Vitrectomy as an Adjunct to Treat-and-Extend Anti-VEGF Injections for Diabetic Macular Edema: The Vitrectomy in Diabetic Macular Oedema (VIDEO) Randomized Clinical Trial.

Importance: There are reported benefits from vitrectomy for diabetic macular edema (DME); however, data precede anti-vascular endothelial growth therapy (VEGF) therapy, supporting a need to assess the current role of vitrectomy. Objective: To determine rates of recruitment and efficacy outcomes of vitrectomy plus internal limiting membrane (ILM) peeling adjunctive to treat-and-extend (T&E) anti-VEGF injections for diabetic macular edema (DME). Design, Setting, and Participants: This was a single-masked, multicenter randomized clinical trial at 21 sites in the United Kingdom from June 2018 to January 2021, evaluating single eyes of treatment-naive patients with symptomatic vision loss from DME for less than 1 year. Inclusion criteria were best-corrected visual acuity (BCVA) Early Treatment Diabetic Retinopathy Study letter score greater than 35 (approximate Snellen equivalent, 20/200 or better) and central subfield thickness (CST) greater than 350 µm after 3 monthly intravitreal injections of ranibizumab or aflibercept. Data analysis was performed in July 2023. Interventions: Patients were randomized 1:1 into vitrectomy plus standard care or standard care alone and further stratified into groups with vs without vitreomacular interface abnormality. Both groups received a T&E anti-VEGF injection regimen with aflibercept, 2 mg, or ranibizumab, 0.5 mg. The vitrectomy group additionally underwent pars plana vitrectomy with epiretinal membrane or ILM peel within 1 month of randomization. Main Outcomes and Measures: Rate of recruitment and distance BCVA. Secondary outcome measures were CST, change in BCVA and CST, number of injections, rate of completed follow-up, and withdrawal rate. Results: Over 32 months, 47 of a planned 100 patients were enrolled; 42 (89%; mean [SD] age, 63 [11] years; 26 [62%] male) completed 12-month follow-up visits. Baseline characteristics appeared comparable between the control (n = 23; mean [SD] age, 66 [10] years) and vitrectomy (n = 24; mean [SD] age, 62 [12] years) groups. No difference in 12-month BCVA was noted between groups, with a 12-month median (IQR) BCVA letter score of 73 (65-77) letters (Snellen equivalent, 20/40) in the control group vs 77 (67-81) letters (Snellen equivalent, 20/32) in the vitrectomy group (difference, 4 letters; 95% CI, -8 to 2; P = .24). There was no difference in BCVA change from baseline (median [IQR], -1 [-3 to 2] letters for the control group vs -2 [-8 to 2] letters for the vitrectomy group; difference, 1 letter; 95% CI, -5 to 7; P = .85). No difference was found in CST changes (median [IQR], -94 [-122 to 9] µm for the control group vs -32 [-48 to 25] µm for the vitrectomy group; difference, 62 µm; 95% CI, -110 to 11; P = .11). Conclusions and Relevance: Enrollment goals could not be attained. However, with 47 participants, evidence did not support a clinical benefit of vitrectomy plus ILM peeling as an adjunct to a T&E regimen of anti-VEGF therapy for DME. Trial Registration: isrctn.org Identifier: ISRCTN59902040.

Intraocular lens calcification in a patient with Ehlers-Danlos syndrome.

Introduction: Calcification of hydrophilic intraocular lenses (IOL) is a rare complication following cataract surgery. Secondary calcification is described as due to host factors or changes in the IOL environment and uveitis, proliferative diabetic retinopathy and sequelae of ocular surgery are recognised potentiators. The impact of systemic connective tissue disease on IOL opacification is yet to described. Purpose: To describe the clinical presentation and management of a young patient, with a rare subtype of Ehlers-Danlos syndrome, who presented with secondary IOL calcification 14 years after primary IOL insertion. Observations: Floret-like lesions were observed on the IOL surface. Positive staining for calcification was observed with Alizarin red and von Kossa method on laboratory analysis. Conclusions and importance: Patients with systemic connective tissue disease, such as a subtype of Ehlers-Danlos, may present with secondary IOL calcification many years after primary lens insertion. This poses an additional consideration when implanting IOLs in these patients.Good visual acuity can be achieved with IOL exchange.

Can Visual Acuity Be Reliably Measured at Home? Validation of Telemedicine Remote Computerised Visual Acuity Measurements.

