Does dexamethasone implant combination with aflibercept monotherapy affect one-year outcomes in treatment-naive diabetic macular edema with inflammatory biomarkers?

PURPOSE: To compare the anatomical and functional outcomes of the combination of aflibercept and dexamethasone implant (CT) against aflibercept monotherapy (AM) in treatment-naive diabetic macular edema (DME) patients with serous macular detachment and hyperreflective foci. METHODS: This study included 82 eyes of 82 patients with treatment-naive DME who completed the follow-up period of 12 months. All patients had optical coherence tomography biomarkers of an inflammatory DME phenotype. Patients were consecutively selected and classified into two groups: The CT group consisted of 39 eyes treated with aflibercept therapy and initially combined with a single-dose dexamethasone implant. The AM group consisted of 43 eyes treated with aflibercept alone. The primary outcome measures of the study were the mean reduction of the central macular thickness (CMT) and total macular volume parameters (TMV) and improvement in best-corrected visual acuity. RESULTS: In both groups, the patient characteristics, including age, gender, duration of diabetes, HbA1c levels, phakic percentage, and diabetic retinopathy status were similar (P > 0.05). The mean reduction in CMT and TMV was significantly higher in the CT group compared to the AM group (P < 0.001 and P = 0.002, respectively). In contrast, mean letter gains were not significantly higher (P = 0.240) at the end of the study. In the CT group, 20.5% of patients showed a transient IOP increase, and 18% developed cataracts. In subgroup analysis, the mean letter gain in pseudophakic eyes was significantly higher (12.5 in the CT vs. 9.3 in the AM group, P = 0.027). CONCLUSION: The CT, where inflammation is prominent, can provide faster recovery. The pseudophakic eyes seem to be the ideal patient group for CT.

Long-term outcomes of autologous platelet treatment for optic disc pit maculopathy.

PURPOSE: Optic disc pits (ODPs) are rare congenital cavitary abnormalities of the optic nerve head, which can lead to serous macular detachments. The aim of this study was to evaluate the long-term efficacy of pars plana vitrectomy (PPV) combined with autologous platelet concentrate (APC) for the treatment of optic disc pit maculopathy (ODP-M). METHODS: A retrospective analysis was performed on eleven eyes of ten patients with ODP-M, who received PPV combined with APC. Nine eyes operated primary, four of which had a repeat surgery also with injection of APC and two eyes underwent a rescue surgery, after they have been operated in another eye center without APC. Morphological and functional results were the main outcome parameters, determined by optical coherence tomography (OCT) and best-corrected visual acuity (BCVA), respectively. RESULTS: The mean duration of visual loss before surgery was 4.7 ± 3.89 months (range 0-12 months). The mean BCVA increased significantly from 0.82 ± 0.33 logMAR (range 0.4-1.3) preoperatively to 0.51 ± 0.36 logMAR (range 0-1.2) at the last examination (p = 0.0022). A significant morphological improvement was also noticed with decrease of the mean foveal thickness from 935.82 ± 248.48 µm (range 559-1400 µm) preoperatively to 226.45 ± 76.09 µm (range 110-344 µm) at the final examination (p < 0.0001). The patients were followed-up for a mean 65.36 ± 48.81 months (range 1-144 months). Two eyes developed postoperatively a retinal detachment. Cataract surgery was performed in 5 eyes during the follow-up period. CONCLUSION: Our study demonstrated that PPV with APC can improve functional and morphological outcomes, both as a primary and a rescue therapy, without any recurrence over a long follow-up period. To the best of our knowledge, this was the longest observation period regarding the use of APC in treatment of ODP-M.

Impact of submacular fluid volume on visual outcome in macula-off rhegmatogenous retinal detachment using automated optical coherence tomography volumetric quantification.

