Outcome of Off-Label AREDS 2 Supplementation for the Treatment of Macular Degeneration in Non-Proliferative Idiopathic Type 2 Macular Telangiectasia.

PURPOSE: To evaluate if off-label Age-Related Eye Disease Study 2 (AREDS2) supplementation prevents visual and anatomical deterioration in non-proliferative Idiopathic Macular Telangiectasia Type 2 (IMT2). PATIENTS AND METHODS: This is a single-center retrospective, comparative study of 82 IMT2 eyes treated with AREDS2 from January 1st, 2013 to January 1st, 2018. The study analysis consisted of a non-comparative arm, which included all AREDS2 eyes, and a comparative arm (27 AREDS2 and 42 untreated eyes) that only included eyes with complete follow-up data. Eyes were evaluated at baseline, 12 and 24 months. Better/worse eye sub-analysis was performed in the comparative study arm. Primary outcomes were best corrected visual acuity (BCVA) and optical coherence tomography (OCT) anatomical characteristics including largest cavitation diameter, central macular thickness (CMT), and length of ellipsoid zone (EZ) loss at 24 months. RESULTS: In the non-comparative arm, AREDS2 eyes showed stable BCVA (0.28 ± 0.18 logMAR at baseline vs 0.26 ± 0.19 logMAR at 24 months; p = 0.35) and OCT anatomical features after 24 months of supplementation. In the comparative arm, BCVA mean difference was greater for untreated eyes at 24 months (-0.09 ± 0.15 vs 0.03 ± 0.11 logMAR; p = <0.001). AREDS2 eyes had decreased cavitary diameter and EZ loss compared to untreated eyes at the study endpoint (p = 0.01 and p = 0.02, respectively). CMT remained stable for both cohorts throughout the study. For better/worse eye analysis, untreated eyes had worse BCVA at 24 months in both better and worse eyes (both p = 0.01). For anatomical outcomes, increases in both EZ loss (p = 0.04) and cavitary diameter (p = 0.001) among untreated eyes were only significant for eyes with worse baseline BCVA. CONCLUSION: Our results suggest that off-label AREDS2 supplementation in non-proliferative IMT2 may prevent anatomical and visual deterioration in a subset of eyes.

COMBINED PHACOEMULSIFICATION SURGERY WITH MULTIFOCAL INTRAOCULAR LENS IMPLANTATION AND PARS PLANA VITRECTOMY FOR SYMPTOMATIC VITREOUS OPACITIES.

PURPOSE: To report surgical outcomes of combined vitrectomy for vitreous floaters and phacoemulsification surgery with multifocal intraocular lens implantation. METHODS: Retrospective, interventional, noncomparative case series of five eyes from five patients who underwent same-day combined phacoemulsification surgeries with apodized, diffractive multifocal intraocular lens implantation for cataract and pars plana vitrectomy for symptomatic vitreous opacities, that is, floaters. Primary outcomes were distance and near visual acuities, and resolution of symptoms. Secondary outcomes included intraocular pressure, refractive outcomes, and surgical complications. RESULTS: Mean logarithm of the minimum angle of resolution glare distance visual acuity improved from 0.36 (best-corrected Snellen 20/47) preoperatively to an uncorrected distance visual acuity of 0.05 (Snellen 20/23) at 6 months postoperatively (P = 0.042). All but one patient achieved multifocality with a near visual acuity of J2 or better. All patients noted subjective improvement in symptoms from floaters postoperatively. Mean intraocular pressure remained stable during follow-up. Two eyes ultimately required YAG capsulotomies for symptomatic posterior capsular opacification, one of which additionally received LASEK for refractive correction. CONCLUSION: Multifocality and improvement in symptoms from symptomatic vitreous opacities were observed in this pilot series of carefully selected patients who underwent combined phacovitrectomy with multifocal intraocular lens implantation. A high rate of retinal tears was found in these patients. Appropriate caution should be taken in preoperative assessment and patient selection for the combined procedure.

Fluocinolone acetonide (0.19 mg) intravitreal implant reduces treatment burden and improves practice resource utilisation for patients with diabetic macular oedema.

OBJECTIVE: Patients with diabetic macular oedema (DME) are known to have significantly greater medical treatment burden than patients with non-DME. Frequent injections and office visits can have a substantial impact on patient adherence and quality of life. This analysis assesses the impact of the 0.19 mg fluocinolone acetonide (FAc) implant (or injection) on treatment burden and practice resource utilisation in patients with DME. METHODS AND ANALYSIS: This study is a single-centre retrospective chart review of 30 eyes (23 patients) that received a single FAc implant. Data was collected for a 12-month period pre-injection and post-injection of the FAc implant. Primary outcomes included the frequency of injections and ophthalmology office visits. Secondary outcomes included visual acuity (VA), intraocular pressure (IOP) and central subfield thickness (CSFT). RESULTS: The injection frequency significantly decreased from one injection every 2.6 months pre-injection to one injection every 8.8 months post-injection of the FAc implant (p<0.001). Sixty-three percent of the subjects did not require additional injections post-FAc implant. The mean number of ophthalmology office visits significantly decreased from 12.7 visits pre-FAc to 9.3 visits post-FAc implant (p<0.001). The mean VA (p=0.24) and CSFT (p=0.39) showed a mild numerical improvement that was not statistically significant. Thirty-seven percent of the eyes required additional IOP lowering drops. No eyes required incisional glaucoma surgeries. CONCLUSIONS: The FAc implant significantly decreased the treatment burden and improved practice resource utilisation while maintaining or improving VA and CSFT. IOP events were mostly well-controlled with drops and no eyes required incisional glaucoma surgery.

