Retinal detachment during COVID-19 era: a review of challenges and solutions.

Background: Since the beginning of the Coronavirus disease 2019 (COVID-19) pandemic, there have been obstacles in the proper diagnosis and management of many diseases. We evaluated the changes in retinal detachment (RD) presentation and surgery during the COVID-19 pandemic and propose solutions to minimize the detrimental effects of lockdown on RD diagnosis. Materials and methods: PubMed, Embase, Scopus, Web of Science, and Google Scholar were searched for relevant articles with the keywords "Retinal detachment" AND "Coronavirus OR COVID-19 OR SARS OR MERS." Results: The COVID-19 lockdown was associated a 53-66% reduction in RD presentation. The decrease in the rate of macula-on RD, the increase in the mean duration of symptoms, and the rise in the number of patients with proliferative vitreoretinopathy were all suggestive of a delayed presentation of RD. Moreover, a drop of 56-62% in RD repair surgeries was observed. However, the most frequently performed ophthalmic surgery changed from cataract surgery in April 2019 to RD repair in April 2020. Using phacovitrectomy instead of vitrectomy alone can reduce the number of operations in ophthalmology centers, decrease the use of personal protective equipment by 50%, and cut costs per patient by 17-20%. Also, developing a well-organized telemedicine system can decrease unnecessary visits and delayed presentations. Conclusion: Delay in RD presentation and surgery is associated with a poorer prognosis. Optimizing the guidelines of RD management and developing a well-organized telemedicine system can minimize the impact of lockdown on RD management.

Pars plana vitrectomy versus scleral buckling for repairing simple rhegmatogenous retinal detachments.

BACKGROUND: Rhegmatogenous retinal detachment (RRD) is a separation of neurosensory retina from the underlying retinal pigment epithelium. It is caused by retinal tears, which let fluid pass from the vitreous cavity to the subretinal space. Pars plana vitrectomy (PPV), scleral buckling surgery and pneumatic retinopexy are three accepted management strategies whose efficacy remains controversial. Pneumatic retinopexy is considered in a separate Cochrane Review. OBJECTIVES: The primary objective of this review was to assess the efficacy of PPV versus scleral buckling for the treatment of simple RRD (primary RRD of any extension with up to two clock hours large break(s) regardless of their anterior/posterior localisation) in people with (phakia) or without (aphakia) a natural lens in the eye, or with an artificial lens (pseudophakia). A secondary objective was to assess any data on economic and quality-of-life measures. SEARCH METHODS: We searched CENTRAL, which contains the Cochrane Eyes and Vision Trials Register; MEDLINE; Embase; LILACS; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 5 December 2018. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing PPV versus scleral buckling surgery with at least three months of follow-up. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology. Two review authors independently extracted the data and study characteristics from the studies identified as eligible after initial screening. We considered the following outcomes: primary retinal reattachment, postoperative visual acuity, final anatomical success, recurrence of retinal detachment, number of interventions needed to achieve final anatomical success, quality of life and adverse effects. We assessed the certainty of evidence using GRADE. MAIN RESULTS: This review included 10 RCTs (1307 eyes of 1307 participants) from Europe, India, Iran, Japan and Mexico, which compared PPV and scleral buckling for RRD repair. Two of these 10 studies compared PPV combined with scleral buckling with scleral buckling alone (54 participants). All studies were high or unclear risk of bias on at least one domain. Five studies were funded by non-commercial sources, while the other five studies did not report source of funding.There was little or no difference in the proportion of participants who achieved retinal reattachment at least 3 months after the operation in the PPV group compared to those in the scleral buckling group (risk ratio (RR) 1.07, 95% confidence intervals (CI) 0.98 to 1.16; 9 RCTs, 1261 participants, low-certainty evidence). Approximately 67 in every 100 people treated with scleral buckling had retinal reattachment by 3 to 12 months. Treatment with PPV may result in 4 more people with retinal reattachment in every 100 people treated (95% confidence interval (CI) 2 fewer to 11 more).There was no evidence of any important difference in postoperative visual acuity between participants in the PPV group compared to those in the scleral buckling group (mean difference (MD) 0.00 logMAR, 95% CI -0.09 to 0.10, 6 RCTs, 1138 participants, low-certainty evidence).There was little or no difference in final anatomical success between participants in the PPV group and scleral buckling group (RR 1.01, 95% CI 0.99 to 1.04, 9 RCTs, 1235 participants, low-certainty evidence). There were 94 out of 100 people treated with control (scleral buckling) that achieved final anatomical success compared to 96 out of 100 in the PPV group.Retinal redetachment was reported in fewer participants in the PPV group compared to the scleral buckling group (RR 0.75 (95% CI 0.59 to 0.96, 9 RCTs, 1320 participants, low-certainty evidence). Approximately 28 in every 100 people treated with scleral buckling had retinal detachment by 3 to 36 months. Treatment with PPV may result in seven fewer people with retinal detachment in every 100 people treated (95% CI 1 to 11 fewer).Participants treated with PPV on average needed fewer interventions to achieve final anatomical success but the difference was small and data were skewed (MD -0.20, 95% CI -0.34 to -0.06, 2 RCTs, 682 participants, very low-certainty evidence).Very low-certainty evidence on quality of life suggested that more people in the PPV group were "satisfied with vision" compared with the scleral buckling group (RR 6.22, 95% CI 0.88 to 44.09, 1 RCT, 32 participants).All included studies reported adverse effects, however, it was not always clear whether they were reported as number of participants or number of adverse effects. Cataract development or progression was more prevalent in the PPV group (RR 1.71, 95% CI 1.45 to 2.01), choroidal detachment was more prevalent in the scleral buckling group (RR 0.19, 95% CI 0.06 to 0.65) and new/iatrogenic breaks were observed only in the PPV group (RR 8.21, 95% CI 1.91 to 35.21). Estimates of the relative frequency of other adverse effects, including postoperative proliferative vitreoretinopathy, postoperative increase in intraocular pressure, development of cystoid macular oedema, macular pucker and strabismus were imprecise. Evidence for adverse effects was low-certainty evidence. AUTHORS' CONCLUSIONS: Low- or very low-certainty evidence indicates that there may be little or no difference between PPV and scleral buckling in terms of primary success rate, visual acuity gain and final anatomical success in treating primary RRD. Low-certainty evidence suggests that there may be less retinal redetachment in the PPV group. Some adverse events appeared to be more common in the PPV group, such as cataract progression and new iatrogenic breaks, whereas others were more commonly seen in the scleral buckling group such as choroidal detachment.

