THE TEXAS TACO TECHNIQUE FOR INTERNAL LIMITING MEMBRANE FLAP IN LARGE FULL-THICKNESS MACULAR HOLES: A Short-Term Pilot Study.

PURPOSE: To determine the efficacy of a novel application of a surgical internal limiting membrane flap technique that requires no additional surgical adjuvants in closure of large full-thickness macular holes (FTMHs). METHODS: The electronic medical records of patients (n = 8) with large (>400 µm) FTMHs repaired with the "Texas Taco" technique were retrospectively reviewed. RESULTS: Operated patients had a mean age of 63.8 ± 19.2 (range, 19-80) years. There were five (62.5%) phakic and three (37.5%) pseudophakic eyes preoperatively. Mean follow-up time was 9.1 ± 4.7 (1.5-14.5) months. Across all patients, mean FTMH diameter at the shortest and greatest widths were 529 ± 101 (404-661) and 1,189 ± 290 (829-1,656) µm, respectively. Mean best-corrected logarithm of the minimum angle of resolution visual acuity was 1.3 ± 0.23 preoperatively (approximately Snellen acuity 20/400) and 0.66 ± 0.40 postoperatively (approximately Snellen acuity 20/100) (P < 0.001). All FTMHs remained closed at all postoperative visits. CONCLUSION: The Texas Taco technique provided anatomical and functional improvement in challenging cases of large FTMHs without the need of additional surgical adjuvants.

Fovea-sparing rhegmatogenous retinal detachments: impact of clinical factors including time to surgery on visual and anatomic outcomes.

PURPOSE: Evaluate the impact of time to surgery and other clinical factors on visual and anatomic outcomes following surgical repair of fovea-sparing rhegmatogenous retinal detachments (RRD). METHODS: Visual and anatomic outcomes were analyzed for their association with clinical factors, including lens status, preoperative visual acuity (VA), contralateral RRD, RRD symptom duration, time to surgery, single-operation anatomic success, number of quadrants involved, posterior RRD extent, RRD extent closest to the fovea, number of retinal breaks, quadrants with retinal breaks, and surgery performed Saturday or Sunday versus Monday-Friday. RESULTS: Medical records of 423 eyes with fovea-sparing RRD repaired with pneumatic retinopexy (PR), scleral buckle (SB), pars plana vitrectomy (PPV), and PPV with SB (PPV/SB) were included. Sixty-seven percent and 89% were operated within 24 and 72 h of RRD presentation, respectively. Single-operation anatomic success rates were 59%, 89%, 84%, and 92% for PR, SB, PPV, and PPV/SB interventions, respectively. Final anatomic success was 100%. Three clinical factors correlated with faster time to surgery: shorter symptom duration (p < 0.02), RRD superior location (p = 0.001), and posterior extension into the macula (p = 0.01). The time to surgery did not correlate with visual or anatomic outcomes. Two clinical factors positively correlated with postoperative vision: preoperative VA (r > 0.25, p < 0.04) and single-operation anatomic success (p < 0.04). Surgeries performed on Monday through Friday (n = 411) were associated with better anatomic outcomes compared with the limited number performed on Saturday or Sunday (n = 12) (p = 0.005), although a greater proportion of operated cases over the weekend were PR. CONCLUSIONS: In the context of the current series, time to surgery did not correlate with visual or anatomic outcomes following the surgical repair of fovea-sparing RRDs. Preoperative VA and single-operation anatomic success correlated with improved visual outcome.

Office-based intravitreal injection of expansile gas for management of macular hole in previously vitrectomized eyes.

PURPOSE: To report the successful closure of full-thickness macular hole (MH), using an office-based intravitreal gas injection, in two eyes having undergone prior pars plana vitrectomy (PPV). OBSERVATIONS: Patient 1 presented with acute loss of visual acuity to 20/300 in the left eye 5 months following PPV for fovea-off rhegmatogenous retinal detachment; MH was confirmed by examination and optical coherence tomography (OCT). 0.6 cc of 100% C3F8 gas was injected, with subsequent MH closure following one week of face-down positioning. Patient 2 presented with right eye visual acuity of 20/60 one month following PPV for optic nerve pit-associated maculopathy; MH was confirmed by examination and OCT. 0.85 cc of 100% C3F8 gas was injected in the office, with subsequent MH closure following one week of face-down positioning. CONCLUSIONS AND IMPORTANCE: MH management in previously vitrectomized eyes has traditionally been repeat PPV with internal limiting membrane peeling, fluid-air exchange, and expansile gas exchange. Intravitreal gas injection, in an office-based setting, is a viable clinical approach to close MH in some previously vitrectomized eyes.

Distribution of Nonperfusion and Neovascularization on Ultrawide-Field Fluorescein Angiography in Proliferative Diabetic Retinopathy (RECOVERY Study): Report 1.

PURPOSE: To explore the distribution of nonperfusion area (NPA) on ultrawide-field fluorescein angiography (UWF FA) in proliferative diabetic retinopathy (PDR) and its relationship with the presence of neovascularization of the optic disc (NVD) and distribution of neovascularization elsewhere (NVE). DESIGN: Prospective, observational case series. METHODS: Baseline Optos 200Tx UWF FA images of 38 eyes with treatment-naïve early-stage PDR from the RECOVERY (NCT02863354) study were stereographically projected at the Doheny Image Reading Center. Two independent/masked certified graders manually delineated the NPA and the total visible retinal area (TRA). NPA and TRA were then computed in square millimeters using the manufacturer software. Ischemic index (ISI) was calculated by dividing NPA by TRA. NPA and ISI were correlated with the presence and distribution of neovascularization in the corresponding zones. RESULTS: Eyes with NVD appeared to have more severe global NPA than those without (P = .026). Although the ISI appeared to increase with increasing distance from the foveal center (P < .001), NVE was more likely to be located in the posterior pole than the midperiphery or far-periphery (P < .001). Presence of NVE in the posterior polar retina appeared to demonstrate more severe ischemia in the posterior pole and midperiphery than those without (P < .05), but interestingly, was not correlated with the severity of overall global ischemia or of ischemia in the far-periphery alone (P > .05). CONCLUSIONS: Whereas the presence of NVD was associated with the severity of global ischemia, the distribution of NVE did not appear to be influenced by the distribution of ischemia.

