A Masquerade Case: Choroidal Hemangioma Misdiagnosed As Central Serous Retinopathy.

Purpose: To report a case of misdiagnosed choroidal hemangioma, initially treated as central serous retinopathy (CSR) complicated by choroidal neovascularization (CNV), and to improve the proper identification of this disorder. Observations: Fundus images revealed a subtle, elevated choroidal lesion with an associated exudative detachment and choroidal vascular lesion on indocyanine green (ICG) angiography. Combined treatment with photodynamic therapy (PDT) and anti-VEGF therapy led to resolution of fluid and improvement in VA from 20/50 to 20/25. Conclusion: It is critical to understand the clinical features of choroidal hemangiomas and their physical presentation on retinal testing to diagnose and treat them in a timely and appropriate manner.

Combined Central Retinal Artery and Vein Occlusion with Ischemic Optic Neuropathy After COVID-19 Vaccination.

PURPOSE: To report a case of combined central retinal vein and artery occlusion that evolved into ischemic optic neuropathy following the Pfizer COVID-19 vaccination. METHODS: Patient was followed with optical coherence tomography (OCT), fluorescein angiography, and Humphrey visual field. RESULTS: Patient was able to recover vision from count fingers to 20/30 on a combination of aflibercept, steroidal and non-steroidal anti-inflammatories, a diuretic (acetazolamide), antiplatelet agents (aspirin and pentoxifylline), and an anticoagulant (apixaban). CONCLUSION: COVID-19 vaccination may be associated with a myriad of sight-threatening ocular thrombotic conditions, which may respond to a combination of anti-inflammatory and anticoagulant therapies.

Macular Hole Surgery in Dome-Shaped Maculopathy.

PURPOSE: To present a successful case of macular hole surgery in a patient with dome-shaped maculopathy (DSM). OBSERVATIONS: Patient with DSM had successful closure of a full-thickness macular hole with surgery. There was persistent subretinal fluid after the surgery, which showed some response to a combination of a diuretic and a nonsteroidal anti-inflammatory drug (NSAID). CONCLUSIONS AND IMPORTANCE: Full-thickness macular hole in DSM may be effectively managed with modern surgical techniques.

Visual Snow-Like Symptoms and Posterior Uveitis following COVID-19 Infection.

Visual snow (VS) is a neurologic condition consisting of a constant positive visual disturbance described as "static" with diagnosis requiring exclusion of competing neurologic and ophthalmologic disorders. The authors describe the first case of visual snow-like symptoms in a patient following coronavirus disease 2019 (COVID-19) infection. He was found to have a transient subtle mild inflammatory reaction in the vitreous and optic nerve edema which resolved, but the VS persisted. Our findings suggest that COVID-19 may precipitate a transient autoimmune response in some patients with resultant ocular inflammation as well as long-term symptoms of VS. This has potential implications for the understanding and treatment of complications related to COVID-19 and in VS.

Anti-VEGF-Resistant Retinal Diseases: A Review of the Latest Treatment Options.

Anti-vascular endothelial growth factor (anti-VEGF) therapy currently plays a central role in the treatment of numerous retinal diseases, most notably exudative age-related macular degeneration (eAMD), diabetic retinopathy and retinal vein occlusions. While offering significant functional and anatomic benefits in most patients, there exists a subset of 15-40% of eyes that fail to respond or only partially respond. For these cases, various treatment options have been explored with a range of outcomes. These options include steroid injections, laser treatment (both thermal therapy for retinal vascular diseases and photodynamic therapy for eAMD), abbreviated anti-VEGF treatment intervals, switching anti-VEGF agents and topical medications. In this article, we review the effectiveness of these treatment options along with a discussion of the current research into future directions for anti-VEGF-resistant eyes.

Emerging biological therapies for the treatment of age-related macular degeneration.

