LONG-TERM OUTCOMES OF SUTURELESS INTRASCLERAL INTRAOCULAR LENS FIXATION IN CHILDREN AND ADULTS: Single-Surgeon Case Series With and Without Haptic Flanging With Up to 11 Years of Follow-Up.

PURPOSE: Report and compare long-term outcomes and complications of sutureless scleral tunnel (SST) and flanged haptic (FH) scleral-fixated intraocular lens, with spontaneous intraocular lens (IOL) dislocation as primary outcome measure. METHODS: Retrospective single-surgeon case series of 95 SST and 458 FH eyes from 2011 to 2022 (553 total eyes). Demographics, surgical indications, ocular history, visual acuity, and complication rates were collected. RESULTS: Reoperation-requiring spontaneous IOL dislocation rate was significantly different ( P = 0.0167) between FH (3.7%) and SST (10.5%). Mean follow-up was 3.31 ± 0.30 versus 1.58 ± 0.07 years for SST and FH, respectively. There was no significant difference between preoperative (20/305 vs. 20/300) or final postoperative (20/77 vs. 20/62) visual acuity. Other complications included any cystoid macular edema (20.0% vs. 25.3%), elevated intraocular pressure (16.8% vs. 9.6%), IOL tilt requiring reoperation (5.3 vs. 0%), haptic exposure (2.1% vs. 3.3%), and reverse pupillary block (4.2% vs. 1.1%). CONCLUSION: Haptic flanging resulted in fewer eyes meeting the primary end point of IOL dislocation. We reported the longest-to-date follow-up of both nonflanged SST IOL fixation and our FH-modified Yamane technique. Our FH-modified Yamane technique represents a safe, durable, and potentially superior option for scleral-fixated intraocular lens.

Flanged Sutureless Intrascleral Fixation of Dislocated Hard 1-Piece Polymethyl Methacrylate Intraocular Lenses.

PURPOSE: To describe the vitreoretinal surgical technique and report the outcomes of our method of sutureless flanged intrascleral haptic fixation of dislocated 1-piece polymethyl methacrylate intraocular lenses with rigid haptics. METHODS: Ciliary sulcus-based scleral tunnels were created by placing valved 27-gauge (g) trocar cannulas limbus parallel with conjunctival displacement. After complete vitrectomy, the rigid haptics were then externalized using 27g forceps. Cautery was then used to form flanges at the haptic tips. The haptics were then pushed back into the mouths of the scleral tunnels. RESULTS: Flanged intrascleral fixation was successfully achieved in eight eyes of seven patients. The average age at the time of surgery was 75 ± 13.7 years, with a mean follow-up of 17.9 ± 16.3 months (range 3-42 months). Intraocular lens dislocation/subluxation was the most common indication for surgery. All patients fully recovered to their potential acuity by their third postoperative visit. The most significant complication was erosion of one haptic in one patient, which was successfully managed without requiring intraocular lens exchange. There were no complications of subsequent dislocation, endophthalmitis, retinal detachment, or uveitis-glaucoma-hyphema syndrome. CONCLUSION: Flanged sutureless intrascleral fixation of dislocated 1-piece polymethyl methacrylate intraocular lenses with rigid haptics can be safely and successfully performed, avoiding the large wound creation accompanying intraocular lens exchange and the disadvantages of suture-based techniques.

27-GAUGE SUTURELESS INTRASCLERAL FIXATION OF INTRAOCULAR LENSES WITH HAPTIC FLANGING: Short-Term Clinical Outcomes and a Disinsertion Force Study.