BACKGROUND: We investigated effects of submacular fluid volume (SMFV) on visual outcomes following surgery for macula-off primary rhegmatogenous retinal detachment (RRD) using automated fluid volumetric quantification with optical coherence tomography (OCT). METHODS: We analysed 127 eyes that were surgically treated for macula-off RRDs. We obtained preoperative images following the spectral domain (SD)-OCT dense volume protocol, applied automated retinal segmentation and used an automated algorithm to quantify each eye's SMFV. We used multivariate models to identify various risk factors for impaired visual outcome. RESULTS: Linear regression showed that preoperative SMFV (ß = 0.013; P = .005) was significantly associated with a reduced visual outcome 12 months after the treatment of macula-off RRDs. SMFV was negatively correlated with 12-month postoperative (r = .311; P = .001) visual acuity (VA). The group with low preoperative SMFV (≤9.0 mm3 ) showed an increasing VA up to 12 months postoperatively (P < .001), while the VA did not increase in the group with high SMFV (>9.0 mm3 ) beyond 3 months of follow-up. Patients with a high SMFV were 8.0 times more likely to have worse visual outcomes after 12 months of follow-up (P = .018). CONCLUSIONS: SMFV was negatively correlated with visual outcomes after the surgical treatment of macula-off RRDs. Patients with SMFV <9.0 mm3 12 months after surgery had an 8.0 times greater chance for better visual recovery than patients with high preoperative SMFV. Our findings highlight the efficacy of automated SMFV quantification in predicting surgical outcomes in patients with RRDs, which could be useful in future clinical practice and the development of research models.

Spectral domain optical coherence tomography classification of diabetic macular edema: a new proposal to clinical practice.

PURPOSE: To classify the types of diabetic macular edema (DME) and evaluate its morphological features on spectral domain optical coherence tomography (SD-OCT) and determine correlations between visual acuity and OCT findings. METHODS: We assessed 406 eyes of 309 patients with a diagnosis of DME retrospectively. Three types based on SD-OCT were identified: diffuse macular edema, cystoid macular edema, and cystoid degeneration. Morphological features such as serous macular detachment (SMD), vitreomacular interface abnormalities (VMAI), hard exudates, photoreceptor status, and correlations between visual acuity and those morphological features were also evaluated by SD-OCT. RESULTS: The most common type of DME was cystoid edema (68.5%). No statistically significant difference was found between groups in sex (P = 0.40), type of diabetes (P = 0.50), or diabetic retinopathy (P = 0.78). However, the duration of symptoms and BCVA was significantly lower in the group with cystoid degeneration compared with the group with cystoid edema (P < 0.001) and the group with diffuse macular edema (P < 0.001). In the group with cystoid degeneration compared with the groups with cystoid and diffuse edema, the central fovea and central subfield were significantly thicker (both (P < 0.001), the subfoveal choroid was significantly thinner (P = 0.049), rate of serous macular detachment was significantly lower (P < 0.001), and the rate of outer retinal damage was significantly higher (P < 0.001). CONCLUSIONS: Cystoid macular degeneration, which is consistent with poor functional and morphological outcomes, should be differentiated from cystoid macular edema. Serous macular detachment, which is mostly seen in eyes with early stages of DME, should be evaluated as an accompanying morphological finding rather than a type of DME.

Surgically Induced Macular Detachment for Treatment of Refractory Full-Thickness Macular Hole: Anatomical and Functional Results.

PURPOSE: The purpose of this study was to investigate the efficacy and safety of surgically induced macular detachment (MD) for the treatment of refractory full-thickness macular hole (FTMH). MATERIALS AND METHODS: Clinical data were age, gender, lens status, and best corrected visual acuity (BCVA). Preoperative tomographic parameters were: FTMH morphology (intraretinal cyst and elevated or flat edges) and FTMH diameter. Postoperative FTMH closure and outer retinal layer (ORL) restoration were evaluated. Fundus autofluorescence (FAF), optical coherence tomography (OCT) findings, and BCVA were analyzed at the 1st, 3rd, and 6th postoperative month. The interval between the first surgery for idiopathic FTMH and the surgically induced MD for refractory FTMH was collected (intersurgical interval, days). RESULTS: Ten eyes of 10 patients were included. The mean age was 68.8 ± 6.8 years. FTMH closure was obtained in 9 patients; in 8 patients, ORL restoration was detected. BCVA improved from 1.06 ± 0.1 (baseline) to 0.56 ± 0.2 (final) logMAR (p = 0.0001). A negative correlation between the intersurgical interval and postoperative visual gain was demonstrated (r = -0.3618). FAF and OCT showed a permanent retinal pigment epithelium (RPE) damage corresponding to the retinotomy points. CONCLUSION: This study demonstrates the efficacy of this technique and highlights the risk of RPE damage, suggesting the need to perform the retinotomy points outside the macula.

Morphological and clinical characteristics of myopic posterior staphyloma in Caucasians.