INTRODUCTION: Age-related macular degeneration (AMD) is the leading cause of blindness in individuals over age 50 in developed countries. Current therapy for nonexudative AMD (neAMD) is aimed at modifying risk factors and vitamin supplementation to slow progression, while intravitreal anti-vascular endothelial factor (VEGF) injections are the mainstay for treatment of choroidal neovascularization in exudative AMD (eAMD). AREAS COVERED: Over the past decade, promising therapies have emerged that aim to improve the current standard of care for both diseases. Clinical trials for neAMD are investigating targets in the complement cascade, vitamin A metabolism, metformin, and tetracycline, whereas clinical trials for eAMD are aiming to decrease treatment burden through novel port delivery systems, increasing drug half-life, and targeting new sites of the VEGF cascade. Stem cell and gene therapy are also being evaluated for treatment of neAMD and eAMD. EXPERT OPINION: With an aging population, the need for effective, long term, low burden treatment options for AMD will be in increasingly high demand. Current investigations aim to address the shortcomings of current treatment options with breakthrough treatment approaches. Therapeutics in the pipeline hold promise for improving the treatment of AMD, and are on track for widespread use within the next decade.

A Bibliometric Analysis of the Top 100 Cited Papers in Retinal Detachment.

Purpose: This work aimed to identify and analyze the most frequently cited articles in retinal detachment (RD). Methods: Institute for Scientific Information's Web of Science index (Thomas Scientific) was used to identify the top 100 most cited articles on RD between 1900 and 2019. Data from the top 100 most cited articles that met inclusion criteria were analyzed based on title, citation frequency, authorship, institution, journal, year of publication, and country of origin. Results: The top 100 articles in RD were cited 88 to 480 times. Steven K. Fisher was the most cited individual, with the University of California system being the most cited organization. Sixty-four percent of the top 100 articles originated from the United States and were published in the American Journal of Ophthalmology, Ophthalmology, and Archives of Ophthalmology at frequencies of 36%, 24%, and 11%, respectively. The top funding agencies included the US Department of Health and Human Services, the National Institutes of Health, and the National Eye Institute at 29%, 28%, and 27%, respectively. The top-cited article, which assessed the role of the retinal pigment epithelium by histologic and electron microscopic analysis of RDs in eyes of owl monkeys, was by Machemer and Laqua in the American Journal of Ophthalmology. Conclusions: This bibliometric analysis provides researchers and clinicians with a detailed overview of the most cited manuscripts in RD. Such analyses may guide researchers and funding agencies on important research areas in the field.

Outcomes of Epiretinal Membrane Removal Utilizing Triamcinolone Acetonide Visualization and Internal Limiting Membrane Forceps.

PURPOSE: To evaluate epiretinal membrane (ERM) removal utilizing internal limiting membrane (ILM) forceps and visualization with triamcinolone acetonide (TA). METHODS: Retrospective interventional case series of eyes undergoing ERM removal with TA visualization with follow-up of up to five years. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and incidence of complications were reviewed. RESULTS: A total of 132 eyes were included with 54 and 16 eyes completing 3- and 5-year follow-up, respectively. Mean BCVA and CMT improved significantly at all postoperative evaluations compared to baseline (p<0.001). Pre-operative presence of PVD did not affect outcome measures. No intraoperative complications were reported. Immediate post-operative complications included one case of sterile endophthalmitis and one case of vitreous and perimacular hemorrhage. At one year, complications included progression of cataract in phakic eyes (65.4%), steroid-induced glaucoma (2.2%), retinal tear (0.8%), recurrent ERM (4.5%), and recurrent macular edema (11.3%). No further complications were reported at three- and five-year follow-up. CONCLUSION: Combination ILM forceps and TA visualization offers an affordable and safe option for ERM removal with comparable or better outcomes than traditional methods of ERM surgery.

Multifocal ERG and Microperimetry Changes in Response to Ranibizumab Treatment of Neovascular AMD: Randomized Phase 2 Open-Label Study.