PURPOSE: To determine whether haptic flanging during 27-gauge sutureless intrascleral fixation of intraocular lenses (IOLs) increases IOL stability and to report the short-term clinical outcomes of sutureless intrascleral surgery using 27-gauge trocar cannulas with haptic flanging. METHODS: Retrospective surgical case series using live and cadaveric human eyes. RESULTS: In the cadaveric experiment using five eyes, flanged haptics required more force to dislocate the IOL compared with unflanged haptics (14 ± 4 vs. 3 ± 1 g, P = 0.03). The clinical series included 52 eyes from 52 patients. The average age at the time of surgery was 73 ± 14 years, with a mean follow-up of 27 ± 19 weeks. The most common indication for surgery was IOL dislocation/subluxation (n = 43, 83%). Mean visual acuity improved from 20/140 preoperatively to 20/50 at postoperative Month 1 (P < 0.001). The most common postoperative issue was intraocular pressure elevation (n = 12, 23%). Two patients (4%) needed a reoperation for IOL dislocation. CONCLUSION: Haptic flanging during 27-gauge sutureless intrascleral surgery creates a more stable scleral-fixated IOL compared with the traditional unflanged technique based on a cadaveric human eye study. In addition, this variation of sutureless intrascleral surgery seems safe and effective for patients who require secondary IOLs.

INDUCTION OF MACULAR DETACHMENT FOR THE TREATMENT OF PERSISTENT OR RECURRENT IDIOPATHIC MACULAR HOLES.

PURPOSE: To analyze the efficacy of induced macular detachment for the treatment of persistent or recurrent idiopathic macular holes after treatment with one or more standard pars plana vitrectomies (PPVs) with internal limiting membrane peeling. METHODS: This study is a retrospective consecutive case series of 10 patients who underwent a PPV with subretinal balanced salt solution injection from 2011 to 2014 to treat persistent or recurrent idiopathic macular holes. All patients had previously undergone PPV with internal limiting membrane peeling. Visual acuity, ocular examination findings, and optical coherence tomographic images were reviewed preoperatively and postoperatively to assess the anatomical and visual outcomes of this procedure. RESULTS: Nine of the 10 patients who underwent the procedure had closure of their macular holes postoperatively (90%) and remained closed 6 months postoperatively. Most patients reported a subjective visual improvement. A mean objective visual improvement of 16 letters (Early Treatment Diabetic Retinopathy Study, 0.324 logMAR) was seen between preoperative and 6-month postoperative assessments of all patients (pre = 1.490, post = 1.166; P = 0.022). Subgroup analysis of patients with successful closure revealed 20 letters of improvement (0.398 logMAR) in visual acuity (pre = 1.491, post = 1.093; P = 0.004). There were no intraoperative or postoperative complications. CONCLUSION: In eyes with persistent or recurrent idiopathic macular holes after standard PPV with internal limiting membrane peeling, repeat PPV with subretinal balanced salt solution injection to create a macular detachment may be a viable surgical treatment option. Our results show improved anatomical and visual outcomes postoperatively that compare favorably to other case series describing various surgical treatments for these challenging cases.

Late Vitreoretinal Complications of Regressed Retinopathy of Prematurity: Retinal Break, Vitreous Hemorrhage, and Retinal Detachment.

PURPOSE: To investigate late vitreoretinal complications and visual outcomes in patients with regressed retinopathy of prematurity (ROP) with or without prior treatment. DESIGN: International, multicenter, noncomparative retrospective case series. PARTICIPANTS: We analyzed 264 eyes of 238 patients from 13 centers worldwide who developed vitreoretinal complications (retinal detachment [RD], vitreous hemorrhage [VH], or retinal break) ≥ 2 years after resolution of acute ROP. METHODS: Each participant was assigned to 1 of 3 groups (the RD, VH, and retinal break groups) according to their primary diagnosis. The average age at presentation, visual acuities, refractive error, axial length, gestational age, birth weight, acute ROP classification, prior treatments for acute ROP, postoperative visual acuity (VA), and concomitant eye conditions in the 3 groups were documented and compared. MAIN OUTCOME MEASURES: Clinical features and visual outcomes of late vitreoretinal complications in patients with regressed ROP. RESULTS: A total of 264 eyes of 238 patients were included. The prior acute ROP status was comparable among the 3 groups, except that the VH group had a higher proportion of patients with type 1 ROP (P = 0.03) and prior treatment (P < 0.001) than the other groups. The average age at presentation was earlier in the RD (20.3 ± 15.5 years) and VH (21.4 ± 18.9 years) groups than in the retinal break group (31.9 ± 18.2 years; P < 0.001). The retinal break group had the best presenting best-corrected VA, followed by the RD and VH groups (P < 0.001). Surgical intervention improved VA in both the RD and VH groups (both P < 0.05). The overall trend of VA was the most favorable in the retinal break group, followed by that in the VH and RD groups. Cicatricial changes in the fellow retina were observed in > 90% of patients with unilateral involvement. CONCLUSIONS: Infants with acute ROP remain at a high risk of vision-threatening complications throughout childhood and adulthood. Continual follow-up of patients with ROP is important. When severe complications, such as RD or VH, are detected, timely surgical intervention is necessary to ensure favorable visual outcomes in these patients.