Dynamic intraoperative optical coherence tomography for inverted internal limiting membrane flap technique in large macular hole surgery.

BACKGROUND/OBJECTIVES: To assess the efficacy of dynamic intraoperative spectral-domain optical coherence tomography (iSD-OCT) imaging for inverted internal limiting membrane (ILM) flap technique (IILMFT) in large macular hole (MH) surgery. SUBJECTS/METHODS: Prospective, non-randomized, observational study was conducted on 8 eyes of 7 patients with large, chronic and recurrent MHs, which were treated by pars plana vitrectomy (PPV) with IILMFT. All patients underwent standard pre- and postoperative examination. The iSD-OCT imaging was performed using microscope integrated systems before, during, and after ILM peeling. The iSD-OCT data were post-processed using graphic software and reviewed for tissue behavior and instruments position. RESULTS: The real-time iSD-OCT-assisted IILMFT allowed for real-time imaging of the entire surgery with visualization of the MH, vitreoretinal instruments, and all steps of inverted ILM flap formation. In spite of shadowing created by the steel instruments, it was possible to follow and control the distance between the instrument tips and retinal layers. Dynamic imaging of the surgical maneuvers including ILM peeling and mechanical apposition of MH edges revealed the iatrogenic impact on the retina (depression and appearance of hyporeflective zones). iSD-OCT imaging could confirm the proper position of the inverted ILM flap at the very end of the surgery after fluid-air exchange. CONCLUSIONS: iSD-OCT imaging is an effective tool for learning and performing a well-controlled and safe inverted ILM flap technique in patients with large MH. Clinical significance of the structural iSD-OCT findings has to be further studied.

Mapping diurnal changes in choroidal, Haller's and Sattler's layer thickness using 3-dimensional 1060-nm optical coherence tomography.