PURPOSE: To compare monthly versus pro re nata (PRN) ranibizumab injections in the treatment of exudative macular degeneration (AMD) while assessing the utility of microperimetry (MP) and multifocal electroretinography (mfERG) testing when monitoring response to treatment. METHODS: A randomized exploratory trial comparing the efficacy of monthly versus PRN dosing of ranibizumab (0.5 mg or 2.0 mg) for patients with exudative AMD over 12 months. High-resolution optical coherence tomography (HR-OCT) studies were used to guide PRN treatment and any cystic spaces or subretinal fluid prompted retreatment. Macular function was assessed using mean sensitivity on MP and N1-P1 response density on mfERG. Best-corrected visual acuity (BCVA) was measured with Early Treatment Diabetic Retinopathy Study (ETDRS) letters and anatomic response assessed with central foveal thickness (CFT) using HR-OCT studies. RESULTS: The 12-month study was completed by 43 patients in the PRN cohort and 33 patients in the monthly cohort. Mean BCVA improved by 6.0 ± 1.3 ETDRS letters in the PRN cohort compared to 7.3 ± 2.8 ETDRS letters in the monthly cohort (p=0.68). A reduction in mean CFT of 64.5 ± 13.3 and 96.3 ± 22.0 µm occurred in the PRN and monthly cohorts, respectively (p=0.22). Macular function assessed with mfERG decreased comparably in both the PRN and monthly cohorts (p=0.33). For all patients, average mean sensitivity significantly improved by 1.7 ± 0.5 dB (p<0.05) and N1-P1 response density significantly decreased by 0.52 ± 0.21 nV/deg2 (p<0.05). CONCLUSION: Both PRN and monthly treatment of exudative AMD with ranibizumab improve visual function as assessed by BCVA and MP. Macular thickening also improved as demonstrated by HR-OCT findings. However, the decreased retinal function noted by mfERG suggests that some loss of retinal function still occurs despite effective treatment. These measures of visual function may be useful in assessing retinal health and response to treatment in future clinical trials.

Case Series on Initial Responses to Intravitreal Brolucizumab in Patients with Recalcitrant Chronic Wet Age-Related Macular Degeneration.

PURPOSE: To report a case series of initial responses to intravitreal brolucizumab in patients already undergoing anti-VEGF therapy for wet age-related macular degeneration. CASE SERIES: Six eyes (6 patients) with a history of wet age-related macular degeneration presented with either decline in vision or no improvement while undergoing treatment with anti-VEGF therapy - aflibercept or bevacizumab. Patients were switched to intravitreal brolucizumab. Four weeks post-injection, there was no significant change in visual acuity. Optical coherence tomography scans were taken and improved IRF/SRF, central macular thickness and average pericentral thickness were observed in all 6 patients. No serious adverse reactions were observed, including signs of vasculitis or increase in anterior chamber cell count at the 4-week follow-up for all 6 patients. CONCLUSION: Intravitreal brolucizumab appears to be a safe and limitedly effective option for patients with recalcitrant CNV from wet AMD.

A case of Legionnaire's endophthalmitis.

Purpose: To report a case of endophthalmitis associated with Legionella Pneumophila . Case Report: A 46-year-old, highly myopic male with a complex history of recurrent retinal detachments, macular hole, cataract surgery and an infected scleral buckle in the left eye, presented with pain, redness, hypopyon and vision loss in the left eye, 14 days following blunt head trauma. Empirical treatment for endophthalmitis with intravitreal injections of Vancomycin and Ceftazidime afforded minimal improvement. He developed recurrent hypopyon and underwent vitrectomy surgery with intravitreal antibiotic injections at the time of surgery and had improvement. Intraoperative culture was positive for Legionella Pneumophila. He had continued episodes of recurrent inflammation which were quelled by intravitreal moxifloxacin injections performed every 3-10 days. He developed a recurrent RD with proliferative vitreoretinopathy (PVR) and underwent vitrectomy with silicone oil. The retina was reattached but had no light perception vision in the affected eye. Conclusion: When endophthalmitis is contracted in a work-place setting, a culture for L. pneumophila should be considered. A combination of intravitreal moxifloxacin and oral azithromycin may be effective.

Silicone oil droplets following intravitreal bevacizumab injections.

PURPOSE: To report the transient resurgence of symptomatic silicone oil droplets following intravitreal bevacizumab injections. OBSERVATIONS: We report seven patients presenting with silicone oil droplets following intravitreal bevacizumab injections. These were the first cases noted in 10 years using the same supplier of preloaded syringes in an estimated 90,413 injections performed by 7 physicians. They occurred during a 4 month period (06-10/2016), suggesting they may have been related to a batch or batches of syringes. Symptomatic floaters attributed to the droplets were noted on an average of 6.7 ± 1.5 days following the injection and followed an average of 10.4 ± 3.75 injections over a period of 3.4 ± 1.9 years and resolved in 5 of our 7 patients within 9 months. CONCLUSIONS AND IMPORTANCE: Symptomatic intravitreal silicone oil droplets are a rare complication of intravitreal injections. Symptoms are generally transient and not clinically significant and hence the benefits of treating potentially blinding eye diseases in this fashion appear to outweigh the limited risk of the rare, temporary floaters. The current series may be related to a batch or batches of syringes.