25-Gauge pars plana vitrectomy for retained lens fragments.

PURPOSE: The purpose of this study was to report the outcomes and complications of 25-gauge pars plana vitrectomy for the management of retained lens fragments after complicated cataract surgery. METHODS: This is a retrospective consecutive case series of 17 patients who presented with retained lens fragments, ranging from mostly cortex to the entire lens, which were managed using only 25-gauge instrumentation. RESULTS: Eight men and 9 women (mean age, 73.1 years) were followed for a mean of 4.5 months after 25-gauge vitrectomy for removal of retained lens fragments. Mean preoperative visual acuity was 20/427 and mean final postoperative visual acuity was 20/62. Mean surgical operating time was 48.5 minutes. Mean preoperative intraocular pressure was 24.5 mmHg and mean 1-day postoperative intraocular pressure was 17.9 mmHg. No cases required the use of a phacofragmatome, no sutures were required to close the sclerotomies, and there were no cases of postoperative hypotony. Cystoid macular edema and glaucoma developed postoperatively in 29.4% and 5.9% of eyes, respectively. There were no cases of postoperative retinal detachment or endophthalmitis. CONCLUSION: A 25-gauge vitrectomy technique, without the use of a phacofragmatome, may be a suitable alternative to 20-gauge vitreous surgery using a phacofragmatome in the management of retained lens fragments after complicated cataract surgery. Clinical outcomes and complication rates are comparable to those found in the literature for 20-gauge surgery.

Early vitrectomy effective for bilateral combined anterior and posterior persistent fetal vasculature syndrome.

PURPOSE: The purpose of this study was to review our surgical experience with patients with bilateral combined anterior and posterior persistent fetal vasculature syndrome (PFVS). METHODS: We retrospectively reviewed the charts of all patients seen in our tertiary care pediatric retinal practice from 1988 to 2008 with a potential diagnosis of bilateral PFVS with posterior involvement. Clinical diagnosis required the presence of either bilateral persistent hyaloidal stalk tissue with retinal involvement or bilateral dense retrolental fibrovascular plaques (usually with no posterior view preoperatively) without a family history or genetic testing consistent with Norrie disease or familial exudative vitreoretinopathy. RESULTS: Chart review showed 22 vitrectomized patients with clinical findings consistent with bilateral PFVS with posterior involvement who did not have a family history or genetic testing consistent with Norrie disease or familial exudative vitreoretinopathy. All 22 of these patients with posterior retinal involvement also had anterior findings and thus can be classified as combined anterior and posterior PFVS. Of the 13 patients with visual acuity follow-up data, 9 patients (69%) maintained at least light perception vision in at least 1 eye at last follow-up. Of the 28 operated eyes in 16 patients with follow-up data, 3 eyes (11%) were phthisical at last follow-up. CONCLUSION: Children with bilateral PFVS with posterior retinal involvement have a dismal visual prognosis if left unoperated. In this relatively large series of a rare condition, we find that vitrectomy with or without lensectomy is beneficial in bilateral combined anterior and posterior PFVS in two regards: maintenance or restoration of vision and avoidance of phthisis bulbi.

