VISUAL OUTCOMES AFTER INTERNAL LIMITING MEMBRANE PEELING VERSUS FLAP IN THE CLOSURE OF FULL-THICKNESS MACULAR HOLES.

PURPOSE: To examine postoperative outcomes of internal limiting membrane peeling (ILMP) versus flap (ILMF) in the closure of full-thickness macular holes. METHODS: Retrospective chart review of patients who underwent pars plana vitrectomy and gas tamponade with ILMP or ILMF to close full-thickness macular hole at the Atrium Health Wake Forest Baptist from January 2012 to October 2022 with at least 3 months follow-up. Main outcome measures were type 1 primary full-thickness macular hole closure and postoperative best-corrected visual acuity in mean logMAR. RESULTS: One hundred thirty and 30 eyes underwent ILMP and ILMF, respectively. There were no significant differences in baseline characteristics between the groups. Ninety-six percent of ILMP eyes and 90% of ILMF eyes achieved primary hole closure ( P = 0.29). Among all eyes with primary hole closure, best-corrected visual acuity at 1 year was not different between the groups, but when stratified by lens status, it was superior in the ILMP versus ILMF group in pseudophakic eyes: the estimated least-squares mean best-corrected visual acuity (Snellen equivalent) (95% confidence interval) was 0.42 (20/50) (0.34, 0.49) in the ILMP group and 0.71 (20/100) (0.50, 0.92) in the ILMF group. CONCLUSION: Internal limiting membrane peeling and ILMF techniques yielded similarly high full-thickness macular hole closure rates. In pseudophakic eyes with primary hole closure, ILMF eyes had worse best-corrected visual acuity at 1 year.

ENDOGENOUS ENDOPHTHALMITIS ASSOCIATED WITH INJECTION DRUG USE COMPARED WITH OTHER ETIOLOGIES.

PURPOSE: To compare features of endogenous endophthalmitis associated with injection drug use (IDU) to endogenous endophthalmitis from other etiologies. METHODS: The authors retrospectively collected data on patients with endogenous endophthalmitis due to IDU or other causes from three academic tertiary care centers over a six-year period. Differences in presenting characteristics, culture results, treatment, and visual acuity were compared between groups. RESULTS: Thirty-eight patients (34%) had IDU-associated endogenous endophthalmitis while 75 patients (67%) had endogenous endophthalmitis from other causes. Compared with patients in the non-IDU group, IDU patients were significantly younger, more frequently male, had longer duration of symptoms at diagnosis, and were less likely to have bilateral disease ( P < 0.05 for all). Injection drug use patients were less likely to have a systemic infection source identified (29% vs. 71%, P < 0.001) or have positive cultures (47% vs. 80%, P < 0.001). The IDU group was less likely to be admitted to the hospital (71% vs. 92%, P = 0.005) and less likely to receive treatment with intravenous antimicrobials (55% vs. 83%, P = 0.003). Visual acuity did not significantly differ between groups. CONCLUSION: Endophthalmitis related to IDU presents in younger patients with less comorbidities and frequently without positive cultures or an identifiable systemic source; therefore, a high index of suspicion is needed to identify this disease.

Predictors of treatment-warranted retinopathy of prematurity in the SUNDROP cohort: influence of photographic features.