PURPOSE: To test the significance of diurnal changes in choroidal, Haller's and Sattler's layer thickness in healthy subjects using spatial analysis of three-dimensional (3D) 1060-nm optical coherence tomography (OCT) scans. METHODS: Automatically generated choroidal, Haller's and Sattler's layer thickness maps were statistically analyzed for 19 healthy subjects at two time points (8 a.m. and 6 p.m.) that represent the currently proposed ChT peak and nadir. All subjects were imaged by high-speed 1060-nm OCT over a 36° × 36° field of view. Spatial distribution of layer thickness was analyzed using the Early Treatment Diabetic Retinopathy Study (ETDRS) grid. RESULTS: The choroid was significantly thicker at 8 a.m. than at 6 p.m. (p < 0,0125, paired t-test, Bonferroni correction). Diurnal variation of mean choroidal thickness (ChT) for all ETDRS subfields was 12 µm. Haller's layer thickness showed no significant diurnal variation (P > 0.0125), but Sattler's layer was thicker in the morning than in late afternoon (P < 0.0125). CONCLUSIONS: Our measurements indicate that diurnal ChT variation may exist, but is less relevant than previously proposed by studies using single location imaging. Sattler's layer shows diurnal variation in line with ChT.

Intraoperative optical coherence tomography assisted analysis of pars Plana vitrectomy for retinal detachment in morning glory syndrome: a case report.

BACKGROUND: The pathogenesis of non-rhegmatogenous retinal detachment (non-RRD) associated with morning glory syndrome (MGS) is not established, as well as best surgical approach to treat RD. Our purpose was to analyse intraoperative optical coherence tomography data (iOCT) in all steps of pars plana vitrectomy (PPV) for non-RRD in MGS, in order to follow pathophysiological aspects of the disease and to understand the tissues behaviour during surgical workflow. CASE PRESENTATION: Intraoperative spectral domain optical coherent tomography (iSD-OCT) assisted PPV using Rescan 700 (Carl Zeiss Meditech, Jena, Germany) with epiretinal membrane (ERM) and internal retinal membrane (ILM) peeling, and air endotamponade was performed on the only eye of a 21 years old female with non-RRD associated with MGS. BCVA, pre-, intra- and postoperative OCT were performed along with standard ocular examination. iOCT video and snapshots were analysed intra- and postoperatively using post-processing approach using graphic software. The progression of non-RRD resulted in best corrected visual acuity (BCVA) decrease from 0.8 to 0.2. Triamcinolone enhanced iOCT imaging revealed strong vitreous traction and adhesion above the macula and optic disc. Internal limiting membrane was peeled under iOCT control to prevent the peeling of inner layers of the retinal schisis. No retinal break was detected, and only air endotamponade was performed. The retina reattached during first 4 weeks of follow-up with gradual resolution of intraretinal- and subretinal fluid, and remained stable in 12 months. BCVA improved to 0.8. CONCLUSION: Based on iSD-OCT findings we assume that non-RRD in this case of MGS is caused primarily by the vitreous traction with further possible formation of the retinal breaks. Retinal reattachment reached only with air endotamponade strongly advocates the tractional component of non-RRD and retinal schisis assotiated with MGS. Early PPV for central non-RRD and retinal schisis with the use of iOCT can be performed in more safe and controlled manner and has to be considered to reduce the risk of retinal break formation and to prevent the central vision loss.

Primary Retinal Detachment Surgery: Changes in Treatment and Outcome in an Austrian Tertiary Eye Center.

PURPOSE: The surgery of choice for primary retinal detachment (RD) has shifted towards primary vitrectomy (PPV) in recent years. In this study, 2 cohorts of consecutive patients, treated by 8 retinal surgeons within a 7-year time span were compared. METHODS: Baseline demographic data, surgical procedure, and outcome of patients with primary RD surgery between January 2007 and December 2008 (group 1, G1) and January 2012 and December 2013 (group 2, G2) were compared. Statistical analysis included univariate comparisons (Wilcoxon rank-sum test and χ2 test) and ANCOVA (analysis of covariance) models. RESULTS: The most common primary procedure was scleral buckling (n = 92, 66%) in G1 and PPV (n = 252, 85%) in G2 (p < 0.0001). Primary anatomical success rates were comparable (89%). The percentage of eyes with best corrected visual acuity (BCVA) equal or better than 0.3 logMAR (6/12) at final follow-up was significantly higher in G2 (61%, n = 156) compared to 49% (n = 68) in G1 (p = 0.0223). CONCLUSIONS: Within 7 years, a complete trend reversal could be observed shifting the primary surgical approach for RD towards PPV. Primary and final anatomical success rates were comparable, yet the later group experienced a significantly higher gain in BCVA, which approves the change in treatment regimen.

