Rate of Postoperative Autofluorescent Macular Shift with Expanding Gas Bubble Tamponade and No Prone Posture Ambulatory Care in Patients with Macula-Involved Retinal Detachment.

PURPOSE: Chronically distorted vision is an important adverse outcome in patients with otherwise successfully treated macula-involved retinal detachment (RD). Symptomatic distortion is associated with macular vessel shift on fundus autofluorescence (FAF) imaging. Immediate prone posture has to date been the only mechanism adopted to reduce postoperative FAF shift. The aim of this study was to establish the rates of primary anatomical success and (FAF) macular shift in 67 eyes with macula-involved RD and superior breaks treated with vitrectomy, retinopexy, 0.7-1 mL 100% gas tamponade, and no prone posture. METHODS: Single-center, retrospective series. RESULTS: Rates of primary anatomical success and fundus autofluorescent imaging macular shift were 89 and 26%, respectively. CONCLUSION: Vitrectomy with a 0.7-1 mL expanding gas bubble tamponade and no prone posture were associated with an acceptable rate of primary anatomical success. We found the lowest yet reported rate of FAF shift in patients with macula-involved RD. If confirmed, this simple technique modification could improve the visual outcome of RD surgery whilst facilitating postoperative ambulatory care.

Does Same-Day Postoperative Increased Intraocular Pressure Affect Endothelial Cell Density After Descemet Membrane Endothelial Keratoplasty?

PURPOSE: High intraocular pressure (IOP) is common in association with intracameral air and gas tamponade after Descemet membrane endothelial keratoplasty (DMEK); yet its influence on endothelial cell survival is unknown. Our aim was to determine the effect of high IOP measured 2 hours after DMEK on 1-month endothelial cell density (ECD). The influence of other potentially relevant factors was also investigated. METHODS: Retrospective, consecutive series. Inclusions: low-to-moderate risk DMEK surgery alone or combined with phacoemulsification. EXCLUSIONS: previous penetrating keratoplasty or glaucoma surgery; grafts with any of the following in the first month: rebubble, rejection, or graft failure. RESULTS: Sixty-two grafts met inclusion with 60 having IOP recorded at 2 hours. Thirty-eight percent (23/60) had IOP >30 mm Hg and 22% (13/60) had IOP >40 mm Hg at 2 hours. All grafts with IOP >30 mm Hg had air released and immediate normalization of pressure. One-month ECD (mean ± standard error of mean) was 1872 ± 58 cells/mm, representing cell loss of 29.8 ± 2.0%. Two-hour IOP was highly insignificant against 1-month ECD when tested as a continuous variable (P = 0.78). Lower 1-month ECD was statistically correlated with lower donor count (P = 0.002) and combined DMEK-phaco surgery (P = 0.01) on univariate and multivariate analysis. Insignificant factors (P > 0.05) against 1-month ECD included patient age, sex and race, surgical indication (Fuchs endothelial dystrophy vs. non-Fuchs endothelial dystrophy), and donor age. CONCLUSIONS: Increased IOP at 2 hours is common after DMEK, but does not seem to influence early endothelial cell survival. One-month ECD was influenced by donor counts and combined cataract surgery.

Descemet's membrane endothelial keratoplasty: surgical outcomes and endothelial cell count modelling from a UK centre.