Photodynamic therapy combined with antivascular endothelial growth factor treatment for recalcitrant chronic central serous chorioretinopathy.

PURPOSE: To determine whether combination photodynamic therapy (PDT) and antivascular endothelial growth factor (VEGF) therapy is effective in the management of chronic central serous chorioretinopathy (CSC) recalcitrant to conventional therapy. METHODS: This was a retrospective analysis of eight patients with chronic CSC unresponsive to topical nonsteroidal anti-inflammatory drugs, focal photocoagulation, anti-VEGF alone, or PDT alone. All patients were evaluated with a full ophthalmic examination, spectral-domain optical coherence tomography (OCT), fluorescein angiography (FA), and most with indocyanine green angiography (ICGA) followed by treatment with half-fluence PDT and intravitreal anti-VEGF injection (seven bevacizumab, one aflibercept). Patients were seen in follow-up 1 month after treatment. RESULTS: All eight patients achieved complete resolution in subretinal fluid following combination treatment. Average duration of CSC prior to initiation of combination therapy was 7.5 months. Mean central macular thickness on OCT decreased significantly from 401.2±52.7 µm to 297.9±18.2 µm (p=0.0010) by 4 months after treatment (1.63±1.18 months). Seven of eight patients were followed up for an average of 13 months with no recurrence during that time. One case recurred at 8 months and was treated with repeat combination at that time. Frank choroidal neovascularization (CNV) was not identified in these cases on FA or ICGA studies. Eight of eight patients showed significant improvement in vision from a logMAR of 0.1125±0.099 to 0.0125±0.064 (p=0.019). CONCLUSION: Combination PDT and anti-VEGF is effective for chronic CSC which has failed conventional therapy. Associated CNV and/or inflammation may be reasons for greater success in patients treated with combination therapy.

Identifying rhegmatogenous detachments in bullous retinoschisis with optical coherence tomography studies.

PURPOSE: To demonstrate a novel technique for capturing optical coherence tomography images of peripheral retina and its application in identifying rhegmatogenous retinal detachments within bullous retinoschisis. OBSERVATIONS: We report two patients presenting with bullous retinoschisis noted on clinical examination. After performing optical coherence tomography studies utilizing our image acquisition technique these lesions were found to be associated with rhegmatogenous retinal detachments. Both patients were subsequently treated without further complications. CONCLUSIONS AND IMPORTANCE: The image acquisition technique described herein allows visualization of peripheral retina utilizing optical coherence tomography studies to identify areas of rhegmatogenous retinal detachment within bullous retinoschisis that are otherwise difficult to discern.

Combination verteporfin photodynamic therapy ranibizumab-dexamethasone in choroidal neovascularization due to age-related macular degeneration: results of a phase II randomized trial.

PURPOSE: To assess whether combination therapy (CT) reduces retreatments when compared to ranibizumab monotherapy (RM), while safely maintaining similar vision outcomes. METHODS: In this 24-month trial, patients with age-related macular degeneration (AMD) were randomized to 1) quarter-fluence or 2) half-fluence triple therapy (verteporfin photodynamic therapy [vPDT] + ranibizumab + dexamethasone), 3) half-fluence double therapy (vPDT + ranibizumab), or 4) RM. The primary outcomes were number of retreatment visits and change from baseline in visual acuity (VA) at 12 months. RESULTS: One hundred sixty-two subjects enrolled. There were 4.0 (P=0.02), 3.2 (P<0.001), 4.1 (P=0.03), and 5.7 retreatment visits through month 12, and 5.9 (P=0.03), 4.3 (P<0.001), 5.9 (P=0.02) and 8.7 through month 24, in groups 1, 2, 3, and 4, respectively (P-value comparing with RM). Month 12 VA score change from baseline (95% confidence interval) was +3.6 (-0.9 to +8.1), +6.8 (+2.4 to +11.1), +5.0 (+0.6 to +9.3), and +6.5 (+1.7 to +11.4), respectively. CONCLUSION: CT resulted in significantly fewer retreatment visits than a RM regimen at months 12 and 24. VA results appeared similar although wide confidence intervals preclude conclusions regarding vision outcomes.