VISION-RELATED QUALITY OF LIFE AND VISUAL FUNCTION AFTER RETINAL DETACHMENT SURGERY.

PURPOSE: To investigate and compare the vision-related quality of life after rhegmatogenous retinal detachment (RRD) surgery with that of normal controls and to evaluate the relationship between the vision-related quality of life and visual function after surgery for RRD. METHODS: In this prospective, consecutive, comparative case series, the 25-Item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) was completed by 100 RRD patients at 6 months after surgery. Among the patients with RRD, 86 underwent pars plana vitrectomy and 14 received scleral buckling. Best-corrected visual acuity was obtained using ETDRS charts and converted to the logarithm of the minimum angle of resolution for statistical calculations. The VFQ-25 also was administered to 107 normal controls. RESULTS: The VFQ-25 composite score and the subscales associated with general vision, mental health, social functioning, driving, and color vision were significantly lower in the RRD group than in the normal controls (P < 0.05). The VFQ-25 composite score significantly correlated with logarithm of the minimum angle of resolution best-corrected visual acuity (P < 0.0001) on both the operated and the fellow eye. CONCLUSION: The vision-related quality of life is significantly impaired in patients after surgery for RRD. Higher age and female gender negatively influences the results of the composite score.

INTRASURGICAL MICROSCOPE-INTEGRATED SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY-ASSISTED MEMBRANE PEELING.

PURPOSE: To evaluate microscope-integrated intrasurgical spectral domain optical coherence tomography during macular surgery in a prospective monocenter study. METHODS: Before pars plana vitrectomy and before, during, and after membrane peeling, 512 × 128 macular cube scans were performed using a Carl Zeiss Meditec Cirrus high-definition OCT system adapted to the optical pathway of a Zeiss OPMI VISU 200 surgical microscope and compared with retinal staining. RESULTS: The study included 51 patients with epiretinal membranes, with 8 of those having additional lamellar macular holes, 11 patients with vitreomacular traction, and 8 patients with full-thickness macular holes. Intraoperative spectral domain optical coherence tomography allowed performing membrane peeling without using retinal dyes in 40% of cases (28 of 70 patients). No residual membranes were found in 94.3% of patients (66 of 70 patients) in intrasurgical spectral domain optical coherence tomography and subsequent (re)staining. In patients with vitreomacular traction, intrasurgical spectral domain optical coherence tomography scans facilitated decisions on the need for an intraocular tamponade after membrane peeling. CONCLUSION: Intraoperative spectral domain optical coherence tomography was comparable with retinal dyes in confirming success after membrane peeling. However, the visualization of flat membranes was better after staining.

Effect of photodynamic therapy on short-wavelength fundus autofluorescence in eyes with acute central serous chorioretinopathy.

PURPOSE: To evaluate short-wavelength FAF as a parameter of retinal pigment epithelium function in eyes with acute symptomatic central serous chorioretinopathy after indocyanine green angiography-guided verteporfin photodynamic therapy with half-fluence rate. METHODS: A retrospective review over a period of 1 year of short-wavelength FAF images of 15 consecutive patients treated with half-fluence rate (25 J/cm) indocyanine green angiography-guided verteporfin photodynamic therapy due to acute symptomatic central serous chorioretinopathy was performed. Short-wavelength (488 nm) FAF gray values were evaluated with a confocal scanning laser ophthalmoscope at a 350-µm diameter and a 1,200-µm diameter circle centered on the fovea. The change in short-wavelength (488 nm) FAF gray values for the 2 circles was evaluated by calculating the differences of respective values between the first month after treatment and the 3, 6, 9, and 12 months follow-up. RESULTS: Mean differences (95% confidence interval) in short-wavelength (488 nm) FAF gray values of the 350-µm and 1,200-µm diameter circle between the 1-month and the 3-month (n = 15) follow-up were -0.03 (-0.11 to 0.05) (P = 0.46) and -0.03 (-0.17 to 0.10) (P = 0.6). Respective differences between the 1 month and the 6 (n = 15), 9 (n = 14), and 12 months (n = 13) of follow-up were -0.03 (-0.11 to 0.05) (P = 0.42) and -0.04 (-0.16 to 0.08) (P = 0.5); -0.05 (-0.12 to 0.03) (P = 0.23) and -0.06 (-0.18 to 0.07) (P = 0.33); -0.03 (-0.12 to 0.07) (P = 0.57) and -0.07 (-0.20 to 0.05) (P = 0.22). CONCLUSION: Half-fluence rate (25 J/cm) indocyanine green angiography-guided verteporfin photodynamic therapy did not significantly affect short-wavelength FAF at a 350-µm diameter and a 1,200-µm diameter circle in eyes with resolved acute symptomatic central serous chorioretinopathy throughout 12 months of follow-up.