PURPOSE: To report surgical outcomes and endothelial cell density (ECD) trends up to 2 years post-operatively in the first cohort of eyes undergoing Descemet's membrane endothelial keratoplasty (DMEK) for low-to-moderate risk indications at our UK centre. Tight corneal sutures were used to ensure high intraoperative pressure from intracameral air for 10-min and to maintain a good post-operative air fill. Outcomes were compared to a prior series at our unit of similar eyes having Descemet's stripping endothelial keratoplasty (DSEK). METHODS: Retrospective, interventional series. Inclusions: all DMEKs with a minimum of 1-month follow-up. EXCLUSIONS: prior glaucoma surgery, penetrating keratoplasty or anterior chamber lens. RESULTS: 88 DMEKs met inclusion. Median follow-up: 332 days. Main indication: Fuchs dystrophy (90%). COMPLICATIONS: re-bubbling 2%, primary failure 6%, retinal detachment 2%, rejection 3%. At 3 months, BCVA ≥6/6 and ≥6/9 were 67% and 86%, respectively. Graft survival at both 1 and 2 years was 94 ± 2%. Mean(±SD) cell-loss at 1 month, 3 months, 6 months, 12 months and 24 months: 30 ± 15%, 29 ± 16%, 33 ± 17%, 35 ± 17% and 48 ± 16%, respectively. Compared to a prior series at our unit of 210 low-to-moderate risk DSEKs, cell loss was lower for DMEK at all time-points (p < 0.001) through to 12 months but was not statistically different at 24 months. Mixed-modelling of ECD over time demonstrated the convergence of DMEK and DSEK curves by 2 years. CONCLUSIONS: DMEK using tissue from UK eye-banks resulted in high survival and excellent visual acuity. ECD through 1 year was superior to DSEK in a similar cohort. Our low re-bubble rate (2%) may be attributable to use of intracameral air at temporarily elevated intraocular pressure.

Vitreoretinal surgery on the fellow eye: A retrospective analysis of 18 years of surgical data from a tertiary center in England.

Purpose: To determine the long-term incidence of fellow-eye surgical involvement in patients who have undergone first-eye vitreoretinal (VR) surgery for a variety of indications. This was a single-institution retrospective, consecutive series. Methods: Eighteen years of electronic surgical data were reviewed at our institution. All patients having surgery for the following indications were included: rhegmatogenous retinal detachment (RRD), macular hole (MH), epiretinal membrane (ERM), proliferative diabetic retinopathy (PDR), vitritis, and dropped nucleus. Primary outcome was the cumulative incidence of fellow-eye surgery at 10 years by Kaplan-Meier analysis. Results: Total follow-up was 29,629 patient-years. Cumulative incidence (± standard error) of fellow-eye surgery at 10 years was 7.2% ± 0.6% for RRD, 9.1% ± 1.3% for ERM, 7.5% ± 1.8% for MH, 30.6% ± 1.9% for PDR, 13.7% ± 2.9% for vitritis, and 2.8% ± 1.6% for dropped nuclei. The hazard for second-eye surgery was greatest in the early postoperative period after first-eye surgery for all indications. For RRD, the hazard was 2.7% ± 0.3% at year 1, 1.1% ± 0.2% at year 2, and 0.5% ± 0.2% at year 5. Risk factors for fellow-eye involvement for RRD were younger age (P < 0.001) and male gender (P < 0.01). Conclusion: We report the long-term risk of fellow-eye involvement in various VR pathologies, which is important in counseling patients regarding their risks as well as planning service provision.

Acute retinal detachment induced by the Valsalva manoeuvre in morning glory disc anomaly.

We present a case in which a large, bullous, predominantly inferior, serous retinal detachment developed acutely after the Valsalva manoeuvre (from a coughing fit) in an eye with morning glory disc anomaly. We postulate that a rapid alteration in intracranial pressure was transmitted through the cavitary disc defect. This allowed a sudden influx of cerebrospinal fluid and/or liquefied vitreous into the subretinal space. This previously unreported case provides important evidence for the role of intracranial pressure fluctuations in the pathogenesis of macular schisis and neurosensory detachment secondary to optic disc cavitations.

INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS IN PHACOVITRECTOMY FOR EPIRETINAL MEMBRANE AND MACULAR HOLE: A Clinical Audit of 1,000 Consecutive Eyes.

