Democratizing Vitreoretinal Surgery Training With a Portable and Affordable Virtual Reality Simulator in the Metaverse.

Purpose: The purpose of this study was to develop and validate RetinaVR, an affordable, portable, and fully immersive virtual reality (VR) simulator for vitreoretinal surgery training. Methods: We built RetinaVR as a standalone app on the Meta Quest 2 VR headset. It simulates core vitrectomy, peripheral shaving, membrane peeling, and endolaser application. In a validation study (n = 20 novices and experts), we measured: efficiency, safety, and module-specific performance. We first explored unadjusted performance differences through an effect size analysis. Then, a linear mixed-effects model was used to isolate the impact of age, sex, expertise, and experimental run on performance. Results: Experts were significantly safer in membrane peeling but not when controlling for other factors. Experts were significantly better in core vitrectomy, even when controlling for other factors (P = 0.014). Heatmap analysis of endolaser applications showed more consistent retinopexy among experts. Age had no impact on performance, but male subjects were faster in peripheral shaving (P = 0.036) and membrane peeling (P = 0.004). A learning curve was demonstrated with improving efficiency at each experimental run for all modules. Repetition also led to improved safety during membrane peeling (P = 0.003), and better task-specific performance during core vitrectomy (P = 0.038), peripheral shaving (P = 0.011), and endolaser application (P = 0.043). User experience was favorable to excellent in all spheres. Conclusions: RetinaVR demonstrates potential as an affordable, portable training tool for vitreoretinal surgery. Its construct validity is established, showing varying performance in a way that correlates with experimental runs, age, sex, and level of expertise. Translational Relevance: Fully immersive VR technology could revolutionize surgical training, making it more accessible, especially in developing nations.

The role of optical coherence tomography angiography in dome-shaped maculopathy.

PURPOSE: To demonstrate the role of optical coherence tomography angiography (OCT-A) in the management of dome-shaped maculopathy (DSM). METHODS: Retrospective case review. RESULTS: A 52-year-old woman was referred to our retina service for potential bilateral choroidal neovascular membrane (CNVM) and blurry vision bilaterally. Initial spectacle-corrected visual acuity (VA) was 20/30-2 in the right eye (RE) and 20/30+2 in the left eye (LE). DSM was diagnosed on OCT. In both eyes, OCT B-scan passing through the fovea showed shallow, irregular RPE elevation (SIRE) suspicious of occult (type 1) CNVM. The outer retina and choriocapillaris angiograms showed a zone of nonexudative CNVM in the RE and exudative CNVM in the LE. Given the persistent SRF with CNVM in the LE, we elected to perform intravitreal injections of ranibizumab 0.5 mg on a treat and extend regimen. Upon the most recent follow-up, the best corrected VA improved to 20/20 in the LE with no persisting SRF. CONCLUSION: We present a case where assessing disease progression, the development of CNVM and evaluating the efficiency of therapies were realized through the application of novel OCT-A technology. This diagnostic tool may be used to guide clinicians in their management of DSM, as demonstrated through our experience. OCT-A can also make it possible to visualize nonexudative CNVM lesions that may be missed on traditional imaging assessments.

Paracentral Acute Middle Maculopathy in Migraines with Aura.

Paracentral acute middle maculopathy (PAMM) has recently been described following episodes of migraine. In this report, we present a case of PAMM and describe the role of en face optical coherence tomography (OCT). A 75-year-old woman presented with subjective vision loss over a 2-week period in the right eye. She was known for migraines with aura that presented with progressive spreading of positive and negative visual phenomena which usually resolved in under an hour. Her recent migraine episode was "atypical," as it lasted 3 days. She also experienced a monocular central scotoma with "black spots and jagged, zig-zag edges." The positive auras resolved spontaneously, whereas the central scotoma persisted. Spectral domain OCT showed an area of perifoveal hyperreflectivity from the inner plexiform to the outer plexiform layers consistent with PAMM. The mid-retina en face OCT and OCT angiography demonstrated an ovoid focal patch of hyperreflectivity with flow interruption, characteristic of globular PAMM. We diagnosed her with migraines with aura and presumed retinal vasospasm, complicated by retinal ischemia in the form of globular PAMM. Acute retinal ischemia, which may require urgent neurovascular workup and giant cell arteritis evaluation, must be considered in patients with migraines alongside persistent visual changes. Diagnosing PAMM requires a high level of suspicion since it can present without significant changes in visual acuity, visual fields, and fundus photographs. With the inclusion of en face OCT in the clinicians' diagnostic armamentarium, the slightest signs of retinal ischemic changes, such as PAMM, become evident.