Clinical significance of signal shadowing during intraoperative optical coherence tomography-assisted vitreoretinal surgery.

This study aimed to analyze the clinical significance of signal shadowing during intraoperative optical coherence tomography (iOCT)-assisted vitreoretinal surgery caused by vitreoretinal instruments, tissue dyes, and vitreous substitutes, and to objectively quantify its impact on iOCT imaging. This is a retrospective observational study of postoperative image analysis from one hundred seventeen (117) patients who underwent iOCT-assisted vitrectomy. The image data were divided into three groups: vitreoretinal instruments, tissue dyes, and vitreous substitutes. The data was then processed using graphic software to measure the grade of picture quality distortion and compared to paired image controls without clinically perceptive interference, then analyzed statistically. The intraocular portion of all studied vitreoretinal instruments caused a high average gray level interference compared to controls ranging from 32 to 68% reduction, obscuring the area of interest significantly. The tips of the instruments produced low-grade shadowing, allowing the underlying tissue to be distinguished. The analyzed dyes demonstrated a wide interference range: ICG (- 75.12%), and triamcinolone (- 26.13%) showed dose-dependent high shadowing, while VITREODYNE™ (49.3%) and brilliant blue G (14.06%) exhibited no perceived distortions whilst increasing average gray levels. All analyzed vitreous substitutes (air, SF6, C3F8, PFCL, and silicone oil) showed an insignificant shadowing effect on iOCT. Certain dyes and vitreous substitutes produce a negligible shadowing effect compared to controls and other dyes, providing an advantage during real-time iOCT imaging. All analyzed vitreoretinal instruments showed a significant interference that should prompt the development of new imaging techniques or the implementation of materials with low-grade interference to overcome a clinically relevant shadowing effect on iOCT, maximizing the technology's visual accuracy and surgical diagnostic aid proficiency.

Epimacular brachytherapy for neovascular age-related macular degeneration: a randomized, controlled trial (CABERNET).

PURPOSE: To evaluate the safety and efficacy of epimacular brachytherapy (EMBT) for the treatment of neovascular age-related macular degeneration (AMD). DESIGN: Multicenter, randomized, active-controlled, phase III clinical trial. PARTICIPANTS: Four hundred ninety-four participants with treatment-naïve neovascular AMD. METHODS: Participants with classic, minimally classic, and occult lesions were randomized in a 2:1 ratio to EMBT or a ranibizumab monotherapy control arm. The EMBT arm received 2 mandated, monthly loading injections of 0.5 mg ranibizumab. The control arm received 3 mandated, monthly loading injections of ranibizumab then quarterly injections. Both arms also received monthly as needed (pro re nata) retreatment. MAIN OUTCOME MEASURES: The proportion of participants losing fewer than 15 Early Treatment Diabetic Retinopathy Study (ETDRS) letters from baseline visual acuity (VA) and the proportion gaining more than 15 ETDRS letters from baseline VA. RESULTS: At 24 months, 77% of the EMBT group and 90% of the control group lost fewer than 15 letters. This difference did not meet the prespecified 10% noninferiority margin. This end point was noninferior using a 20% margin and a 95% confidence interval for the group as a whole and for classic and minimally classic lesions, but not for occult lesions. The EMBT did not meet the superiority end point for the proportion of participants gaining more than 15 letters (16% for the EMBT group vs. 26% for the control group): this difference was statistically significant (favoring controls) for occult lesions, but not for predominantly classic and minimally classic lesions. Mean VA change was -2.5 letters in the EMBT arm and +4.4 letters in the control arm. Participants in the EMBT arm received a mean of 6.2 ranibizumab injections versus 10.4 in the control arm. At least 1 serious adverse event occurred in 54% of the EMBT arm, most commonly postvitrectomy cataract, versus 18% in the control arm. Mild, nonproliferative radiation retinopathy occurred in 3% of the EMBT participants, but no case was vision threatening. CONCLUSIONS: The 2-year efficacy data do not support the routine use of EMBT for treatment-naïve wet AMD, despite an acceptable safety profile. Further safety review is required.