PURPOSE: The recent pandemic has identified the need for telemedicine assessment of ophthalmology patients. A vital component of such assessment is visual acuity (VA) measurement. The aim of this study was to determine the feasibility and reliability of computerised 'at home' VA measurements using COMPlog software. METHODS: A Bland Altman method comparison study of worse eye 'in clinic' and 'at home' orthoptist-supervised COMPlog computerised VA measurements. Subjects underwent gold standard semi-automated computerised test and retest logMAR VA measurements on their habitually corrected worse eye both 'in clinic' and 'at home.' The orthoptist ran the test from the eye clinic with the patient viewing a secondary PC monitor either in the same clinic room or at home. A screen sharing voice and video conferencing application and standard consumer IT hardware were employed to present the test optotypes in the patient's home. RESULTS: 23 paediatric and 13 adult patients with a range of ocular diseases and worse eye visual acuities were included (range -0.14 to 1.06 logMAR). No significant bias was found between 'in clinic' and 'at home' measurements (mean -0.01 logMAR and 95% confidence interval -0.03, 0.00 logMAR). Test-retest variability of 'in clinic,' 'at home' and 'in clinic' versus 'at home' measurements were within normal reported ranges at 0.12 logMAR (6 ETDRS letters) or less. CONCLUSION: Remote home VA testing performed by an eye care professional using a semi-automated VA measurement program and video conferencing application provided unbiased measurements with acceptable test-retest reliability. Home testing was both feasible and acceptably reliable in appropriately equipped patients.

OUTCOME OF REVISION PROCEDURES FOR FAILED PRIMARY MACULAR HOLE SURGERY.

PURPOSE: To analyze the outcomes of revision surgery for idiopathic full-thickness macular holes that have failed to close after primary surgery, and also to assess factors predicting success and to review the relative effect of adjunctive surgical techniques. METHODS: A multicenter retrospective study. Anatomical closure rates and visual acuity change between pre and postrevision surgery were assessed. Hole size, age, symptom duration, surgical interval, and reduced hole size were analyzed as predictive factors for success. Effectiveness of adjunctive surgical techniques was reviewed. RESULTS: Seventy-seven eyes were included in the study. Anatomical closure was achieved in 71% (55/77) cases. There was a median gain of 11 Early Treatment of Diabetic Retinopathy Score letters in all holes and 14 letters in closed holes. Full-thickness macular holes that increased in size by more than 10% following primary surgery had a closure rate of 50% compared with 80% in holes that reduced by 10% or stayed the same (P = 0.015). Increasing hole size is associated with a modest reduction in odds of closure (odds ratio = 0.99; P = 0.04). Surgical interval <2 months is not associated with better outcomes compared with >2 months (P = 0.14). CONCLUSION: Revision surgery for full-thickness macular holes that have failed to close after primary surgery is associated with high closure rates and significant visual gains.

Visual outcome after removal of silicone oil in patients undergoing retinectomy for complex retinal detachment.

AIM: To evaluate the functional outcome after removal of silicone oil (ROSO) in patients undergoing retinectomy for complex retinal detachment. METHODS: We performed a retrospective case note review of patients who underwent ROSO after retinectomy for complex retinal detachment. Patients with less than 6mo follow up and recurrent retinal detachment following ROSO were excluded. RESULTS: Thirty-six patients were included. The mean best corrected visual acuity (BCVA) pre-ROSO was 1.13 logMAR (SD 0.5). The mean BCVA 3mo following ROSO was 1.16 logMAR (SD 0.53), 6mo following ROSO 1.13 (SD 0.63), and 12mo following ROSO 1.18 (SD 0.69). At 12mo after ROSO, the BCVA improved in 38.9% of patients, remained unchanged in 25%, and deteriorated in 36.1%, although there was no statistical significant difference in BCVA after ROSO at 3, 6 and 12mo (P=0.93). The size of retinectomy ranged from 15° to 270° (SD 53) and did not influence the visual outcome (P=0.11). CONCLUSION: There was no statistically significanT difference in BCVA between pre- and post- ROSO following retinectomy for complex retinal detachment. There was no statistical difference in visual outcome related to the size of the retinectomy.

Identification of retinal breaks using subretinal trypan blue injection.