Intravitreal Aflibercept for Retinal Nonperfusion in Proliferative Diabetic Retinopathy: Outcomes from the Randomized RECOVERY Trial.

PURPOSE: Evaluate the impact of intravitreal aflibercept (Eylea; Regeneron, Tarrytown, NY) on retinal nonperfusion (RNP) in eyes with proliferative diabetic retinopathy (PDR). DESIGN: Prospective, randomized clinical trial. PARTICIPANTS: Eyes with treatment-naïve PDR and extensive RNP without diabetic macular edema. METHODS: Patients were randomized 1:1 to intravitreal 2 mg aflibercept every 4 weeks (monthly) or every 12 weeks (quarterly). MAIN OUTCOME MEASURES: The primary outcome measure was change in total RNP area (in square millimeters) from baseline to year 1. Secondary outcomes included ischemic index (ISI), diabetic retinopathy severity scale (DRSS) scores, visual acuity, central retinal thickness, and adverse events. The mean and 95% confidence interval were calculated for each outcome. RESULTS: Through 1 year, the monthly (n = 20) and quarterly (n = 20) cohorts received 11.0 and 3.95 mean aflibercept injections, and DRSS scores improved 2 steps or more in 74% and 67% of patients, respectively. Among all patients through 1 year, mean total area of RNP increased from 235 mm2 to 266 mm2 (P = 0.18) and ISI increased from 25.8% to 31.9% (P = 0.004). Retinal nonperfusion outcomes favored monthly dosing. Mean total RNP increased from 207 mm2 at baseline to 268 mm2 (P = 0.01) at 1 year in the quarterly cohort and remained stable at 264 mm2 at baseline and 1 year (P = 0.70) in the monthly cohort (P = 0.05, monthly vs. quarterly cohorts). Although many eyes demonstrated increased areas of RNP longitudinally (n = 24 [66.7%]), this was more common with quarterly dosing (n = 14 [77.8%]), and a proportion of eyes (n = 12 [33.3%]) demonstrated localized areas of apparent reperfusion of nonperfused retina, more commonly in the monthly cohort (n = 8 [44.4%]). CONCLUSIONS: Widespread evidence of retinal reperfusion with aflibercept dosing of PDR eyes with extensive RNP was not identified, and therefore the primary outcome of the current study was not met. Nevertheless, zones of apparent reperfusion were detected in some patients, and a dose response was identified with a reduction of RNP progression with monthly compared to quarterly dosing.

Longitudinal Quantification of Retinal Nonperfusion in the Macula of Eyes With Retinal Vein Occlusion Receiving Anti-VEGF Therapy: Secondary Analysis of the WAVE Randomized Trial.

BACKGROUND AND OBJECTIVE: Longitudinal quantification of retinal nonperfusion (RNP) in eyes with retinal vein occlusion (RVO) undergoing anti-vascular endothelial growth factor therapy. PATIENTS AND METHODS: Thirty eyes with ischemic RVO were randomized to ranibizumab (Lucentis; Genentech, South San Francisco, CA) (monotherapy) or ranibizumab plus peripheral laser (combination therapy) in a 12-month, prospective trial. RNP on fluorescein angiography was quantified within the macula through 12 months of follow-up. RESULTS: Baseline mean macular RNP areas were 5.04 mm2 and 8.30 mm2 in the monotherapy (n = 5) and combination therapy (n = 15) cohorts, respectively. Through month 12, mean macular RNP area increased 0.36 mm2 and 0.53 mm2 in the monotherapy and combination therapy cohorts, respectively (P = .77). Marked, progressive RNP was observed in three eyes (12%). No areas of reperfusion were detected in any eye. CONCLUSION: Among ischemic RVO eyes in WAVE, macular RNP was common at baseline and remained stable over time in most eyes, though marked RNP progression occurred in a minority of eyes. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:258-264.].

Suprachoroidal Space Alterations Following Delivery of Triamcinolone Acetonide: Post-Hoc Analysis of the Phase 1/2 HULK Study of Patients With Diabetic Macular Edema.

BACKGROUND AND OBJECTIVE: To study anatomic changes in the suprachoroidal space (SCS) following suprachoroidal injection of CLS-TA, triamcinolone acetonide injectable suspension. PATIENTS AND METHODS: Eyes with diabetic macular edema receiving CLS-TA were imaged serially using anterior segment spectral-domain optical coherence tomography to examine the SCS. RESULTS: At the final imaging session, the SCS was not significantly different in study eyes (n = 14; 8.4 µm) compared to fellow eyes (n = 10; 8.1 µm; P = .698). Two eyes were imaged immediately before and 30 minutes after suprachoroidal injections; in these eyes, mean suprachoroidal width increased significantly following CLS-TA injection, 9.9 µm to 75.1 µm (P < .001), and subsequently returned to 14.9 µm 1 month after the final injection (P = .221). CONCLUSION: Suprachoroidal CLS-TA injection caused a measurable increase in the SCS, which returned to preinjection levels by 1 month following injection with no apparent lasting impact on SCS anatomy. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:692-697.].