Outcomes of Pars Plana Vitrectomy and 4-Point Sutured Scleral Fixation of Akreos AO60 Intraocular Lens in Clinical Settings: A Case Series.

PURPOSE: To determine the long-term anatomic outcomes and surgical complications of pars plana vitrectomy (PPV) and 4-point Gore-Tex-sutured Akreos AO60 intraocular lens (IOL) scleral fixation. DESIGN: Retrospective, multicenter, multisurgeon case series. PARTICIPANTS: Ninety-seven patients in tertiary eye care centers. METHODS: The patients underwent PPV and intraocular fixation of the Akreos AO60 IOL using Gore-Tex CV-8 sutures between January 2015 and April 2020. The inclusion criteria were aphakia, no capsular support, and a minimal 1 year of follow-up. MAIN OUTCOME MEASURES: Uncorrected visual acuity (VA), complication rates or types, and refraction. RESULTS: Data from 101 eyes of the 97 patients were analyzed (mean follow-up duration, 33.4 months; range, 12-62 months). The mean ± standard deviation uncorrected logarithm of the minimum angle of resolution VA improved from 1.04 ± 0.73 (20/200 Snellen equivalent) before surgery to 0.66 ± 0.65 (20/80) at 6 months after surgery (P < 0.001). The most prevalent complications included hypotony (12.9%), ocular hypertension (12.9%), corneal edema (8.9%), cystoid macular edema (6.9%), and vitreous hemorrhage (5.9%). Refraction was measured between 3 and 6 months after surgery, and 61.8% of the patients had spherical equivalent of ± 2.0 diopters. Most complications occurred in the first postoperative month and resolved spontaneously or with medical treatment. CONCLUSIONS: The results demonstrated that this surgical technique is well tolerated by the eyes, with a low complication rate in the long term. The rates of IOL opacification were infrequent for up to 62 months of follow-up.

Indications and pathologic diagnoses of diagnostic chorioretinal biopsies in the province of Quebec, Canada.

OBJECTIVE: To review the clinical usefulness of chorioretinal biopsies in diagnostically undefined cases of intraocular inflammation or chorioretinal lesions. DESIGN: Retrospective case series. PARTICIPANTS: Seven patients who underwent chorioretinal biopsies. METHODS: This case series included all consecutive patients who underwent chorioretinal biopsies in 2 academic tertiary care centres in the province of Quebec between 2014 and 2020. RESULTS: A total of 7 patients were included in the study. Five patients with intraocular inflammation underwent chorioretinal biopsies to rule out an infectious or neoplastic etiology, whereas 2 patients underwent biopsies for suspicion of neoplastic chorioretinal masses. Final diagnoses included primary chorioretinal lymphoma (n = 2), toxoplasmosis (n = 1), benign choroidal mass (n = 1), nonnecrotizing granuloma (n = 1), and peripheral exudative hemorrhagic chorioretinopathy (n = 1). No specific diagnosis was defined in 1 case of panuveitis with scleritis. No postoperative complications were reported. CONCLUSIONS: Chorioretinal biopsies clarified the diagnosis in 6 of 7 patients, including a definitive diagnosis of lymphoma in 2 patients. This is a high rate of diagnosis that also represents clinically meaningful results that influence management. Future directions include identifying patients in whom adjuvant chorioretinal biopsy would yield a high rate of diagnosis.

Accuracy of automated machine learning in classifying retinal pathologies from ultra-widefield pseudocolour fundus images.

AIMS: Automated machine learning (AutoML) is a novel tool in artificial intelligence (AI). This study assessed the discriminative performance of AutoML in differentiating retinal vein occlusion (RVO), retinitis pigmentosa (RP) and retinal detachment (RD) from normal fundi using ultra-widefield (UWF) pseudocolour fundus images. METHODS: Two ophthalmologists without coding experience carried out AutoML model design using a publicly available image data set (2137 labelled images). The data set was reviewed for low-quality and mislabeled images and then uploaded to the Google Cloud AutoML Vision platform for training and testing. We designed multiple binary models to differentiate RVO, RP and RD from normal fundi and compared them to bespoke models obtained from the literature. We then devised a multiclass model to detect RVO, RP and RD. Saliency maps were generated to assess the interpretability of the model. RESULTS: The AutoML models demonstrated high diagnostic properties in the binary classification tasks that were generally comparable to bespoke deep-learning models (area under the precision-recall curve (AUPRC) 0.921-1, sensitivity 84.91%-89.77%, specificity 78.72%-100%). The multiclass AutoML model had an AUPRC of 0.876, a sensitivity of 77.93% and a positive predictive value of 82.59%. The per-label sensitivity and specificity, respectively, were normal fundi (91.49%, 86.75%), RVO (83.02%, 92.50%), RP (72.00%, 100%) and RD (79.55%,96.80%). CONCLUSION: AutoML models created by ophthalmologists without coding experience can detect RVO, RP and RD in UWF images with very good diagnostic accuracy. The performance was comparable to bespoke deep-learning models derived by AI experts for RVO and RP but not for RD.