The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole.

OBJECTIVE: The International Vitreomacular Traction Study (IVTS) Group was convened to develop an optical coherence tomography (OCT)-based anatomic classification system for diseases of the vitreomacular interface (VMI). DESIGN: The IVTS applied their clinical experience, after reviewing the relevant literature, to support the development of a strictly anatomic OCT-based classification system. PARTICIPANTS: A panel of vitreoretinal disease experts was the foundation of the International Classification System. METHODS: Before the meeting, panel participants were asked to review 11 articles and to complete 3 questionnaires. The articles were preselected based on searches for comprehensive reviews covering diseases of the VMI. Responses to questionnaires and the group's opinions on definitions specified in the literature were used to guide the discussion. MAIN OUTCOME MEASURES: Optical coherence tomography-based anatomic definitions and classification of vitreomacular adhesion, vitreomacular traction (VMT), and macular hole. RESULTS: Vitreomacular adhesion is defined as perifoveal vitreous separation with remaining vitreomacular attachment and unperturbed foveal morphologic features. It is an OCT finding that is almost always the result of normal vitreous aging, which may lead to pathologic conditions. Vitreomacular traction is characterized by anomalous posterior vitreous detachment accompanied by anatomic distortion of the fovea, which may include pseudocysts, macular schisis, cystoid macular edema, and subretinal fluid. Vitreomacular traction can be subclassified by the diameter of vitreous attachment to the macular surface as measured by OCT, with attachment of 1500 µm or less defined as focal and attachment of more than 1500 µm as broad. When associated with other macular disease, VMT is classified as concurrent. Full-thickness macular hole (FTMH) is defined as a foveal lesion with interruption of all retinal layers from the internal limiting membrane to the retinal pigment epithelium. Full-thickness macular hole is primary if caused by vitreous traction or secondary if directly the result of pathologic characteristics other than VMT. Full-thickness macular hole is subclassified by size of the hole as determined by OCT and the presence or absence of VMT. CONCLUSIONS: This classification system will support systematic diagnosis and management by creating a clinically applicable system that is predictive of therapeutic outcomes and is useful for the execution and analysis of clinical studies.

The effect of photodynamic therapy on macular sensitivity in eyes with acute central serous chorioretinopathy.

BACKGROUND: To evaluate the effect of half-fluence rate indocyanine green angiography (ICGA)-guided verteporfin photodynamic therapy (PDT) on macular sensitivity (MS) in eyes with acute symptomatic central serous chorioretinopathy (CSC). METHODS: Single-center consecutive case series by retrospective chart review. Sixteen eyes of 16 patients with acute CSC of 3 months duration or less, treated with half-fluence (25 mJ/cm(2)) ICGA-guided verteporfin PDT were reviewed. At baseline and after 1, 3, and 6 months, all patients underwent MS testing of the central 20 °, MS testing of the retinal area covered by the PDT laser spot (MSLS), and evaluation of fixation stability (FS) for the central two degrees with the MP-1 microperimeter (Nidek, Vigonza, Italy). RESULTS: Macular sensitivity improved from 16.4 ± 3.0 dB at baseline (n = 16) to 18.2 ± 2.4 dB (p < 0.001) at 1 month (n = 16). At the 3-month (n = 13) and 6-month (n = 12) follow-up, MS stabilized at 19.5 ± 0.9 dB (p = 0.21) and 19.0 ± 1.3 dB (p = 0.74), without changes when compared to respective precedent follow-up. Mean MSLS improved from 12.9 ± 5.4 dB at baseline to 16.4 ± 4.9 dB (p < 0.001) after 1 month. At the 3- and 6-month follow-up, MSLS was 19.1 ± 1.2 dB (p= 0.1) and 18.9 ± 1.9 dB (p = 0.8) respectively. Mean FS at the central 2 ° was 78.8 ± 30.4 % before treatment and 81.8 ± 29.5 % (p = 0.7), 81.9 ± 27.5 % (p = 0.7) and 83.6 ± 17.1 % (p = 0.5) respectively 1, 3 and 6 months after treatment. CONCLUSION: Half-fluence (25 mJ/cm(2)) PDT significantly increased mean MS of central 20 ° and mean MSLS, in eyes with acute symptomatic CSC. Fixation stability was stable at baseline and throughout 6 months of follow-up.

