Choroidal ischemia as one cardinal sign in giant cell arteritis.

PURPOSE: To describe chorioretinal signs in a case series of Giant Cell Arteritis (GCA). METHODS: This is a multicenter retrospective observational case series with GCA that presented with a headache and an abrupt, unilateral loss in vision. Workup included temporal artery biopsies, intravenous fluorescein angiography, optical coherence tomography (OCT), optical coherence tomography angiography (OCTA), blood levels of erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). RESULTS: There are a total of 8 GCA instances presented. Average age was 74.5. (Range 68-83 years). The patients reported that one eye's visual loss had suddenly started, along with a fresh headache and other systemic symptoms. Eight patients exhibited choroidal ischemia, five paracentral acute middle maculopathy (PAMM) lesions, five cotton wool spots, four anterior ischemic optic neuropathy, and one central retinal arterial occlusion at the time of presentation. The average ESR at presentation was 68 mm/hr (range 4-110), and 4/6 individuals had a significant increase. The mean CRP level was 6.2 mg/dL (range 2.0-15.4), and the level was always over the normal range. All patients' temporal artery biopsies were positive. CONCLUSION: Alongside PAMM lesions, cotton wool spots, anterior ischemic optic neuropathy, and central retinal artery occlusion, choroidal ischemia is a key angiographic indicator in the diagnosis of GCA. It may be crucial to recognize these typical ischemic chorioretinal signs while diagnosing GCA.

Treatment of Secondary Full-Thickness Macular Holes with Topical Therapy.

PURPOSE: To report the outcomes of secondary full-thickness macular holes (FTMHs) treated with topical therapy. DESIGN: Retrospective case series. PARTICIPANTS: Patients with secondary FTHMs initially treated with topical therapy in a referral-based retina practice. METHODS: Patients evaluated between April 14, 2016, and February 22, 2019, for secondary FTMHs who underwent topical therapy were included. Patient demographics, ocular history, type of drops used, duration of therapy, and duration of follow-up as well as anatomic features on OCT, including hole diameter and presence of vitreomacular traction, epiretinal membrane (ERM), and cystoid macular edema (CME), were analyzed. MAIN OUTCOME MEASURES: Closure rate of FTMHs and change in visual acuity. RESULTS: A total of 123 FTMHs were seen during the study, of which 12 were secondary macular holes. Topical therapy was attempted in 9 eyes (8 patients). Six of these 9 FTMHs were associated with prior retinal detachment (RD). Previous pars plana vitrectomy (PPV) had been performed in 3 eyes (1 for RD, 2 for ERM). One eye had vitreomacular traction and a remote history of blunt trauma. Average initial hole diameter was 79.6 µm (range, 44-132 µm). Average follow-up was 53 weeks (range, 5-153 weeks). All FTMHs had some element of ERM and CME. All patients received difluprednate with the addition of a topical carbonic anhydrase inhibitor in 6 eyes and nonsteroidal anti-inflammatory drug (NSAID) drops in 2 eyes. Eight eyes (89%) achieved successful hole closure and resolution of CME with concurrent improvement in visual acuity after an average of 6 weeks of therapy (range, 2-19 weeks). Average vision among all 9 eyes improved from 0.69 to 0.37 logarithm of the minimum angle of resolution (Snellen equivalent from approximately 20/100 to approximately 20/50). No episodes of corneal melts or ulcers occurred. One patient showed mild keratopathy and elevation of intraocular pressure with topical NSAID and steroid therapy that resolved when the topical NSAID was stopped and difluprednate was tapered down to once weekly. CONCLUSIONS: Topical therapy achieved high closure rates in secondary FTMH and can be considered as an initial treatment option especially in those with small holes and CME.

The Evolving Treatment of Diabetic Retinopathy.

