESIDUAL INTRARETINAL EDEMA AFTER 25-GAUGE VITRECTOMY AND MACULAR PUCKER REMOVAL: Is Intraoperative Sustained-release Dexamethasone a Real Treatment Option?

PURPOSE: To investigate the efficacy and safety of intraoperative slow-release dexamethasone implant and 25-gauge (G) vitrectomy plus epiretinal membrane removal in patients affected by idiopathic macular pucker. METHODS: In this randomized, clinical, multicenter study, 60 eyes of 60 pseudophakic eyes having idiopathic macular pucker were enrolled. Thirty eyes underwent 25-G pars plana vitrectomy and internal limiting membrane peeling ("Control group"), whereas 30 eyes underwent 25-G pars plana vitrectomy and internal limiting membrane peeling combined with dexamethasone implant ("DEX group"). Best-corrected visual acuity was investigated using Snellen visual acuity ratio. Anatomical outcomes (foveal thickness and total macular volume) were analyzed with spectral domain optical coherence tomography. RESULTS: After 6-month follow-up, best-corrected visual acuity significantly increased in each group (P < 0.05), but there were no significant differences between groups (P = 0.60). Foveal thickness showed a significant decrease in both groups (P < 0.05), but no differences were seen between groups (P = 0.80). Finally, also total macular volume decreased significantly in both groups at the last follow-up visit (P < 0.05), but both groups a showed similar trend (P = 0.12). CONCLUSIONS: Intraoperative sustained-release dexamethasone implant, a powerful antiinflammatory agent with significant efficacy in vitrectomized eyes, did not result in a significant change in macular thickness and volume compared with the vitrectomy alone without dexamethasone implant at 6-month follow-up. These data support the hypothesis that its etiology does not seem to be mainly related to an inflammatory process.

Macular hole closure patterns associated with different internal limiting membrane flap techniques.

PURPOSE: To compare the anatomic and functional outcome of two variants of the inverted internal limiting membrane (I-ILM) flap technique for idiopathic macular holes (IMH) larger than 400 µm. METHODS: Twenty-seven consecutive patients undergoing PPV for IMH were randomly assigned to different variants of I-ILM technique: the Cover group included 14 patients in which the I-ILM was folded upside-down over the MH as a single layer while the Fill group enrolled 13 patients in which the I-ILM was folded within the MH in multiple layers. RESULTS: MH closed in 12/14 Cover and in 13/13 Fill eyes (84.6 vs. 100%, p = 0.14; n.s.). Vision at 1 month was Snellen 0.44 ± 0.17 vs. 0.28 ± 0.21 (p = 0.05) and 0.48 ± 0.20 vs. 0.37 ± 0.25 (n.s.) at 3 months. IS/OS line interruption width was 463 ± 385 vs. 602 ± 210 µm, respectively, at 1 month (n.s.) and 602 ± 210 vs. 563 ± 209 µm at 3 months (n.s.). The Cover group showed outer retina cystic changes more often (p < 0.01). MH over 700 µm closed in 0/2 and in 2/2 cases, respectively, in the Cover and Fill groups (0.045). CONCLUSIONS: Cover and Fill I-ILM techniques allowed similar closure rates and post-operative vision at 3 months. The Cover group showed better anatomical restoration and vision at 1 month while the Fill technique might be more efficient in closing larger MHs.

Ocular perfusion pressure control during pars plana vitrectomy: testing a novel device.

PURPOSE: To study the efficacy of a novel device intended to control infusion pressure based on mean ocular perfusion pressure (MOPP) during pars plana vitrectomy (PPV). METHODS: An arm blood pressure cuff connected to a vitrectomy machine calculated mean arterial pressure (MAP), while a pressure sensor close to the infusion trocar measured intraocular pressure (IOP). MOPP was calculated in real time in 36 consecutive patients undergoing PPV, who were divided into two groups. The device lowered IOP every time that calculated MOPP fell below 30 mmHg in the Control ON group (18 patients), while no action was taken in the Control OFF group (18 patients). RESULTS: Baseline IOP and blood pressure were similar between groups. The Control ON group had significantly lower average intraoperative IOP (30.5 ± 2.1 vs. 35.9 ± 6.9 mmHg; p = 0.002) and higher MOPP (56.4 ± 5.9 vs. 49.7 ± 6.1 mmHg) than the Control OFF group. The Control ON group also spent less time at MOPP < 10 mmHg and < 30 mmHg: 0 vs. 3.40 ± 2.38 min (p < 0.001) and 9.91 ± 7.15 vs. 16.13 ± 8.12 min (p = 0.02), respectively. CONCLUSIONS: The MOPP control device effectively maintained lower IOP and higher MOPP throughout surgery. It also helped avoid dangerous IOP peaks and MOPP dips, allowing patients to spend less time at MOPP of < 10 and < 30 mmHg.

LONGITUDINAL MICROPERIMETRY EVALUATION AFTER INTRAVITREAL OCRIPLASMIN INJECTION FOR VITREOMACULAR TRACTION.