A prospective, randomised, multicenter trial for surgical treatment of central retinal vein occlusion: results of the Radial Optic Neurotomy for Central Vein Occlusion (ROVO) study group.

BACKGROUND: To compare the surgical outcomes and evaluate the effectiveness of two treatments for central retinal vein occlusion (CRVO), radial optic neurotomy (RON) and intravitreal triamcinolone (IVT), in comparison to natural history. METHODS: A prospective, placebo-controlled, randomised and multi-center study. Patients with CRVO were treated in three groups - with either RON, a single intravitreal injection of 4 mg triamcinolone acetonide, or a placebo treatment. The main outcome measures were change of VA (visual acuity) and proportion of eyes with a significant improvement (defined as > 3 lines logMAR scale) of VA from baseline to month 12. RESULTS: Ninety patients were included. Due to insufficient data, seven were excluded. Forty-seven percent (n = 18) of patients treated with RON showed an increase in VA, in comparison to 10 % (n = 2) of placebo-treated patients, and 20 % (n = 5) of patients treated with IVT. Significantly more patients showed an improvement in VA following RON than in the placebo group (p = 0.009). Significantly more patients showed an improvement in VA following RON than in the IVT group (p = 0.034). No significant difference was found when directly comparing improvement in VA following IVT and placebo (p = 0.667) treatment.Significantly (p = 0.007) more patients in the placebo group (35 %, n = 7) showed a deterioration (defined as > 3 lines LogMAR scale) in VA than patients in the RON group (8 %, n = 3). CONCLUSION: Our study showed that following treatment with RON, patients with CRVO display a significantly better long-term VA than untreated patients and patients treated with a single dose of IVT.

Half-fluence photodynamic therapy in chronic central serous chorioretinopathy.

PURPOSE: To evaluate the results of indocyanine green angiography (ICGA)-guided verteporfin (Visudyne®; Novartis Pharma, Switzerland) photodynamic therapy (PDT) with half-fluence rate in the treatment of chronic central serous chorioretinopathy. METHODS: A retrospective review was conducted of 20 eyes of 19 consecutive patients with subfoveal fluid cause by chronic central serous chorioretinopathy with choroidal hyperpermeability on ICGA and symptoms of at least 6 months. ICGA-guided verteporfin (6 mg/m) PDT with half-fluence rate (25 J/cm) was performed. ICGA findings were classified as intense, intermediate, or minimal hyperfluorescence depending on the degree of choroidal hyperpermeability. The resolution of the subretinal fluid and recurrence rates were assessed in relation to the different degrees of choroidal hyperfluorescence. RESULTS: Best-corrected visual acuity at baseline was 40 letters (±13; n = 20) according to the Early Treatment Diabetic Retinopathy Study chart. At 12 months after PDT, the mean best-corrected visual acuity improved to 44 letters (P < 0.01). Pretreatment central foveal thickness 325 µm and decreased by a mean of 103 µm at Month 12 control (P < 0.05). At Month 1 after PDT, subretinal fluid in spectral-domain optical coherence tomography was completely resolved in 100% of eyes regardless to their degree of choroidal hyperfluorescence. Two eyes of the intense hyperfluorescence group and 1 eye of the intermediate hyperfluorescence group developed recurrence of symptoms over 12 months and received another PDT with half-fluence rate within the 12-month control period. Treatment effect was not depending on the degree of choroidal hyperpermeability at baseline. No systemic side effects were observed during the 12-month follow-up. CONCLUSION: ICGA-guided half-fluence PDT with verteporfin is effective in treating chronic symptomatic central serous chorioretinopathy with choroidal hyperpermeability in ICGA, resulting in both visual improvement and reduction of central foveal thickness.