PURPOSE: We aimed to study the morphological characteristics of myopic posterior staphyloma in Caucasians and to evaluate the correlation between posterior staphyloma, myopic macular lesions and visual acuity. METHODS: Ninety eyes of 67 consecutive patients affected by high myopia associated with posterior staphyloma were recruited between January 2012 and December 2013. Posterior staphyloma was classified according to Curtin's criteria. Every patient underwent fundoscopic examination and best corrected visual acuity measurement (BCVA). A and B-scan ultrasound (US), high-resolution, three-dimensional magnetic resonance image (MRI), optical coherence tomography (OCT), fundus autofluorescence (FAF), red free (RF) and color fundus photography studies were performed. RESULTS: The mean age was 64.4 ± 9.48 years (range: 41-82). The mean BCVA was 0.7 ± 0.5 logMAR (range: 0-2). The mean axial length was 29.92 ± 2.39 millimeters (range: 24.25-36.53). The authors found four types of posterior staphyloma according to Curtin's classification: I, II, IV and IX. Significant prevalence of posterior staphyloma in female sex was observed (p = 0.0235). Significant correlation between the depth and the diameters of posterior staphyloma was demonstrated (p < 0.0001). Significant association between posterior staphyloma type and tomographic foveal patterns (p = 0.0230) was highlighted. Posterior staphyloma type I was more frequently associated with peripapillary atrophy and less with macular atrophy compared to type II and IX (p = 0.0169). The prevalence of macular atrophy was more than double in posterior staphyloma type II (33.3 %) in comparison to posterior staphyloma type I (12.5 %). CONCLUSIONS: This study confirms that the type I and II are the most common types of posterior staphyloma, as already highlighted in the literature. A significant association between the type of posterior staphyloma and the MRI ocular shape pattern, the OCT patterns of macular profile and the location of chorioretinal atrophy was highlighted. The correlation between the depth and the width of posterior staphyloma has demonstrated that the deeper the staphyloma, the wider it was. The deepest area of the posterior staphyloma was characterized by a greater thinning of the sclera and by a higher prevalence of chorioretinal atrophy compared to the other parts of the eye. More studies are necessary to support our findings and to add more information on the natural evolution of posterior staphyloma and on its associated complications.

Multimodal Imaging of Bilateral Retinal Pigment Epithelial Immunoglobulin Light Chain Deposition in Patients with Systemic Immunoglobulin Light Chain Deposition.

OBJECTIVE: To describe multimodal imaging of peculiar bilateral globular subretinal deposits and acquired serous retinal detachment in patients with systemic immunoglobulin light chain deposition. DESIGN: A retrospective observational case series. PARTICIPANTS: We examined 6 eyes in 3 patients (1 with multiple myeloma, 1 with membranous nephropathy, and 1 with immunoglobulin A nephropathy) at the Eye and ENT Hospital of Fudan University. The patients presented with peculiar globular subretinal deposits along the retinal pigment epithelium (RPE)‒Bruch's membrane complex and acquired serous retinal detachment. METHODS: Fundus appearance was documented with multimodal imaging, which included fundus photography, fundus autofluorescence, spectral domain OCT, swept-source OCT (SS-OCT), en face OCT, and SS-OCT angiography. Additional evaluations included serum protein electrophoreses, positron emission tomography computed tomography, and renal and bone biopsies to assess the primary diseases. MAIN OUTCOME MEASURES: Multimodal imaging, course, and prognosis of bilateral RPE immunoglobulin light chain deposition in patients with systemic immunoglobulin light chain deposition. RESULTS: Bilateral, multiple, speckled, or patchy RPE changes in the posterior fundus that corresponded to striking multifocal hyperautofluorescence on fundus autofluorescence and lumpy, globular hyperreflective deposits along the RPE‒Bruch's membrane complex were identified as characteristic features of bilateral RPE light chain deposition. These features may be accompanied by dense light chain deposits in the choriocapillaris and choroid vessels, diffuse choroidal thickening, and "angiographically silent" serous retinal detachment in patients with systemic immunoglobulin light chain deposition. CONCLUSIONS: We have documented the characteristic features, clinical course, and prognosis of bilateral RPE immunoglobulin light chain deposition in patients with systemic immunoglobulin light chain deposition. Appropriate evaluations, including serum protein electrophoresis and hematologic consultation, are recommended to manage patients with this fundus abnormality. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

A New Model of a Macular Buckle and a Refined Surgical Technique for the Treatment of Myopic Traction Maculopathy.