PURPOSE: To review the current therapeutic options for the management of diabetic retinopathy (DR) and diabetic macular edema (DME) and examine the evidence for integration of laser and pharmacotherapy. METHODS: A review of the PubMed database was performed using the search terms diabetic retinopathy, diabetic macular edema, neovascularization, laser photocoagulation, intravitreal injection, vascular endothelial growth factor (VEGF), vitrectomy, pars plana vitreous surgery, antiangiogenic therapy. With additional cross-referencing, this yielded 835 publications of which 301 were selected based on content and relevance. RESULTS: Many recent studies have evaluated the pharmacological, laser and surgical therapeutic strategies for the treatment and prevention of DR and DME. Several newer diagnostic systems such as optical coherence tomography (OCT), microperimetry, and multifocal electroretinography (mfERG) are also assisting in further refinements in the staging and classification of DR and DME. Pharmacological therapies for both DR and DME include both systemic and ocular agents. Systemic agents that promote intensive glycemic control, control of dyslipidemia and antagonists of the renin-angiotensin system demonstrate beneficial effects for both DR and DME. Ocular therapies include anti-VEGF agents, corticosteroids and nonsteroidal anti-inflammatory drugs. Laser therapy, both as panretinal and focal or grid applications continue to be employed in management of DR and DME. Refinements in laser devices have yielded more tissue-sparing (subthreshold) modes in which many of the benefits of conventional continuous wave (CW) lasers can be obtained without the adverse side effects. Recent attempts to lessen the burden of anti-VEGF injections by integrating laser therapy have met with mixed results. Increasingly, vitreoretinal surgical techniques are employed for less advanced stages of DR and DME. The development and use of smaller gauge instrumentation and advanced anesthesia agents have been associated with a trend toward earlier surgical intervention for diabetic retinopathy. Several novel drug delivery strategies are currently being examined with the goal of decreasing the therapeutic burden of monthly intravitreal injections. These fall into one of the five categories: non-biodegradable polymeric drug delivery systems, biodegradable polymeric drug delivery systems, nanoparticle-based drug delivery systems, ocular injection devices and with sustained release refillable devices. At present, there remains no one single strategy for the management of the particular stages of DR and DME as there are many options that have not been rigorously tested through large, randomized, controlled clinical trials. CONCLUSION: Pharmacotherapy, both ocular and systemic, will be the primary mode of intervention in the management of DR and DME in many cases when cost and treatment burden are less constrained. Conventional laser therapy has become a secondary intervention in these instances, but remains a first-line option when cost and treatment burden are more constrained. Results with subthreshold laser appear promising but will require more rigorous study to establish its role as adjunctive therapy. Evidence to support an optimal integration of the various treatment options is lacking. Central to the widespread adoption of any therapeutic regimen for DR and DME is substantiation of safety, efficacy, and cost-effectiveness by a body of sound clinical trials.

Infusion Misdirection in Microincisional Vitrectomy Surgery.

PURPOSE: To review the incidence and possible mechanisms of 2 problems caused by infusion misdirection during microincisional vitrectomy in 1 physician's practice and to find an estimate of the broader occurrence among other physicians. DESIGN: Observational series of 1 surgeon's cases over 2 periods. A survey also was sent to other retinal specialists. PARTICIPANTS: Patients undergoing microincisional vitrectomy. METHODS: The physician tracked the occurrence of intraoperative hypotony and unintentional anterior chamber air infusion in his practice. A survey was sent to 2000 members of the American Society of Retina Specialists and the Retina Society. MAIN OUTCOME MEASURES: Primary outcome measure was the incidence of hypotony during microincisional vitrectomy, defined as softening of the globe to the point of corneal or scleral infolding, or both, that resolved with repositioning of the infusion cannula. The secondary outcome measure was incidence of unplanned air flow into the anterior chamber. Survey questions included frequency of observed infusion interruption and incidence of inadvertent anterior chamber air infusion. RESULTS: In the earlier series, of 232 vitrectomies, 37 (16%) showed signs of episodic hypotony after infusion blockage. Seven cases (3%) showed inadvertent air flow into the anterior chamber. One hundred fifty-two physicians responded to the survey. Fifty-seven percent reported infusion blockage and hypotony in 1% to 5% of cases. Fifty-nine percent reported air flow into the anterior chamber in some cases. In the later series, 12 instances of infusion blockage were noted in 118 cases. Awareness of the issue and additional attention to the infusion line taping did not prevent the problem from occurring. In the survey, most respondents reported observing both infusion interruption and inadvertent anterior chamber air infusion on occasion. CONCLUSIONS: Infusion misdirection resulting in hypotony or air flow into the anterior chamber seems to be infrequent, but it remains a risk. Awareness of the problem reduces the incidence, but does not eliminate it. The potential inadvertently to touch the retina, choroid, or lens increases when these events occur. Infusion misdirection can be avoided by maintaining the correct position of the cannula, which may be facilitated by an external support to the tubing.

Near-infrared reflectance bull's eye maculopathy as an early indication of hydroxychloroquine toxicity.

IMPORTANCE: In some patients, hydroxychloroquine ocular toxicity may progress even following cessation of therapy. Any leverage the clinician may use to allow earlier detection may avert significant vision loss. OBSERVATION: We report three cases suggesting that bull's eye maculopathy seen on near-infrared reflectance with a confocal scanning laser ophthalmoscope could be an early, objective manifestation of hydroxychloroquine ocular toxicity, and with progression of the disease this near-infrared "bull's eye" change may disappear. CONCLUSION AND RELEVANCE: Alerting clinicians to this observation may allow a larger case series to corroborate the hypothesis that bull's eye maculopathy detected by near-infrared reflectance may represent an early sign of hydroxychloroquine toxicity.