Late-Onset Retinal Findings and Complications in Untreated Retinopathy of Prematurity.

PURPOSE: To investigate late retinal findings and complications of eyes with a history of retinopathy of prematurity (ROP) that did not meet treatment criteria and did not receive treatment during infancy. DESIGN: Retrospective, nonconsecutive, noncomparative, multicenter case series. PARTICIPANTS: Three hundred sixty-three eyes of 186 patients. METHODS: Data were requested from multiple providers on premature patients with a history of ROP and no treatment during infancy who demonstrated late retinal findings or complications and included age, gender, gestational age and weight, zone and stage at infancy, visual acuity, current retina vascularization status, vitreous character, presence of peripheral retinal findings such as lattice retinal tears and detachments (RDs), retinoschisis, and fluorescein findings. MAIN OUTCOME MEASURES: Rate of RDs and factors conferring a higher risk of RDs. RESULTS: The average age was 34.5 years (range, 7-76 years), average gestational age was 26.6 weeks (range, 23-34 weeks), and average birth weight was 875 g (range, 425-1590 g). Findings included lattice in 196 eyes (54.0%), atrophic holes in 126 eyes (34.7%), retinal tears in 111 eyes (30.6%), RDs in 140 eyes (38.6 %), tractional retinoschisis in 44 eyes (11.9%), and visible vitreous condensation ridge-like interface in 112 eyes (30.5%). Fluorescein angiography (FA) was performed in 113 eyes, of which 59 eyes (52.2%) showed leakage and 16 eyes (14.2%) showed neovascularization. Incomplete vascularization posterior to zone 3 was common (71.6% of eyes). Retinal detachments were more likely in patients with a gestational age of 29 weeks or less (P < 0.05) and in eyes with furthest vascularization to posterior zone 2 eyes compared with zone 3 eyes (P = 0.009). CONCLUSIONS: Eyes with ROP not meeting the treatment threshold during infancy showed various late retinal findings and complications, of which RDs were the most concerning. Complications were seen in all age groups, including patients born after the Early Treatment for Retinopathy of Prematurity Study. Contributing factors to RDs included atrophic holes within peripheral avascular retina, visible vitreous condensation ridge-like interface with residual traction, and premature vitreous syneresis. We recommend regular examinations and consideration of ultra-widefield FA examinations. Prospective studies are needed to explore the frequency of complications and benefit of prophylactic treatment and if eyes treated with anti-vascular endothelial growth factor therapy are at risk of similar findings and complications.

In vivo time-lapse imaging of synaptic takeover associated with naturally occurring synapse elimination.

During development, competition between axons causes permanent removal of synaptic connections, but the dynamics have not been directly observed. Using transgenic mice that express two spectral variants of fluorescent proteins in motor axons, we imaged competing axons at developing neuromuscular junctions in vivo. Typically, one axon withdrew progressively from postsynaptic sites and the competing axon extended axonal processes to occupy those sites. In rare instances when the remaining axon did not reoccupy a site, the postsynaptic receptors rapidly disappeared. Interestingly, the progress and outcome of competition was unpredictable. Moreover, the relative areas occupied by the competitors shifted in favor of one axon and then the other. These results show synaptic competition is not always monotonic and that one axon's contraction in synaptic area is associated with another axon's expansion.

Axon branch removal at developing synapses by axosome shedding.

In many parts of the developing nervous system, the number of axonal inputs to each postsynaptic cell is dramatically reduced. This synapse elimination has been extensively studied at the neuromuscular junction, but how axons are lost is unknown. Here, we combine time-lapse imaging of fluorescently labeled axons and serial electron microscopy to show that axons at neuromuscular junctions are removed by an unusual cellular mechanism. As axons disappear, they shed numerous membrane bound remnants. These "axosomes" contain a high density of synaptic organelles and are formed by engulfment of axon tips by Schwann cells. After this engulfment, the axosome's contents mix with the cytoplasm of the glial cell. Axosome shedding might underlie other forms of axon loss and may provide a pathway for interactions between axons and glia.