Myopic traction maculopathy (MTM) affects 20% of eyes with pathologic myopia (PM). The MTM Staging System (MSS), published in 2020, describes the nomenclature of MTM as well as a proposal of pathogenesis, natural evolution, and prognosis. A study of customized treatment for each stage of MTM has been published previously and suggested to treat maculoschisis and detachment by placing a macular buckle (MB) behind the macula to push the sclera towards the retina, selecting pars plana vitrectomy (PPV) only in cases where a macular hole is associated with MTM. We hereby describe a new model of a macular buckle, known as NPB, and an NPB loading device, with the aim to standardize the surgical technique and render it more user friendly, efficient, and safe. Macular buckle is an effective and safe procedure to treat maculoschisis and macular detachment in MTM. We recommend using it as a unique and first-line treatment.

Morning Glory Anomaly With Serous Macular Detachment.

The morning glory (MG) disc anomaly is a congenital excavation of the posterior globe involving the optic disc, with a distinct appearance reminiscent of the MG flower. Various intracranial and ocular associations with MG have been documented. Conditions such as trans-sphenoidal encephalocele and hypoplasia of the intracranial vasculature have been observed in association with this anomaly. In this report, we present a case of MG optic disc anomaly accompanied by serous macular detachment.

Epiretinal implant of human amniotic membrane to treat highly myopic macular hole retinal detachments: A novel surgical technique.

PURPOSE: To describe a new surgical technique involving the use of a human amniotic membrane (hAM) epiretinal patch to treat a primary macular hole retinal detachment (MHRD) in a highly myopic patient. METHODS: A 60 years old highly myopic man was referred to our clinic with a diagnosis of MHRD in his right eye. The patient was pseudophakic, with a visual acuity of counting fingers at the baseline evaluation. Pars plana vitrectomy was performed, a small retinotomy was created at the inner margin of the staphyloma, and membrane blue dual was used to obtain an adequate peeling of the inner limiting membrane. Then, a 1.5 mm diameter circular hAM patch was obtained and positioned over the macular hole with the chorion layer settled over the retina. After a complete fluid-air exchange, 20% sulfur hexafluoride gas was used as endotamponade, and the patient was asked to remain face down for three days. RESULTS: Four weeks after surgery, optical coherence tomography (OCT) scan showed the hAM patch, visualized as a distinct hyperreflective layer well integrated with the retina. Nine months after surgery, the macular hole was closed, the retina reattached, the hAM patch was adherent to the retina, and the patient presented a best-corrected visual acuity improved to 0.7 logMar. No postoperative adverse events were registered during the follow-up. CONCLUSIONS: Epiretinal hAM implant could represent a novel surgical technique, feasible and easier compared to other current techniques used to treat MHRD in highly myopic patients.

Personalized Management of Patients with Proliferative Diabetic Vitreoretinopathy.

Purpose: To evaluate prognostic factors for visual outcome in patients with diabetes who have undergone vitrectomy (PPV) for severe proliferative diabetic vitreoretinopathy (PDVR) in at least one eye in the past 15 years. Methods: Medical records of 132 eyes of 66 patients were analyzed (median age 52 years 21-80; patients with type 1/2 diabetes 40/26; median follow-up 38 months 9-125). Correlations between final favorable visual outcome defined as 0.5≤ best-corrected visual acuity (BCVA) and prognostic factors (age, sex, type and duration of diabetes, metabolic status, BCVA, diabetic retinopathy status, data of preoperative management, data of vitrectomy, and postoperative complications) were analyzed. Results: BCVA improved significantly in the entire study cohort (from median 0.05 min-max 0.001-1 to 0.32, 0.001-1, p < 0.001). Visual stabilization was achieved in the majority of patients, and good visual acuity (0.5 ≤ BCVA) was maintained in more than one-third of the eyes. Multivariable GEE statistics showed that in addition to the duration of diabetes and stable HbA1c values, only preoperative tractional macular detachment proved to be an independent significant predictor of visual outcome. Conclusions: Pars plana vitrectomy is a useful tool when performed early before tractional macular detachment. However, long-term visual stability can only be achieved with good metabolic control.

Inverted internal limiting membrane flap combined with subretinal viscoelastic injection for large or chronic macular holes.