PURPOSE: To describe the use of subretinal trypan blue to identify retinal breaks during vitrectomy for rhegmatogenous retinal detachment (RD). DESIGN: Interventional case series. PARTICIPANTS: Five patients with RD in whom no retinal break could be identified by internal search with scleral indentation. METHODS: Trypan blue 0.15% was injected transretinally into the subretinal space using a 41-gauge cannula designed for macular translocation surgery. Perfluorocarbon heavy liquid was then injected into the vitreous cavity and the eye was rotated such that trypan blue was vented out of the break. The plume of trypan blue was used to identify retinal breaks, or in some cases staining of the break facilitated break detection. Subretinal fluid was then drained through the break or a drainage retinotomy and surgery was completed using standard techniques. MAIN OUTCOME MEASURE: Identification of previously unseen retinal breaks. RESULTS: This technique successfully identified a retinal break in 4 out of 5 patients. After absorption of the gas tamponade all retinas remained attached with a median visual acuity of 6/12. CONCLUSION: Failure to identify a retinal break during RD surgery is a well-recognized clinical challenge that may adversely affect outcome. In this setting, chromophore-assisted retinal break detection may be a useful surgical technique.

Traumatic aniridia after small incision cataract extraction.

INTRODUCTION: Phacoemulsification and falls are both common in the elderly population. We present a case of acquired total aniridia and vitreous haemorrhage occurring as a result of trauma in a pseudophakic eye. METHODS: Interventional case report with history, clinical photograph and discussion with literature review. RESULTS: A previously healthy 74-year-old Caucasian female was referred with a painful left eye and poor vision following a fall and trauma to the left side of her face. Initial examination confirmed visual acuity of perception of light with total hyphaema and vitreous haemorrhage. Subsequent examination revealed complete aniridia with an intact capsular bag and well-centred posterior chamber intraocular lens and attached retina. Final visual acuity after treatment was 6/9. CONCLUSIONS: Blunt trauma may cause total iris disinsertion in and expulsion from pseudophakic eyes. This relatively novel injury may present increasingly commonly to casualty departments and ophthalmologists.

Visual fields in patients who have undergone vitrectomy for complications of diabetic retinopathy. A prospective study.

BACKGROUND: To determine the extent of visual field loss in patients who had required a pars plana vitrectomy secondary to complications of proliferative diabetic retinopathy. METHODS: Patients that had undergone a vitrectomy on at least one eye for treatment of either vitreous haemorrhage or tractional retinal detachment were selected for study. ETDRS acuity and Humphrey binocular Esterman visual field testing were performed and compared to the minimum standards for safe driving as defined by the Royal College of Ophthalmologists in 1999. In addition to this Goldman kinetic visual fields using a III4e and V4e stimulus size and central 24-2 threshold test with the SITA-fast strategy were performed on the vitrectomised eye. RESULTS: 20 patients (n = 20) were recruited. Mean visual acuity in the eye being tested was 0.20 (Snellen 6/9.5). Results from the Humphrey field analyzer showed a mean number of abnormal stimulus locations of 71.2% (p < 0.005). 70% of patients had sufficient binocular acuity to drive and of these 71.4% were shown not to have a minimum visual field for safe driving on binocular Esterman field analysis. CONCLUSION: Vitrectomy potentially allows retention/restoration of good visual acuity in patients with complications of proliferative diabetic retinopathy. However patients may be suffering from unrecognized visual impairment consequent upon extensive visual field loss which in over two thirds of patients may be sufficiently severe to preclude safe driving.

Frequency and associations of a taut thickened posterior hyaloid, partial vitreomacular separation, and subretinal fluid in patients with diabetic macular edema.

PURPOSE: To determine prospectively among patients with diabetic macular edema (DME) the frequency of a clinically evident taut thickened posterior hyaloid (TTPH), optical coherence tomography (OCT) signs suggestive of partial vitreomacular separation (PVMS), and OCT evidence of subretinal fluid (SRF) and to investigate for associations between these findings. METHODS: In a prospective case series, patients with DME despite previous laser treatment were examined for the presence of a TTPH. OCT was performed to investigate for PVMS and SRF. RESULTS: One hundred forty patients and eyes were included in the study. A TTPH was present in six patients (4%). PVMS was present in 14 (10%) of 140 patients with DME, of whom 5 also had a TTPH. SRF was present in 15 (11%) of 140 patients, of whom 4 had TTPH. OCT showed that 66% of patients with SRF and DME had neither a clinical TTPH nor partial posterior hyaloid separation. CONCLUSION: A TTPH was found in 4% of subjects with DME. Partial posterior hyaloid separation and SRF may be found in patients who do not have a TTPH. SRF in patients with DME may not be tractional.

Anterior and posterior vitreous cysts.

Vitreous cysts are rare structural entities of uncertain aetiology. Although most do not produce troublesome visual symptoms, they can cause diagnostic difficulties in clinical practice. Two different types are described and the possible aetiologies of congenital and acquired vitreous cysts are discussed.