PURPOSE: The aim of this study was to report the intraoperative and postoperative complications of phacovitrectomy for epiretinal membrane (ERM) and macular hole (MH). METHODS: This was a retrospective audit of 1,052 phacovitrectomy operations (410 for ERM and 642 for MH) by the same surgical team between 1998 and 2017. Outcome measures included rates of intraoperative anterior segment and posterior segment complications such as posterior capsule rupture and retinal breaks. A subgroup analysis of 189 procedures in which postoperative complications were rigorously recorded was also undertaken. RESULTS: The rate of posterior capsule rupture was 2.2%, with no difference between ERM and MH (1.7 vs. 2.5%; P = 0.40). Iatrogenic retinal tears were more common in MH than in ERM surgery (15.6 vs. 6.8%; P < 0.001). The chance of one or more anterior segment or posterior segment intraoperative complications occurring (excluding iatrogenic retinal breaks) was not associated with: indication for surgery, grade of surgeon, gauge of surgery, surgical machine, diabetic status, patient sex, or patient age. Subgroup analysis showed postoperative events as follows: posterior capsular opacification 10.6% (20/189), posterior synechiae 4.2% (8/189), uveitis 2.1% (4/189), angle closure glaucoma 1.6% (3/189), and rhegmatogenous retinal detachment 1.1% (2/189). CONCLUSION: Phacovitrectomy seems to be safe in phakic patients with ERM or MH, performed either by fellows or consultants. It avoids the requirement for repeat surgery and is more cost and resource efficient.

Prescribing Trends in a Glaucoma Clinic and Adherence to EGS Guidelines: A Retrospective, Non-Interventional, Single-Center UK Study.

INTRODUCTION: The purpose of this study was to determine prescribing trends in a specialist glaucoma clinic in the UK. Specifically, the aims were to determine which drugs were prescribed as first-, second-, and third-line treatment, the persistence of first-, second-, and third-line treatment regimens, and the proportion of treatment decisions conforming to the European Glaucoma Society (EGS) guidelines. METHODS: A retrospective, non-interventional, single-center, case-note review was performed on a cohort of consecutive patients presenting to a specialist glaucoma clinic for follow-up. Inclusion criteria for the study were (1) a diagnosis of primary open-angle glaucoma or ocular hypertension, (2) glaucoma management entirely within the unit, and (3) minimum of 2 years of follow-up. RESULTS: A total of 114 case notes met the inclusion criteria. Mean age was 71 years (range 40-95 years). Mean length of follow-up was 56 months (range 24-180 months). Prostaglandin analogues (PGA) were the most popular first-line treatment in 73% of patients. As second-line treatment, PGA were again the predominant class, prescribed in 87% of cases, whereas beta-blockers (BB) were prescribed in 70% of cases. Carbonic anhydrase inhibitors (CAI) and alpha-2 agonists (AA) were more popular in third-line regimens. Second-line treatment was introduced at a mean of 28.0 months after first-line treatment (range 1-120 months, 95% CI 22.1-33.9 months). Third-line treatment was introduced at a mean of 22.9 months after second-line treatment (range 1-96 months, 95% CI 17.1-28.8 months). Breaches to EGS guidelines were most common for third-line treatment and included duplication of drug classes. DISCUSSION: There was a clear hierarchy of PGA as first-line, BB as second-line, while CAI and AA were considered third-line choices. First-line choices were generally in line with EGS guidelines. There was a tendency to breach guidelines by escalating treatment in dual steps rather than single steps (especially in third-line treatment). Combination drops were popular. In third-line treatment there was an increased incidence of prescribing errors. This data is important in terms of informing patients of the expected treatment course, to remind clinicians about best practice, and also to guide comparisons of cost-effectiveness with other treatment modalities.

Modeling Endothelial Cell Loss After Descemet Stripping Endothelial Keratoplasty: Data From 5 Years of Follow-up.