Purpose: To report two cases with a large or chronic macular hole (MH) that was closed by combining the inverted internal limiting membrane (ILM) flap technique with the injection of ophthalmic viscoelastic device (OVD) into the subretinal space through the MH. Observations: A 76-year-old woman was referred to our clinic for surgery of a MH with a maximum diameter of 1089 µm as determined by optical coherence tomography (OCT). Her visual acuity was 20/50 in the left eye after vitrectomy was performed at a local clinic to remove vitreous opacities. For our surgery, the ILM was peeled and the ILM flap was inverted and placed over the MH. Then, cohesive OVD was injected into the subretinal space through the MH to create a retinal detachment around the MH. The MH was closed by a gas tamponade, and the vision improved to 20/40. The second patient was a 62-year-old man whose vision had been decreasing for 3 years, and he was referred to our clinic. His vision was 20/40 in the left eye and OCT detected a MH with a maximum diameter of 853 µm. After core vitrectomy, the ILM was peeled, inverted, and placed over the MH. Then, dispersive and cohesive OVD was injected through the MH. During this procedure, the MH appeared to enlarge and elevate. Then a yellowish arch-shaped lesion appeared at the temporal edge of the macular detachment. The intraoperative OCT showed that the curled-up retinal pigment epithelium (RPE) within the temporal arch-shaped lesion was adherent to the outer retinal layer. Following gas tamponade, the MH was closed but the patient noticed a paracentric scotoma on the nasal side. The fundus autofluorescence (FAF) images showed a hypo-autofluorescent lesion corresponding to the RPE defect. At postoperative 4 months, his visual acuity had improved to 20/22 and the OCT image showed that the MH was closed with a recovery of the ellipsoid zone of the photoreceptors. The subjective paracentric scotoma disappeared, however the hypo-autofluorescent lesion persisted. Conclusions and importance: A combination of the inverted ILM flap and the subretinal injection of OVD can close a large or chronic MH. An RPE detachment caused by injecting OVD into the subretinal space should be avoided.

Multifocal Chorioretinitis with Serous Macular Detachment in Diffuse Unilateral Subacute Neuroretinitis (DUSN): Unique Presentation and a Diagnostic Dilemma.

PURPOSE: To report a case of multifocal chorioretinitis with serous macular detachment in diffuse unilateral subacute neuroretinitis (DUSN) and its diagnostic dilemma. DESIGN: Case report. METHOD: A 43-year-old woman presented with painless diminution of vision of right eye for 1 week. Dilated fundoscopy showed mild disc edema, multiple deep grey-white retinitis lesions in posterior pole with mild vitritis. Optical coherence tomography revealed serous macular detachment. Fundus fluorescein angiography was suggestive of active retinitis. Comprehensive workup was unremarkable. Six days later, a live subretinal worm was noticed in inferotemporal retina. A diagnosis of DUSN was made and treated with laser photocoagulation followed by antihelminthic therapy. One month later, patients vision improved and chorioretinal lesions also healed. CONCLUSION: This report presents a unique scenario of serous macular detachment in DUSN in addition to commonly seen multifocal deep retinitis lesions. Prompt treatment with laser, antihelminthic agent can prevent irreversible vision loss.

Purtscher-like retinopathy with serous macular detachment in a case of acute pancreatitis: A case report.

A 28-year-old male hospitalized with a diagnosis of acute pancreatitis presented with sudden onset of blurred vision in both eyes after 48 h of admission. Visual acuity was counting fingers in both eyes. Fundus examination revealed multiple cotton wool spots and intraretinal hemorrhages typical of Purtscher's retinopathy. Optical coherence tomography macula showed serous macular detachment. In 8 weeks follow-up, visual acuity improved to 6/18 oculus dexter (OD) and 6/60 oculus sinister (OS) with resolution of fundus lesions and resorbed subretinal fluid. Purtscher-like retinopathy, though rare should be considered as a differential in all cases with vision loss in acute pancreatitis. This particular case highlights the significance of a thorough examination of the fundus by an ophthalmologist in identifying this infrequent condition that is often overlooked.

Accuracy of ultrasound vs. Fourier-domain optic biometry for measuring preoperative axial length in cases of rhegmatogenous retinal detachment.