In vivo time-lapse fluorescence imaging of individual retinal ganglion cells in mice.

We have developed a technique that permits time-lapse imaging of retinal ganglion cells (RGCs), their dendritic arbors and their axons in mammals in vivo. This technique utilizes a standard confocal laser scanning microscope, transgenic mice that express yellow fluorescent protein (YFP) in a subset of RGCs and survival anesthesia techniques. The same individual RGCs with their dendritic arbors and axons were multiply imaged in vivo in both adult and juvenile mice. Additionally, the same RGC that was imaged in vivo could then be located and imaged in fixed retinal whole mount preparations. This novel technique has many potential applications.

Abnormal foveal avascular zone in nanophthalmos.

PURPOSE: To evaluate the foveas of nanophthalmic patients. DESIGN: Retrospective observational case series. METHODS: Four nanophthalmic patients examined between April 2005 and April 2006 were included. Visual acuity (VA), refractive correction, axial length, corneal diameter, presence or lack of foveal light reflex, as well as fluorescein angiograms (FAs), and optical coherence tomography (OCT) scans of the maculae were evaluated. RESULTS: None of the eight eyes had a foveal light reflex, corresponding to lack of a normal foveal pit on OCT. Fluorescein angiography showed no normal foveal avascular zones; all were either completely absent or small and rudimentary. CONCLUSIONS: Nanophthalmic patients rarely have best-corrected visual acuity (BCVA) better than 20/40 at any point in their lives, even with an absence of known complications, such as uveal effusion or glaucoma. In many patients, this visual deficiency may correspond to an absent or rudimentary foveal avascular zone and lack of a normal foveal pit.

In vivo imaging of the developing neuromuscular junction in neonatal mice.

Although fluorescently labeled structures can be analyzed more easily at high resolution in fixed-tissue preparations than in living animals, some biological questions can only be answered by time-lapse imaging. Changes in nervous system wiring during development cannot be determined reliably by taking tissue from different animals at staggered time points. Rather, the same cells and connections must be viewed repeatedly. To study developmental synapse elimination, we image muscles in transgenic mice that express fluorescent proteins in motor neurons and follow the same neuromuscular junctions (NMJs) over multiple days. This protocol describes the use of confocal microscopy for in vivo imaging of developing NMJs in transgenic neonatal mice expressing cyan fluorescent protein (CFP) or yellow fluorescent protein (YFP). The sternomastoid, a flat, accessible neck muscle with large junctions, is imaged. A principal advantage of confocal microscopy is the ability to acquire multiple fluorescence channels simultaneously. If the channels are acquired sequentially, there is inevitably misalignment because of movement. Moreover, the total imaging time scales linearly with the number of channels. With simultaneous acquisition, only a single scan may be required. With perfect alignment between channels, irrespective of movement that might occur during a scan, color differences can be used to study interactions between axons over time. A limitation of this technique is that axons must be brightly labeled and at the muscle surface. NMJs that are more than one muscle fiber deep may be difficult to scan because of index of refraction changes that cause image blurring.

Retinal detachments involving the posterior pole in hallermann-streiff syndrome.

PURPOSE: To report a case of Hallermann-Streiff syndrome and bilateral retinal detachments involving the posterior pole. METHODS: Retrospective case report and literature review. RESULTS: A 2-year-old girl with Hallermann-Streiff syndrome was evaluated. Fundus examination showed bilateral exudative retinal detachments involving a significant portion of the posterior pole. The left eye showed several large, cyst-like areas of retinal detachment. The child was observed without treatment, and the subretinal fluid remained stable during the follow-up of 10 months. CONCLUSION: Bilateral retinal detachments can be seen in patients with Hallermann-Streiff syndrome. The etiology is likely to be multifactorial, and uveal effusion may contribute to the exudative fluid. Further evaluation is necessary to determine the visual prognosis and optimal management of patients with exudative retinal detachments associated with Hallermann-Streiff syndrome.