PURPOSE: The Stanford University Network for the Diagnosis of Retinopathy of Prematurity (SUNDROP) initiative-an ongoing telemedicine-based initiative for in-hospital screening of high-risk infants for treatment-warranted ROP (TW-ROP)-has been shown to be a safe, reliable, and cost-effective supplement to the efforts of ROP specialists. We utilized data collected in the SUNDROP initiative to determine demographic (birth weight, sex, multiplicity), weight gain, and ocular imaging (media haze, peripapillary atrophy, fundus pigmentation) predictors of TW-ROP. METHODS: This was a retrospective nested case-control study. Cases and controls were selected from a cohort of 843 low birth weight, premature newborns who survived to an estimated gestational age of 31 weeks and underwent screening through the SUNDROP initiative. Infants were screened at one of six neonatal intensive care units from December 1, 2005, to April 1, 2016. Cases (n = 37) were newborns with TW-ROP who underwent retinal ablative therapy. Two controls (n = 74) without TW-ROP were matched to each case by gestational age. One reviewer graded media haze, presence of peripapillary atrophy, and fundus pigmentation in images taken at the baseline exam for each newborn. The main outcome measure was association of TW-ROP with predictive factors. RESULTS: In the SUNDROP trial, 37 out of 843 (4.4%) newborns developed TW-ROP. In a multivariable model, birth weight (OR, 0.32; 95% CI, 0.15-0.70) was inversely associated with TW-ROP. In contrast to prior reports, we found no significant difference in sex, multiplicity, or fundus pigmentation at baseline exam in those with TW-ROP as compared to controls. High levels of media haze (>2, scale 0 to 5) were found in the majority of cases (67.6%, 25/37) and controls (65.7%, 44/67). Presence of peripapillary atrophy did not improve prediction of the development of TW-ROP compared to birth weight and weight gain rate alone. CONCLUSIONS: The finding of high levels of media haze at baseline ROP screening exams is novel. This study supports the current model for detection of TW-ROP using birth weight, gestational age, and weight gain rate. We found no significant difference between newborns with TW-ROP and controls in baseline presence of media haze, fundus pigmentation or peripapillary atrophy.

Four-muscle tenotomy surgery for nystagmus.

PURPOSE OF REVIEW: To describe the history and literature related to four-muscle tenotomy procedure for nystagmus. RECENT FINDINGS: The concept of four-muscle tenotomy surgery for nystagmus initially arose from objective eye movement recordings of patients with nystagmus and an eccentric face turn who had undergone the Anderson-Kestenbaum procedure. These eye movement recordings demonstrated secondary benefits, including broadening of the null region, improved visual acuity, and improved nystagmus waveforms. Studies initially performed in dogs validated the theory that such positive effects could be obtained by horizontal four-muscle tenotomy and reattachment without transposition. Subsequent studies in humans have demonstrated that the procedure results in improved visual acuity, broadening of the null zone, and improved target acquisition in patients with nystagmus. New theories have been described regarding techniques to augment the effects of the procedure and/or replicate its effects with a safer, less invasive alternative. SUMMARY: Horizontal four-muscle tenotomy has proven to be an effective procedure for reducing nystagmus, broadening the null position, and improving visual acuity in primary position for patients with nystagmus.

TRAUMATIC LENS SUBLUXATION FROM PICKLEBALL INJURY: A CASE SERIES.

PURPOSE: The purpose of this study was to describe two cases of traumatic lens subluxation resulting from pickleball injury. METHODS: This is a case series. RESULTS: A 77-year-old man presented with worsening vision and was noted to have subluxation of his intraocular lens 10 days after being struck in the eye with a pickleball. The patient underwent a lens exchange with scleral fixation. A 76-year-old woman presented with blurry vision on the same day as her injury and was noted to have subluxation of her crystalline lens. She also underwent a lens insertion with scleral fixation. However, she experienced additional complications of postoperative cystoid macular edema and traumatic glaucoma. CONCLUSION: We recommend increased use of eye protection in pickleball.

PARACENTRAL ACUTE MIDDLE MACULOPATHY AND OCULAR ISCHEMIC SYNDROME AFTER INTRANASAL STEROID INJECTION: A CASE REPORT AND REVIEW OF THE LITERATURE.

PURPOSE: To describe a case of paracentral acute middle maculopathy and ocular ischemic syndrome after intranasal steroid injection. METHODS: Case report. RESULTS: Following an intranasal steroid injection, the patient experienced an episode of amaurosis fugax in her right eye lasting several minutes. Afterward, her visual acuity returned to baseline, but she noted a persistent central scotoma. Optical coherence tomography demonstrated paracentral acute middle maculopathy and fluorescein angiography showed staining and leakage to peripheral vessels concerning for diffuse ischemia. CONCLUSION: Steroid injections to the face and nasopharynx may result in ischemic and vaso-occlusive events in the retina. Ophthalmologists and other physicians performing these procedures need to be aware of this potential adverse outcome.

Bilateral Proliferative Retinopathy as the Initial Presentation of Atypical Hemolytic Uremic Syndrome: A Case Report.