PURPOSE: To identify a method for accurately measuring preoperative axial length (AL) in cases of rhegmatogenous retinal detachment (RRD). STUDY DESIGN: Retrospective study. METHODS: This retrospective study included 83 eyes of 83 patients who underwent vitrectomy for RRD and had both preoperative and postoperative data for AL. Preoperative AL measurements for the affected eye were obtained using ultrasound (aUS-AL) and compared with those for affected and fellow eyes measured using optical biometry (aOB-AL and fOB-AL, respectively). Absolute differences between preoperative aUS-AL, aOB-AL, or fOB-AL measurements and postoperative AL (aPost-AL) were examined. RESULTS: In the 41 eyes without macular detachment, the absolute difference between aOB-AL and aPost-AL (0.06±0.07 mm) was significantly smaller than between aUS-AL and aPost-AL (0.21±0.18 mm) and that between fOB-AL and aPost-AL (0.29±0.35 mm) (P = 0.017 and P < 0.001, respectively). In the 42 eyes with macular detachment, the absolute difference between aOB-AL and aPost-AL (1.22±2.40 mm) was significantly larger than between aUS-AL and aPost-AL (0.24±0.24 mm) and between fOB-AL and aPost-AL (0.35±0.49 mm) (P = 0.006, P = 0.016, respectively). CONCLUSION: The current findings suggest that aOB-AL is more accurate than aUS-AL or fOB-AL in cases of RRD without macular detachment, while aUS-AL or fOB-AL is more accurate than aOB-AL in cases with macular detachment.

Predictive impact of optical coherence tomography biomarkers in anti-vascular endothelial growth factor resistant macular edema treated with dexamethasone implant.

PURPOSE: To perform a longitudinal analysis of the effect of optic coherence tomography (OCT) biomarkers on macular thickness in patients with persistent macular edema secondary to diabetes mellitus and retinal vein occlusion who recieved intravitreal dexamethasone (DEX) implant. METHODS: Eighty-nine patients were included in the retrospective study. Patients with anti-VEGF-resistant macular edema were included in the study. The effect of the presence or absence of OCT biomarkers before intravitreal DEX implant therapy on central foveal thickness (CFT) was evaluated. In addition, the change in biomarkers from the baseline visit to the final visit was evaluated. The evaluated OCT biomarkers were as follows: ellipsoid zone and external limiting membrane (ELM) integrity, hyperreflective foci (HRF), disorganization of inner retinal layers (DRIL), hard exudates, serous macular detachment (SMD), pearl necklace, posterior vitreous detachment and the epiretinal membrane (ERM). RESULTS: The mean age of the overall sample in the study was 64.4 ± 9.6. CFT decreased significantly from 625.3 ± 22.3 µm at baseline to 365.0 ± 21.7 µm in the 1st month but increased significantly to 430.2 ± 22.6 µm in the 3rd month. In the presence of HRF and SMD, recurrence of macular edema was significant in the 3rd month. The percentage of ELM disruption, DRIL, and ERM deteriorated significantly and the percentage of SMD improved significantly at the final visit. CONCLUSIONS: DEX implant therapy resulted in a satisfactory reduction in CFT in patients with DME and RVO. The presence of HRF and SMD is a negative predictor of recurrence in CFT in short term. DEX implant therapy resulted in satisfactory improvement in SMD.

Inverted ILM Flap Technique in Optic Disc Pit Maculopathy.

Purpose: To present the outcome of optic disc pit maculopathy (ODPM) managed successfully with an inverted internal limiting membrane (ILM) flap over the optic disc. A narrative review of ODPM pathogenesis and surgical management techniques are also provided. Case Report: This prospective interventional case series included three eyes of three adult patients (25-39 years old) with unilateral ODPM and a mean duration of unilaterally decreased visual acuity of 7.33 ± 2.40 months (4-12 months). The pars plana vitrectomy with posterior vitreous detachment induction was performed on eyes, followed by an inverted ILM flap insertion over the optic disc and gas tamponade. Patients were followed for 7-16 weeks postoperatively; best-corrected visual acuity (BCVA) improved dramatically in one patient from 2/200 to 20/25. BCVA in other patients improved two and three lines - to 20/50 and 20/30, respectively. A significant anatomical improvement was achieved in all three eyes, and no complication was detected throughout the follow-up period. Conclusion: Vitrectomy with inverted ILM flap insertion over the optic disc is safe and can yield favorable anatomical improvement in patients with ODPM.

Systemic Inflammatory Marker Levels in Serous Macular Detachment Secondary to Retinal Vein Occlusion.