Bilateral diffuse uveal melanocytic proliferation: Report of a novel optical coherence tomography finding and clinical response to plasmapheresis.

PURPOSE: To describe a novel optical coherence tomography (OCT) finding in a case of bilateral diffuse uveal melanocytic proliferation (BDUMP) and to report the clinical response to plasmapheresis. OBSERVATIONS: We report the case of a 54-year-old man who was being treated with adjuvant immune checkpoint inhibitors for metastatic renal cell carcinoma. He had suffered from bilateral progressive vision loss without ocular pain. At presentation in the retina clinic, visual acuity was counting fingers bilaterally. Examination revealed characteristic findings suggestive of a peculiar paraneoplastic intraocular syndrome called BDUMP. Multiple choroidal nevi-like melanocytic tumors were noted bilaterally. The diagnosis was confirmed using multimodal imaging with fluorescein angiography and fundus autofluorescence, which revealed a typical leopard pattern. Ultrasonography revealed choroidal thickening extending to the ciliary body. OCT showed multiple pockets of serous retinal detachment (SRD) and bacillary layer detachment (BALAD), a newly recognized and rarely described manifestation of the disease. The clinical response to plasmapheresis was robust with resolution of the BALAD and SRD and improvement of the vision to 20/30 in both eyes at the seven-month follow-up. CONCLUSIONS AND IMPORTANCE: BALAD is a newly recognized manifestation of BDUMP. Early recognition of this paraneoplastic syndrome and prompt initiation of plasmapheresis has the potential to improve and stabilize vision.

Impact of patient face mask use on endophthalmitis after intravitreal anti-VEGF injections.

OBJECTIVE: To compare the incidence of endophthalmitis after intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections with and without patient face masking. DESIGN: Two-centre retrospective cohort study PARTICIPANTS: Patients receiving a total of 28 501 injections (period 1 before masking: n = 13 863; period 2 after masking: n = 14 638) METHODS: Periods before and after implementation of patient masking were compared: period 1 (July-December 2019) and period 2 (July-December 2020). All patients requiring treatment for endophthalmitis following intravitreal anti-VEGF injections were reviewed. Endophthalmitis risks were compared. Statistical simulations were run to determine the number of injections or endophthalmitis cases required to detect a statistically significant difference between both periods. RESULTS: Five patients (0.036%) had endophthalmitis in period 1 compared with 7 patients (0.048%) in period 2. Odds ratio, 95% confidence interval, for risk of patient masking was 1.326, 0.421-4.179 (p = 0.63). Three patients (0.022%) in period 1 had culture-positive endophthalmitis compared with 2 patients (0.014%) in period 2. Risk of patient masking for culture-positive endophthalmitis was 0.631, 0.105-3.779 (p = 0.61). Assuming similar rates of endophthalmitis, 476,806 injections in both groups would be required to detect a significant difference. Alternatively, assuming that masking would increase endophthalmitis risk in period 2, a significant difference would require twice as many cases (n = 15, 0.102%) for a risk of 2.843, 1.033-7.825 (p = 0.043). CONCLUSIONS: The implementation of patient masking in clinical practice did not significantly alter the rate of endophthalmitis following intravitreal anti-VEGF injections.

MINIMAL INVASIVE DRAINAGE TECHNIQUE FOR LARGE EXPANDING SUBRETINAL GAS BUBBLE.

PURPOSE: To report a minimally invasive drainage technique for large expanding subretinal gas bubble and conduct a review of the literature. METHODS: Case report, with schematic diagrams and multimodal imaging including fundus photography and spectral domain optical coherence tomography. Controlled drainage of large subretinal gas bubble using a 30-gauge needle introduced through cryotherapy-treated area in office-based setting. RESULTS: Forty-year-old male patient presented with bullous rhegmatogenous retinal detachment and had gas inadvertently injected into the subretinal space during cryo-pneumatic retinopexy. After successful drainage of subretinal gas in clinic, 0.3cc of perfluoropropane (C3F8) gas was injected in different quadrants near the attached retina. The macula remained attached on immediate fundus examination. The gas bubbles of fish eggs coalesced into a single large bubble within 1 week. Spectral domain optical coherence tomography showed unremarkable foveal scans. After 45 days, the gas bubble completely disappeared, the retina remained attached, and vision in the treated eye was 20/20. CONCLUSION: To the best of our knowledge, this is the first case report of a large expanding gas bubble injected into the subretinal spaces being drained successfully by the described minimal invasive technique. Although it may offer a possible office-based approach to a rare complication, it is generally recommended that surgeons capable of dealing with its possible complications may attempt such technique when immediate vitrectomy is not accessible.