PURPOSE: To determine whether improvements in microperimetry testing are associated with anatomic resolution after ocriplasmin treatment in patients with symptomatic vitreomacular adhesion (VMA)/vitreomacular traction and relatively preserved baseline best-corrected visual acuity (BCVA). METHODS: Patients with vitreomacular traction received a single 125-µg intravitreal ocriplasmin injection and were followed longitudinally for 6 months with optical coherence tomography, BCVA testing, and microperimetry. Visual function changes were compared between eyes with and without VMA resolution on optical coherence tomography. RESULTS: Eleven of 16 eyes (68.8%) achieved VMA resolution after treatment. Mean baseline BCVA was relatively good (79 ± 3 Early Treatment Diabetic Retinopathy Study letters; 20/52); no patients had a ≥2-line improvement in BCVA over the 6-month follow-up period. In the group with VMA resolution, mean retinal sensitivity significantly increased in the central 4° (15.2 ± 1.9 dB vs. 18.9 ± 0.7 dB, P < 0.001) when comparing baseline and final follow-up microperimetry testing. No change in mean retinal sensitivity was found in the group without VMA resolution. CONCLUSION: Microperimetry demonstrates a significant gain in retinal sensitivity, particularly in the central 4° area, in eyes with anatomic resolution after treatment of vitreomacular traction with intravitreal ocriplasmin injection, even when no significant gain in BCVA is seen.

Analysis of Choroidal Thickness Change after 25-Gauge Vitrectomy for Idiopathic Epiretinal Membrane with or without Phacoemulsification and Intraocular Lens Implantation.

PURPOSE: This study aimed to evaluate choroidal thickness modifications before and after vitrectomy with or without phacoemulsification for idiopathic epiretinal membrane in the operated eye and in the unaffected fellow eye. METHODS: In total, 53 eyes of 53 patients underwent 25-gauge pars plana vitrectomy plus internal limiting membrane peeling and air tamponade. Twenty-seven eyes underwent combined surgery with phacoemulsification and intraocular lens implantation. Choroidal thickness was measured using enhanced deep image spectral-domain optical coherence tomography at the fovea and at 500 and 2,500 µm from the fovea. Fellow eyes without any previous ocular surgery history served as controls. RESULTS: Baseline comparison did not show significant differences between study and fellow eyes (p > 0.05). Choroidal thickness significantly decreased in the subfoveal area (p = 0.004) as well as at 500 µm (p = 0.026) and 2,500 µm nasally (p = 0.019) and at 500 µm (p = 0.039) and 2,500 µm (p = 0.005) temporally to the fovea. No significant changes were observed postoperatively in the superior and inferior areas (p > 0.05). No differences were found between eyes which underwent combined surgery and those which underwent vitrectomy alone (p > 0.05). The unaffected eyes did not show any significant changes (p > 0.05). CONCLUSIONS: Comparison of baseline values did not show any differences between affected and unaffected eyes, meaning that choroidal thickness was not influenced by the development of epiretinal membrane. Vitrectomy plus epiretinal and inner limiting membrane removal may influence choroidal homeostasis, leading to a decrease in choroidal thickness in the subfoveal, nasal, and temporal areas. Combined surgery did not show significant differences when compared to vitrectomy alone.

Age and diabetes related changes of the retinal capillaries: An ultrastructural and immunohistochemical study.

Normal human aging and diabetes are associated with a gradual decrease of cerebral flow in the brain with changes in vascular architecture. Thickening of the capillary basement membrane and microvascular fibrosis are evident in the central nervous system of elderly and diabetic patients. Current findings assign a primary role to endothelial dysfunction as a cause of basement membrane (BM) thickening, while retinal alterations are considered to be a secondary cause of either ischemia or exudation. The aim of this study was to reveal any initial retinal alterations and variations in the BM of retinal capillaries during diabetes and aging as compared to healthy controls. Moreover, we investigated the potential role of vascular endothelial growth factor (VEGF) and pro-inflammatory cytokines in diabetic retina.Transmission electron microscopy (TEM) was performed on 46 enucleated human eyes with particular attention to alterations of the retinal capillary wall and Müller glial cells. Inflammatory cytokines expression in the retina was investigated by immunohistochemistry.Our electron microscopy findings demonstrated that thickening of the BM begins primarily at the level of the glial side of the retina during aging and diabetes. The Müller cells showed numerous cytoplasmic endosomes and highly electron-dense lysosomes which surrounded the retinal capillaries. Our study is the first to present morphological evidence that Müller cells start to deposit excessive BM material in retinal capillaries during aging and diabetes. Our results confirm the induction of pro-inflammatory cytokines TNF-α and IL-1ß within the retina as a result of diabetes.These observations strongly suggest that inflammatory cytokines and changes in the metabolism of Müller glial cells rather than changes in of endothelial cells may play a primary role in the alteration of retinal capillaries BM during aging and diabetes.