Association of Mentor-to-Program Contact and Applicant Rank Disclosure With Vitreoretinal Fellowship Applicant's Final Match Outcome in 2016 and 2017.

Importance: Communication between applicants, mentors, and training programs is common before the residency and fellowship match. Few studies have examined the association of prematch communication on final match outcomes. Objectives: To report various characteristics of the vitreoretinal surgery fellowship match and to examine the association of mentor-to-program communication and applicant disclosure of their number 1 ranking with the probability of matching number 1. Design, Setting, and Participants: In this cross-sectional study of the 2016 and 2017 vitreoretinal surgery fellowship matches, an online survey examined (1) number of applications submitted, (2) number of programs ranked, (3) rank order of final match, (4) total application and interview-related costs, (5) mentor-to-program contact, (6) applicant disclosure of number 1 ranking, and (7) mentor disclosure of number 1 ranking. A link to an anonymous online survey was sent to 198 matched fellows (105 fellows from the 2016 match and 93 from the 2017 match). Main Outcomes and Measures: Survey responses regarding the vitreoretinal surgery fellowship application process. Results: The survey was sent to 198 matched fellowship applicants, and 152 (77%) completed the survey. Of the 105 matched applicants in 2016, 21 (20%) were women. Of the 93 matched applicants in 2017, 24 (26%) were women. Matched applicants applied to a mean (SD) of 34 (17) programs (range, 1-85) and ranked a mean (SD) of 12 (4) programs (range, 1-27). Of 152 applicants, 66 (43%) matched at their number 1 ranked program, 23 (15%) matched number 2, and 21 (14%) matched number 3. The mean (SD) total cost was $5500 ($2776) (range, $500-$13 500). Two-sided χ2 testing found no association (odds ratio, 0.70; 95% CI, 0.34-1.4; P = .33) between mentor-to-program contact and the probability of applicants matching at their number 1 ranked program. Matched applicants who revealed their number 1 ranking either personally or via a mentor matched at a program ranked lower (more desirable) on their rank list (mean match ranking, 2.8) compared with those who did not reveal their number 1 ranking (mean match ranking, 4.2; 95% CI, 0.2-2.5; P = .01). Applicant disclosure of their intention to rank a program number 1, either personally or via a mentor, was associated with matching number 1 (odds ratio, 2.6; range, 1.1-6.0; P = .03). Conclusions and Relevance: Vitreoretinal fellowship applicants who disclosed their number 1 ranking, either personally or via a mentor, were associated with improved match outcomes compared with their cohorts who did not make such disclosures.

Intravitreal methotrexate infusion for proliferative vitreoretinopathy.

PURPOSE: The purpose of this study was to evaluate intravitreal methotrexate infusion (IMI) during pars plana vitrectomy (PPV) for retinal detachment in patients with high risk for the development of proliferative vitreoretinopathy (PVR). METHODS: Patients presenting with severe recurrent PVR with tractional retinal detachment and/or a history of severe ocular inflammation were treated with IMI. Clinical outcomes were determined from a retrospective medical chart review. RESULTS: Twenty-nine eyes presenting with either tractional retinal detachment and recurrent PVR (n=22) or a history of severe inflammation associated with high PVR risk (n=7) received IMI during PPV. Best-corrected visual acuity at 6 months was ≥20/200 in 19 of 29 eyes (66%) and remained stable or improved compared with initial presentation in 24 of 29 eyes (83%). At the last follow-up examination, the retinas of 26 of 29 eyes (90%) remained attached after IMI while three eyes required another reattachment procedure. Three additional eyes (10%) developed recurrent limited PVR without recurrent RD and were observed. No complications attributable to IMI occurred during a mean follow-up of 27 months. CONCLUSION: Eyes at high risk for PVR development due to a history of prior PVR or intraocular inflammation had a low incidence of PVR following IMI at the time of PPV for RD repair. No significant safety issues from IMI were observed in this series.

Preretinal hemorrhage as a presenting sign of idiopathic macular telangiectasia type 2.

We report three cases of idiopathic macular telangiectasia type 2 with temporally decentered preretinal hemorrhage as the presenting sign. The preretinal blood obscured the telangiectatic vessels such that the diagnosis was only evident by fluorescein angiography of the fellow eyes, which had near-normal vision. The preretinal hemorrhage was associated with Valsalva maneuver in one patient and with type 3 subretinal neovascularization in one patient. We speculate that the vascular dilations in idiopathic macular telangiectasia type 2 may increase patients' susceptibility to rupture and hemorrhage with increased venous pressure.