Combined Scleral Flap with Donor Scleral Patch Graft for Anterior Tube Placement in Glaucoma Drainage Device Surgery.

Purpose. To report a new technique for anterior placement of tubes for glaucoma drainage devices to reduce the risk of tube erosions. Methods. Retrospective review of select cases of Ahmed Valve surgery combined with the novel method of a limbal-based scleral flap covered by a scleral patch graft to cover the tube at the entrance through the limbus. Intraoperative and postoperative illustrations are shown to highlight the method of tube placement. Results. In this retrospective case series, 3 patients are presented illustrating the technique. Two had neovascular glaucoma and one had primary open-angle glaucoma (POAG). On average, intraocular pressure was reduced from 39 ± 14 mmHg to 15 ± 2 mmHg and the number of glaucoma medications was reduced from 4 ± 1 to 0. Preoperative and most recent visual acuities were hand-motion (HM) and HM, 20/60 and 20/50, and 20/70 and 20/30, respectively. Conclusion. The combination of a limbal-based scleral flap with scleral patch graft to cover the tube with glaucoma drainage devices may be an effective means to reduce erosion and protect against endophthalmitis.

Strong topical steroid, NSAID, and carbonic anhydrase inhibitor cocktail for treatment of cystoid macular edema.

PURPOSE: To report the combination cocktail of strong steroid, non-steroidal anti-inflammatory drug (NSAID), and carbonic anhydrase inhibitor drops for treatment of cystoid macular edema. METHODS: This is a retrospective case series of patients with cystoid macular edema managed with a topical combination of strong steroid (difluprednate), NSAID, and carbonic anhydrase inhibitor drops. The patients were followed with optical coherence tomography and fluorescein angiography. RESULTS: In our six cases, resolution of the cystic edema with improvement in visual acuity was achieved with the use of a combination cocktail of drops. Leakage on fluorescein angiography and cystic edema on optical coherence tomography both responded to treatment with the topical cocktail of drops. CONCLUSION: A topical cocktail of strong steroid, NSAID, and carbonic anhydrase inhibitor drops are effective for managing cystoid macular edema. Further studies comparing this combination with more invasive treatments should be undertaken to determine the efficacy of this cocktail over other treatment options.

Acute macular edema following intracorporeal prostaglandin injection for erectile dysfunction.

PURPOSE: We aimed to describe the first case of macular edema following intracorporeal injection of alprostadil, a prostaglandin E1. METHODS: This was a retrospective case report followed with optical coherence tomography, fundus photos, and fluorescein angiography images. RESULTS: A patient developed bilateral cystoid macular edema following intracorporeal injection of alprostadil, a prostaglandin E1 for treatment of erectile dysfunction. The edema resolved following treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, with subsequent recovery in visual acuity. DISCUSSION: Systemic prostaglandin administration can cause macular edema and vision loss, indicating that elevated systemic prostaglandin levels may affect visual function. This has potential implications for other systemic disorders and treatments that could affect macular function.

Topical difluprednate for the treatment of Harada's disease.

PURPOSE: To describe the use of topical difluprednate for treatment of patients who presented with Harada's disease. METHODS: Retrospective case series of patients managed with topical difluprednate alone at the onset of the diagnosis. The patients were followed with optical coherence tomography (OCT) and fluorescein angiography. RESULTS: In our three cases, complete resolution of the exudative detachments with improvement in visual acuity was achieved in each case. Central macular thickness was reduced by a mean of 365±222 µm. Initial loading dose was one drop every hour while awake, followed by a variable tapering regimen. Leakage on fluorescein angiography and exudative detachments on OCT both responded to treatment with difluprednate. In two of the three cases, the patients recovered vision to 20/20, and the third case recovered to 20/25. Steroid-induced glaucoma was observed and managed with one to two glaucoma drops as needed. CONCLUSION: Difluprednate is effective for managing ocular manifestations of Harada's disease. Further studies of this drug for the management of noninfectious posterior uveitis are warranted.