360-degree intra-operative laser retinopexy for the prevention of retinal re-detachment in patients treated with primary pars plana vitrectomy.

PURPOSE: To investigate the effect of 360° intra-operative laser retinopexy (ILR) for the prevention of retinal re-detachment in patients treated with pars plana vitrectomy (PPV) for primary rhegmatogenous retinal detachment (RRD). METHODS: A retrospective single-institution cohort study was performed. Consecutive patients with primary uncomplicated RRD who underwent 23-gauge PPV with gas endotamponade between July 2013 and July 2016 were included in the study (n = 151). Two cohorts were compared: one which received laser retinopexy only around identified tears/holes/lattice zones (Control group, n = 86), and one which received additional 360° intra-operative laser retinopexy (360° ILR group, n = 65). RESULTS: Retinal re-detachment was seen in 4/65 eyes (6%) in the 360° ILR group compared to 18/86 eyes (21%) in the control group. In multiple logistic regression, the 360° ILR was associated with a 75% reduction in the odds of retinal re-detachment compared to control (OR = 0.248, 95% CI [0.079-0.772], p = 0.016). There was no statistically significant difference in the incidence of epiretinal membrane formation between the two groups. CONCLUSIONS: Intra-operative 360° laser retinopexy during PPV with gas endotamponade resulted in a significant reduction in the odds of postoperative retinal re-detachment in eyes with uncomplicated primary RRD.

STELLATE NONHEREDITARY IDIOPATHIC FOVEOMACULAR RETINOSCHISIS: RESPONSE TO TOPICAL DORZOLAMIDE THERAPY.

PURPOSE: To report the clinical course of a patient presenting with stellate nonhereditary idiopathic foveomacular retinoschisis (SNIFR) in response to topical Dorzolamide treatment. METHODS: Case report, with multimodal imaging findings, including spectral domain optical coherence tomography and fluorescein angiography. Topical Dorzolamide Hydrochloride 2% drops were used three times per day in the affected eye. RESULTS: We identified a 27-years-old male patient who presented with 1-week history of decreased vision in his left eye. Spectral domain optical coherence tomography of the affected eye showed macular splitting of the inner plexiform layer and outer plexiform layer involving the fovea with no other evidence of a hereditary or acquired predisposing condition. The patient was started on the topical treatment for 6 months with visual improvement from 20/40 to 20/30 in the left eye, after which the decision to stop topical dorzolamide therapy was made. On 3 months of follow-up, visual acuity decreased back to 20/40 in the left eye with an increase in retinal thickening on spectral domain optical coherence tomography. Topical dorzolamide was restarted three times per day in the left eye. At 1-year point after restarting treatment, visual acuity was 20/20 in the left eye, with resolved inner plexiform layer and outer plexiform layer splitting on spectral domain optical coherence tomography in the left eye. CONCLUSION: Stellate nonhereditary idiopathic foveomacular retinoschisis can be a devastating problem causing decrease in vision. To the best of our knowledge, this is the first case in the literature to report the complete resolution of SNIFR in response to topical dorzolamide hydrochloride 2% therapy. Further prospective studies are vital to better elucidate our understanding of this new disease identity.

Visual Loss from Choroidal Melanoma Mimicking Neurological Syndromes.

Melanoma of the eye is rare, but can mimic a range of disorders. This report highlights 2 cases of choroidal melanoma with vision loss mimicking neurological diagnoses. The first patient is a 41-year-old white male with a known history of multiple sclerosis and a previous episode of optic neuritis in the right eye, who presented with a 6-month history of decreased vision in the same eye, and occasional photopsiae. He was treated with 2 courses of oral steroids for presumed recurrent optic neuritis. After a temporary improvement in his symptoms, his vision worsened, following which he had a head MRI, which revealed a solid intraocular mass. He was subsequently diagnosed with a choroidal melanoma for which he was treated successfully with ruthenium-106 plaque brachytherapy. The second patient is a 57-year-old female, who presented with a progressive cerebellar syndrome under investigation by the neurology service, as well as decreased vision in the right eye. Her visual acuity gradually deteriorated and her neurological assessment, which included a PET-CT, revealed uptake in the right eye. The diagnosis of a choroidal melanoma was made, and following conservative treatment with proton beam radiotherapy, she had an enucleation of the eye. Intraocular tumours can masquerade as many different entities. Unexplained unilateral visual loss, especially if it is atypical for a neurological syndrome, should prompt dilated fundoscopy and referral to an ophthalmologist.