PURPOSE: To report 5-year outcomes for graft survival and endothelial cell survival after Descemet stripping endothelial keratoplasty (DSEK) including regression modeling for cell survival over time. METHODS: This is a single-institution, retrospective, consecutive interventional series of 210 primary DSEK grafts operated for low-to-moderate risk indications, specifically Fuchs dystrophy and bullous keratopathy. Primary outcomes were cumulative graft survival and % endothelial cell loss from 3 months through 5 years; the secondary outcome was to trend endothelial cell density over time by least-squares and mixed nonlinear modeling. RESULTS: Cumulative graft survival was high at 99%, 98%, and 94% at 1, 3, and 5 years, respectively. Mean endothelial cell loss was (mean ± SD) 44% ± 16%, 56% ± 17%, and 67% ± 13% at 1, 3, and 5 years. The trend in mean endothelial cell density over time by least square regression was accurately and parsimoniously described by a straight line taking earliest values (3 mo) through to 5 years, with a rate of cell loss of 148 ± 13 cells·mm·yr. Higher-order polynomial and exponential models did not provide a closer regression fit. Mixed nonlinear modeling using exponential decay equations confirmed a relatively stable rate of cell loss for DSEK from 3 months through to 5 years, in contrast to penetrating keratoplasty models using similar techniques in previous studies. CONCLUSIONS: DSEK graft survival is high in our series through 5 years. Endothelial cell loss occurs at a relatively constant albeit low-grade rate from the earliest postoperative measurements through 5 years.

Chronic postoperative fungal endophthalmitis caused by Penicillium citrinum after cataract surgery.

An 85-year-old man developed chronic postoperative endophthalmitis after complicated cataract surgery. Visual acuity in the affected eye was hand movements. Slitlamp biomicroscopy showed a hypopyon, superonasal iris nodule, and marked vitritis. An anterior chamber washout, iris biopsy, and intravitreal amphotericin injection were performed. Panfungal polymerase chain reaction of anterior chamber and vitreous samples were positive for Penicillium citrinum. The iris biopsy showed hyphae on Grocott staining. Despite treatment, the patient's acuity deteriorated to light perception and he developed severe intractable pain requiring evisceration. Histological analysis showed diffuse infiltration of hyphae. Penicillium species are fungal organisms that are ubiquitous in the environment and can cause chronic endophthalmitis. They are commonly dismissed as culture contaminants. True infection is confirmed by histological demonstration of fungal invasion. Diagnosis can be aided by iris biopsy if iris nodules are present. Polymerase chain reaction testing was beneficial in identifying the causative organism and should be considered early in endophthalmitis cases. Despite intravitreal and systemic antifungal treatment, the visual prognosis for this condition is variable. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Descemet Stripping Endothelial Keratoplasty in Iridocorneal Endothelial Syndrome: Postoperative Complications and Long-Term Outcomes.

PURPOSE: To determine the long-term outcomes of Descemet stripping endothelial keratoplasty (DSEK) in iridocorneal endothelial (ICE) syndrome. METHODS: Retrospective review of a consecutive series of 4 eyes of 4 patients with ICE syndrome treated by DSEK surgery at a single institution with follow-up between 2 and 7 years. RESULTS: Mean follow-up after initial DSEK surgery was 55 months (range, 24-95 months). One eye required 1 repeat DSEK, and 2 eyes required 2 repeat DSEKs for a total of 9 DSEK operations across the 4 eyes. There were no graft dislocations and no primary graft failures. Seven of 9 grafts achieved a visual acuity of 6/12 or better by 6 months. Mean endothelial cell loss at 3, 6, 12, and 24 months was 55 ± 14%, 78 ± 5%, 80 ± 6%, and 83 ± 9%, respectively. Long-term graft survival was poor with 7 of 9 grafts suffering late endothelial failure by a mean of 18 ± 7 months (range, 12-28 months). Mean graft survival on Kaplan-Meier analysis was 19 months (95% confidence interval, 14-24 months). CONCLUSIONS: DSEK has the potential to provide good short-term visual outcomes in eyes with ICE syndrome. However, long-term graft survival beyond 2 years is poor because of late endothelial failure. Patients with ICE considering DSEK surgery should be warned about the high probability of repeat surgery.