In this case report, we describe a 34-year-old male patient who presented with vision loss and was found to have profound occlusive retinal vasculopathy. His initial laboratory studies were unremarkable, but five weeks after his ocular symptoms began, he developed acute multi-organ failure and was ultimately diagnosed with atypical hemolytic uremic syndrome (aHUS). His course was complicated by a stroke, respiratory distress requiring intubation, long-term hemodialysis, and eventually death. Occlusive retinal vasculopathy may be the presenting finding in aHUS, although thrombotic microangiopathy syndromes typically present with acute kidney injury and or failure, hemolytic anemia, and thrombocytopenia. [Ophthalmic Surg Lasers Imaging Retina 2023;54:297-300.].

The Impact of Social Determinants of Health on Presentation, Treatment, and Outcomes in Branch Retinal Vein Occlusion With Cystoid Macular Edema.

BACKGROUND AND OBJECTIVE: To investigate the impact of social determinants of health on the presentation, treatment, and outcomes of branch retinal vein occlusion (BRVO) with cystoid macular edema (CME). PATIENTS AND METHODS: A retrospective chart review was conducted of patients with BRVO and CME treated with anti-vascular endothelial growth factor (anti-VEGF) injections at Atrium Health Wake Forest Baptist from 2013 to 2021. Patients' baseline characteristics including visual acuity (VA), age, sex, race, Area Deprivation Index (ADI), insurance status, baseline central macular thickness (CMT), treatment details, final VA, and final CMT were recorded. The primary outcome measure was final VA comparing more and less deprived groups, and White and non-White groups. RESULTS: Two hundred forty-four eyes of 240 patients were included. Patients with higher socioeconomic deprivation scores had thicker final CMT (P = 0.05). Non-White patients had worse presenting (P = 0.01) and final VA (P = 0.02). CONCLUSION: This study demonstrated disparities in presentation and outcomes based on socioeconomic status and race in patients with BRVO and CME treated with anti-VEGF therapy. [Ophthalmic Surg Lasers Imaging Retina 2023;54:411-416.].

ENDOPHTHALMITIS PRESENTING AS RETINAL VASCULITIS LESS THAN 24 HOURS AFTER AFLIBERCEPT INJECTION: A CASE REPORT.

PURPOSE: We describe a case of endophthalmitis caused by Streptococcus salivarius presenting as a retinal vasculitis less than 24 hours after intravitreal injection. METHODS: A case report. RESULTS: The patient progressed from a hemorrhagic retinal vasculitis to severe endophthalmitis with no view to the posterior segment within 24 hours. The visual acuity progressed from 20 of 20 preinjection to light perception within less than 48 after injection. Vitreous tap and injection was performed within 24 hours of intravitreal aflibercept injection, followed by pars plana vitrectomy the next day. The final visual acuity was hand motions. CONCLUSION: Streptococcus salivarius is a virulent organism that may cause an endophthalmitis early after intravitreal injection with an unusual presentation of hemorrhagic retinal vasculitis. A high index of suspicion for infectious endophthalmitis should be maintained for all patients presenting with ocular inflammation and worsening vision in the days after intravitreal injections.

ANTERIOR MIGRATION OF INTRAVITREAL FLUOCINOLONE ACETONIDE IMPLANTS: A CASE REPORT.

BACKGROUND/PURPOSE: To describe management of anterior migration of a fluocinolone acetonide(FAc) intravitreal implant. METHODS: A retrospective case report. A 61-year-old man with diabetic macular edema and prior vitrectomy had anterior migration of a FAc implant. Anterior segment photos and optical coherence tomography were performed. RESULTS: Approximately 3 months after FAc implant was administered, it was noted to have migrated into the anterior chamber. Vision, intraocular pressure, and optical coherence tomography imaging initially remained stable, and no evidence of detectable corneal edema developed in 30 months of follow-up. However, at 36 months of follow-up, after second FAc implant injection, mild corneal edema developed,suspected to be related to the migrating implants. CONCLUSION: Anterior migration of a FAc implant may lead to less rapid and severe corneal decompensation compared with other steroid implants. Despite this, delayed corneal edema may occur. Careful monitoring of the cornea and intraocular pressure is recommended in cases of anterior FAc migration.

Vitreous and Chorioretinal Lesions in People Who Inject Drugs and Are Hospitalized with Bloodstream and Related Infections.