Choroidal extranodal marginal zone lymphoma diagnosed by full-thickness retinochoroidal biopsy: case report and review of the literature.

The case of an 89-year-old man who was referred for a painless decrease of vision in his right eye (RE) is reported. Fundus examination of the RE showed an elevated amelanotic lesion located in the posterior pole with an adjacent focal round pigmented lesion. There was also a more peripheral amelanotic lesion extending from 6 to 9 o'clock clockwise inferotemporally. Uveitis workup and imaging studies of brain and orbits were normal. A retinochoroidal biopsy was done and showed the presence of choroidal extranodal marginal zone lymphoma. The patient was treated with external beam radiotherapy. This report presents a review of the literature of all reported cases of choroidal extranodal marginal zone lymphoma.

Lymphocytic Microparticles Modulate Angiogenic Properties of Macrophages in Laser-induced Choroidal Neovascularization.

Pathological choroidal neovascularization (CNV) is the common cause of vision loss in patients with age-related macular degeneration (AMD). Macrophages possess potential angiogenic function in CNV. We have demonstrated that human T lymphocyte-derived microparticles (LMPs) exert a potent antiangiogenic effect in several pathological neovascularization models. In this study, we investigated the alteration of proangiogenic properties of macrophages by LMPs treatment in vitro and in vivo models. LMPs regulated the expression of several angiogenesis-related factors in macrophages and consequently stimulated their antiangiogenic effects evidenced by the suppression of the proliferation of human retinal endothelial cells in co-culture experiments. The involvement of CD36 receptor in LMPs uptake by macrophages was demonstrated by in vitro assays and by immunostaining of choroidal flat mounts. In addition, ex vivo experiments showed that CD36 mediates the antiangiogenic effect of LMPs in murine and human choroidal explants. Furthermore, intravitreal injection of LMPs in the mouse model of laser-induced CNV significantly suppressed CNV in CD36 dependent manner. The results of this study suggested an ability of LMPs to alter the gene expression pattern of angiogenesis-related factors in macrophages, which provide important information for a new therapeutic approach for efficiently interfering with both vascular and extravascular components of CNV.

Outcome of viscodilation and tensioning of Schlemm's canal for uveitic glaucoma.

OBJECTIVE: To evaluate the safety and efficacy of circumferential viscodilation and tensioning of Schlemm's canal (canaloplasty) in the treatment of uveitic glaucoma (UG). DESIGN: Pilot, retrospective, noncomparative case series. PARTICIPANTS: Nineteen uveitic eyes of 15 patients with UG. METHODS: The main outcome measure was surgical success. Secondary outcome measures included intraocular pressure, usage of ocular hypotensive medication, visual acuity, and sight-threatening complications. Patients were included when UG could not be controlled despite maximum tolerated medical therapy. Exclusion criteria were peripheral anterior synechiae and previous glaucoma surgery. RESULTS: Mean follow-up time from canaloplasty was 2.6 ± 1.1 years. Mean intraocular pressure decreased from 30.4 ± 8.4 mm Hg preoperatively to 13.8 ± 5.0 mm Hg at last follow-up (p < 0.001). The mean number of ocular hypotensive medications decreased from 3.7 ± 0.8 preoperatively to 0.4 ± 1.0 at last follow-up (p < 0.001). At last follow-up, the complete success, qualified success, and failure rates were 73.7%, 10.5%, and 15.8%, respectively. No canaloplasty-related permanent sight-reducing complications occurred. Preoperative best corrected visual acuity decreased more than 1 Snellen line in 1 eye due to exacerbation of uveitis 18 months postoperatively. CONCLUSIONS: Canaloplasty appears to be a relatively safe and effective initial surgical intervention in UG.

Acquired myelinated nerve fibers in association with optic disk drusen.

Myelinated retinal nerve fibers are a well-recognized anomaly of the ocular fundus associated with many ocular and systemic conditions. Myelination is almost always congenital and stable, but progression has been documented in rare cases. Optic disk drusen are the result of a degenerative process at the optic nerve head and are often found incidentally on ophthalmologic examination. To our knowledge, optic disk drusen have only been reported once in association with acquired and progressive myelinated retinal nerve fibers. We present 2 such cases and consider the implications for the pathogenesis of myelinated nerve fibers.