Purpose: To evaluate the association of systemic inflammatory marker levels in macular edema with serous macular detachment (SMD) secondary to retinal vein occlusion (RVO). Methods: Patients diagnosed with RVO were categorized into two groups based on the presence or absence of SMD: Group 1 included 30 eyes with SMD, while Group 2 included 30 eyes without SMD. Levels of neutrophils, monocytes, lymphocytes, thrombocytes, and mean platelet volume (MPV) were analyzed. Systemic inflammatory markers, including neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII), were calculated and compared between the two groups. Results: The mean neutrophil levels were significantly higher in Group 1 (P = 0.002). The mean lymphocyte, monocytes, thrombocyte, and MPV levels did not differ significantly between groups. NLR and SII levels were significantly higher in the SMD group (P = 0.004 and P = 0.016, respectively). There was no significant difference between the groups in terms of PLR. The optimal receiver operator characteristic (ROC) cut-off value of NLR for SMD was calculated as 1.55 with 73% sensitivity and 63% specificity (area under the curve [AUC] = 0.714, 95% confidence interval [CI]: 0.584-0.845). The optimal ROC cut-off value of SII for SMD was calculated as 451.75 with 63% sensitivity and 63% specificity (AUC = 0.681, 95% CI: 0.546-0.816). In this study, branch RVO was present in 48 patients, and central RVO was present in 12 patients. Neutrophil, MPV levels, and NLR, PLR, SII ratios were similar between patients with branch and central occlusion. Conclusion: Neutrophil levels, NLR, and SII were found to be significantly higher in eyes with SMD secondary to RVO.

Hyperviscosity Syndrome Induced Bilateral Visual and Auditory Impairment in Therapy Resistant Waldenström Macroglobulinemia with MYD88 and CXCR4 Mutations.

Hyperviscosity syndrome (HVS) is an emergent complication of Waldenström macroglobulinemia (WM) characterized by visual, neurologic, and rarely auditory impairment. We report a 69-year-old female with MYD88 and CXCR4-mutant WM who developed HVS resulting in bilateral blindness and deafness associated with neurologic manifestations including confusion, severe generalized weakness, and imbalance. Ophthalmologic evaluation revealed bilateral central retinal vein occlusion (CRVO), diffuse retinal hemorrhages, macular edema, and serous macular detachments (SMD). Magnetic resonance imaging of the brain showed bleeding in the inner ears. Management was challenging as her WM was resistant to systemic therapies including bendamustine + rituximab (BR) and rituximab + bortezomib + dexamethasone (RVD). Bruton's tyrosine kinase inhibitors could not be used initially due to ongoing lower gastrointestinal bleeding. She required five total sessions of plasma exchange and was finally initiated on zanubrutinib, achieving a partial response. She also received intravitreal bevacizumab with rapid resolution of the retinal hemorrhages but with little improvement of the SMD. She had partial restoration of her hearing in the right ear and only slight improvement in her bilateral visual deficits. The management of HVS in frail, elderly patients with therapy-resistant WM can be challenging. In these cases, plasma exchange is required until an effective systemic therapy can be safely instituted. Genomic profiling is important in the management of WM as it can predict treatment resistance and guide therapeutic decisions.

The Spectrum of Ocular Manifestations in Patients with Waldenström's Macroglobulinemia.

PURPOSE: To investigate the ocular manifestations in 91 Waldenström's macroglobulinemia (WM) patients. METHODS: Retrospective, cross-sectional, observational analysis. RESULTS: Ocular impairments, detected in 19 patients, included flame-shaped hemorrhages, venous sausaging, papilledema, macular detachments, or central retinal vein occlusion in 16 patients; paraproteinemic keratopathy in 2; and a CANOMAD syndrome in 1. Best-corrected visual acuity was ≥0.5 logMAR units in 11 of 38 eyes. Intraocular pressure was increased in seven eyes. Genetic analysis in seven patients showed a mutation in the MYD88 gene in six patients and a nonsense mutation in the CXCR4 gene in five patients. Plasmapheresis followed by chemotherapy with or without the addition of rituximab resulted in improvement or normalization of the ophthalmological findings in 15 patients. CONCLUSION: The ocular manifestations of WM are protean and potentially sight threatening. Recent advances in genomic profiling and chemotherapy have remarkably improved the hematological and ophthalmological outcomes of these patients.