Pipeline embolization device: a new source for embolic retinal vascular occlusion.

A 57-year-old woman underwent treatment of a left internal carotid artery aneurysm with a Pipeline embolization device. She subsequently experienced multiple branch retinal artery occlusions in her left eye. Although rare, ophthalmic complications may follow this new technique in the treatment of intracranial aneurysms.

Multifocal iris sphincter ruptures: new sign of the lens-iris diaphragm retropulsion syndrome.

We describe the case of a 78-year-old highly myopic woman who had bilateral phacoemulsification with posterior chamber intraocular lens implantation. During surgery, the anterior chamber was extremely deep and the pupil was excessively dilated, consistent with lens-iris diaphragm retropulsion syndrome (LIDRS). Subsequent biomicroscopy revealed multifocal iris sphincter ruptures, a new finding associated with LIDRS.

Secondary prosthetic iris implantation following traumatic total aniridia and pseudophakia.

We present 2 pseudophakic patients who had traumatic episodes that resulted in total expulsion of the iris without disturbing the intraocular lens (IOL). Because of intolerable glare, each patient was managed by reopening the fibrosed capsular bag and implanting 2 multi-finned prosthetic iris devices through a small incision, leaving the IOL in place. Following surgery, glare was no longer present and excellent visual acuity was maintained. We believe these are the first pseudophakic patients with traumatic total aniridia to be managed by this approach.

Fate of anterior capsule tears during cataract surgery.

PURPOSE: To determine the incidence of anterior capsule tears, at what stage of surgery they occurred, and their intraoperative behavior. SETTING: Ambulatory surgery center, Cincinnati Eye Institute, Cincinnati, Ohio, USA. METHODS: This 5-year retrospective study was of patients having phacoemulsification with posterior chamber intraocular lens (IOL) implantation complicated by unplanned peripheral extension of the capsulorhexis tear or a radial anterior capsule tear. The operative notes and a videotape of the surgery were reviewed. The stage at which the tear was initially observed and when it extended were identified, as was whether the tear extended to the posterior capsule. Anterior vitrectomy and the design and location of the IOL implanted were also analyzed. RESULTS: A discontinuous anterior capsulorhexis or a break in the anterior capsule rim was observed in 21 eyes of 2646 cases, for an overall incidence of 0.79%. Anterior capsule tears were identified during ophthalmic viscosurgical device injection in 1 eye, capsulorhexis in 13 eyes, hydrodissection in 2 eyes, phacoemulsification in 3 eyes, irrigation/aspiration (I/A) in 1 eye, and implantation of a prosthetic iris device in 1 eye. Seven of the 13 tears identified during the capsulorhexis were managed by redirecting the second edge of the "safety" capsulorhexis to incorporate the tear. In 14 eyes, the tear in the anterior capsule extended into the zonules; 4 of these tears were limited. Ten tears extended around the equator and through the posterior capsule, occurring during the hydrodissection in 1 eye, phacoemulsification in 2 eyes, I/A in 1 eye, and IOL implantation in 6 eyes. An anterior vitrectomy was required in 4 eyes that had posterior capsule involvement. Endocapsular fixation of a 1-piece acrylic IOL was achieved in 18 eyes. Three eyes required implantation of a 3-piece acrylic IOL in the ciliary sulcus. CONCLUSIONS: Extension of an anterior capsule tear can complicate cataract surgery at any stage. Extension of the tear through the posterior capsule occurred in almost half the eyes with an anterior capsule tear, often requiring an anterior vitrectomy. Managing an anterior capsule tear can be challenging yet compatible with implantation of a posterior chamber IOL.

Early uncorrected visual acuity as a measurement of the visual outcomes of contemporary cataract surgery.

PURPOSE: To determine the uncorrected visual acuity (UCVA) on the first postoperative day and the fifth week after routine slow-motion phacoemulsification with posterior chamber intraocular lens (IOL) implantation. SETTING: Cincinnati Eye Institute, Cincinnati, Ohio, USA. METHODS: This retrospective chart review performed by 3 research fellows analyzed the UCVA 1 day and 5 weeks postoperatively in 100 consecutive best-case scenario eyes of 99 patients who had routine slow-motion phacoemulsification with implantation of an AcrySof single-piece IOL (Alcon). Reasons for UCVAs worse than 20/40 were sought. The stability of the visual result was analyzed. RESULTS: The UCVA was 20/40 or better in 98% of eyes at 1 day. Ninety-seven percent had a UCVA of at least 20/40 by 5 weeks, confirming stability of acuity. The percentage of patients with a UCVA of 20/20 or 20/25 increased from 49% at 1 day to 77% at 5 weeks. CONCLUSIONS: The UCVA 1 day after slow-motion phacoemulsification was 20/40 or better in 98% of eyes and remained stable to the last measurement at 5 weeks. Early UCVA can serve as a more sensitive measurement than best corrected visual acuity for assessing new surgical technologies and techniques.