PURPOSE: To determine the prevalence of and to characterize vitreous and chorioretinal lesions, to identify causative organisms, and to correlate symptoms with ophthalmic involvement in people who inject drugs and are hospitalized with bloodstream infection (BSI), related metastatic foci of infection (MFI), or both. DESIGN: An academic hospital-based cross-sectional study. PARTICIPANTS: Patients admitted with BSI or MFI related to injection drug use (IDU). METHODS: Patients underwent a complete eye examination within 72 hours of enrollment. Characteristics including gender; age; race; injection drug of choice (DOC); presence of coinfection with hepatitis B, hepatitis C, or human immunodeficiency virus; pathogen causing systemic infection and type of infection; and history of prior infection related to IDU were recorded. MAIN OUTCOME MEASURES: Presence of vitreous or chorioretinal findings, or both. RESULTS: Ninety-one unique patients with 96 separate hospitalizations for systemic infection were enrolled from March 28, 2018, through March 30, 2020. Vitreous or chorioretinal involvement was identified in 16 of 96 patients (16.7%). The most common ocular findings were intraretinal or white-centered hemorrhage in 9 of 96 patients, chorioretinal infiltrate in 8 of 96 patients, endophthalmitis in 5 of 96 patients, and cotton wool spots in 3 of 96 patients. Of the patients with ocular involvement, only 7 of 16 patients (44%) were symptomatic, and 5 of these were patients with endophthalmitis; the others showed chorioretinal infiltrates or intraretinal or white-centered hemorrhage and cotton wool spots. Staphylococcus aureus was the most common causative pathogen in patients with and without ocular findings. Presence of ocular symptoms, worse visual acuity, and injection DOC of methamphetamine were correlated with the presence of ocular findings. CONCLUSIONS: Patients without ocular symptoms with systemic infections related to IDU may have chorioretinal findings. Further study is needed to characterize better the epidemiologic features of these infections and to identify risk factors for ocular involvement in people who inject drugs.

Neurodevelopmental Outcomes Following Intravitreal Bevacizumab With Laser Versus Laser Photocoagulation Alone for Retinopathy of Prematurity.

BACKGROUND AND OBJECTIVE: To assess neurodevelopmental outcomes of infants with treatment-warranted retinopathy of prematurity (TW-ROP) treated with intravitreal bevacizumab (IVB) plus diode laser photocoagulation (DLP) compared to DLP alone. PATIENTS AND METHODS: A retrospective review was performed of infants who underwent treatment for TW-ROP with IVB+DLP or DLP alone from 2010 to 2017. Baseline characteristics and coexisting medical comorbidities were recorded. The presence of neurodevelopmental delay (NDD) at 2-year follow-up and composite Bayley-III scores were recorded. RESULTS: Sixty-six infants were included in the study; 18 received IVB+DLP, and 48 received DLP alone. Average Bayley-III scores for cognition, language, and motor, as well as rates of documental NDD, did not differ between the groups. CONCLUSION: This study does not demonstrate an increased risk of NDD in infants with TW-ROP treated with IVB+DLP compared with DLP alone. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:220-224.].

Telemedicine Follow-Up for Intravitreal Bevacizumab Injection in the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) Cohort.

Telemedicine has emerged as a potential solution to face the disproportion between infants that need to be screened for retinopathy of prematurity (ROP) and the lack of ophthalmologists. We evaluated its utility in the follow-up after off-label intravitreal injection of bevacizumab. None of the treated infants ended up with bad anatomic outcome. Telemedicine is an alternative safe method to monitor patients after treatment.

Automatic Identification of Referral-Warranted Diabetic Retinopathy Using Deep Learning on Mobile Phone Images.

Purpose: To evaluate the performance of a deep learning algorithm in the detection of referral-warranted diabetic retinopathy (RDR) on low-resolution fundus images acquired with a smartphone and indirect ophthalmoscope lens adapter. Methods: An automated deep learning algorithm trained on 92,364 traditional fundus camera images was tested on a dataset of smartphone fundus images from 103 eyes acquired from two previously published studies. Images were extracted from live video screenshots from fundus examinations using a commercially available lens adapter and exported as a screenshot from live video clips filmed at 1080p resolution. Each image was graded twice by a board-certified ophthalmologist and compared to the output of the algorithm, which classified each image as having RDR (moderate nonproliferative DR or worse) or no RDR. Results: In spite of the presence of multiple artifacts (lens glare, lens particulates/smudging, user hands over the objective lens) and low-resolution images achieved by users of various levels of medical training, the algorithm achieved a 0.89 (95% confidence interval [CI] 0.83-0.95) area under the curve with an 89% sensitivity (95% CI 81%-100%) and 83% specificity (95% CI 77%-89%) for detecting RDR on mobile phone acquired fundus photos. Conclusions: The fully data-driven artificial intelligence-based grading algorithm herein can be used to screen fundus photos taken from mobile devices and identify with high reliability which cases should be referred to an ophthalmologist for further evaluation and treatment. Translational Relevance: The implementation of this algorithm on a global basis could drastically reduce the rate of vision loss attributed to DR.

Intraoperative Optical Coherence Tomography Demonstrating Macular Hole Associated With Ruptured Retinal Arterial Macroaneurysm.

A 67-year-old female presented with vitreous hemorrhage and sub-internal limited membrane (ILM) hemorrhage in her right eye associated with ruptured retinal arterial macroaneurysm. During pars plana vitrectomy, intraoperative optical coherence tomography aided in the diagnosis of a small macular hole previously obscured by the sub-ILM hemorrhage. Nonexpansile gas was placed followed by postoperative prone positioning, and the hole closed successfully. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e125-e127.].

The development and spontaneous resolution of a full-thickness macular hole in bartonella henselae neuroretinitis in a 12-year-old boy.

PURPOSE: To describe an unusual case of Bartonella henselae neuroretinitis complicated by macular hole (MH) development. OBSERVATIONS: A full-thickness macular hole developed in a 12-year-old boy in association with serology-confirmed Bartonella henselae neuroretinitis. Following a period of observation, the MH closed without intervention. CONCLUSION AND IMPORTANCE: MH may occur as a complication of neuroretinitis secondary to Cat-Scratch Disease.

Reductions in final visual acuity occur even within the first 3 days after a macula-off retinal detachment.

PURPOSE: To determine if final visual acuity (VA) is affected by duration of macular detachment (DMD) within the first week of macula-off retinal detachment (RD). METHODS: This is a retrospective study of eyes that underwent repair within 7 days with vitrectomy or vitrectomy with scleral buckle for macula-off RD at Stanford University Hospital between 1 May 2007 and 1 May 2017. A generalised linear model was constructed using DMD, postoperative lens status, preoperative VA, patient age and surgeon as the independent variables and the final VA as the dependent variable. The main outcome measure was the final VA. RESULTS: Seventy-nine eyes met the entry criteria. Group 1 included 52 eyes with RD repaired within 3 days of DMD, and group 2 included 27 eyes repaired between 4 and 7 days of DMD. The average final VA in group 1 eyes was logarithm of the minimum angle of resolution (logMAR) 0.21 (Snellen 20/33) and in group 2 eyes was logMAR 0.54 (Snellen 20/69). In group 1 and group 2 eyes, preoperative VA (p=0.017and p=0.007), DMD (p=0.004 and p=0.041) and final lens status (p<0.0001 and p<0.001) predicted postoperative VA. Post-hoc analysis showed significant differences in final VA between detachments of 1day vs 3 days (p=0.0009). CONCLUSION: DMD affects the final VA even among patients whose DMD is <3 days. Based on these results, interventions that shorten DMD, including those occurring within the first 3days, may result in improved long-term VA outcomes.

Photodynamic Therapy-Induced Macular Hole.

A 72-year-old female with neovascular macular degeneration refractory to anti-vascular endothelial growth factor injections underwent photodynamic therapy and subsequently developed a macular hole (MH) associated with vitreomacular traction. After a period of observation, the MH enlarged. Pars plana vitrectomy was performed, and the MH was closed successfully. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:270-272.].

Incontinentia pigmenti with secondary Raynaud's phenomenon: A case report and review of the literature.

PURPOSE: To describe a patient with incontinentia pigmenti (IP) and Raynaud's phenomenon (RP). OBSERVATIONS: A 5 year-old girl with history of IP was noted to have RP. Visual acuity was unaffected in both eyes, and fundus examination demonstrated regressed peripheral neovascularization. Photos of the patient's hands demonstrated pale discoloration associated with exposure to cold. CONCLUSIONS AND IMPORTANCE: IP, known to affect small cerebral and retinal blood vessels, can also affect the small blood vessels in the extremities, resulting in secondary RP.