Monitoring of drusen and geographic atrophy area size after cataract surgery using the MD3RI tool for computer-aided contour drawing.

BACKGROUND/AIMS: To monitor possible changes in the cumulated drusen or geographic atrophy area size (CDGAS) of nonexudative age-related macular degeneration (AMD) in patients before and after cataract surgery, using a new tool for computer-aided image quantification. METHODS: Randomized, prospective, clinical trial. 54 patients with cataract and nonexudative AMD were randomly assigned into an early surgery group (ES = 28) and a control group (CO = 26) with a 6-month delay of surgery. CDGAS was determined with the MD3RI tool for contour drawing in a central region of digitized fundus photographs, measuring 3,000 µm in diameter. To evaluate CDGAS progression, differences in pixels and square millimeters were calculated by equivalent tests. RESULTS: Forty-nine patients completed the visits over the 12-month period (ES = 27 and CO = 22). Mean pixel values increased from 201.5 (11.33 × 10(-3) mm(2)) to 202.7 (11.39 × 10(-3) mm(2)) in the ES group and from 191.6 (10.77 × 10(-3) mm(2)) to 194.6 (10.94 × 10(-3) mm(2)) in the CO group. Finally, equivalence of CDGAS differences between ES and CO could be demonstrated. No exudative AMD was recorded during the study period. CONCLUSION: In our cohorts, no significant changes were found in CDGAS 12 months after cataract surgery. The MD3RI software could serve as an efficient, precise and objective tool for AMD quantification and monitoring in future trials.

Pneumatic Retinopexy Versus Pars Plana Vitrectomy for the Management of Retinal Detachment: A Systematic Review and Meta-Analysis.

INTRODUCTION: Pneumatic retinopexy (PnR) was proposed as an alternative to pars plana vitrectomy (PPV) in certain circumstances. PnR is an outpatient procedure and more cost-effective. However, its benefits should be judged alongside its success rate and adverse events. Herein, we compare the efficacy and safety of PnR and PPV for rhegmatogenous retinal detachment (RRD) repair. METHODS: We searched the PubMed, Scopus, EMBASE, Web of Science, Cochrane, and Google Scholar databases. Observational and interventional studies comparing the efficacy and safety of PnR and PPV were included. The outcomes were the success rate of the treatment, improvement in visual acuity, and adverse event rates. Subgroup analysis was performed based on the lens and macula status. Eleven articles were eligible to enter our study; these consisted of 11,346 patients with a mean age of 74.1. RESULTS: PnR was superior to PPV in terms of retinal displacement, photoreceptor integrity, visual function, and vertical metamorphopsia scores. In the meta-analysis, PPV showed higher a reattachment rate than PnR (OR = 3.39, 95% CI 2.25-5.11). Subgroup analysis showed that the advantage of PPV over PnR was more pronounced in studies with fewer phakic eyes, more macula-on patients, and in cases with primary PnR failure. While PnR patients had better pre-op (SMD = - 0.58, 95% CI = - 1.16 to 0.00) and post-op (SMD = - 0.45, 95% CI = - 0.60 to - 0.30) LogMAR, the improvement in visual acuity after surgery was higher in PPV patients (SMD = 0.49, 95% CI = - 0.15 to 1.13). CONCLUSION: The success rate of PnR was higher in studies published after 2015 compared to previous studies (82% vs. 59%). Cataract formation and surgery were significantly higher in the PPV arm, while the occurrence of new retinal tears was more frequent in the PnR group. PnR can be used as the primary procedure for RRD repair in selected cases. However, we propose some modifications to the PIVOT criteria, e.g., the exclusion of cases presenting with several risk factors of poor outcomes.

[Vitreoretinal surgery in age-related macular degeneration]. / Vitreoretinale Chirurgie bei altersabhängiger Makuladegeneration.

The structure of the vitreous body, its interaction with the retinal surface and tractive alterations of the vitreoretinal interface may play a role in the pathogenesis and the development of age-related macular degeneration (AMD). From clinical trials it can be concluded that posterior vitreous detachment (PVD) or vitreous removal may protect against the development of neovascular AMD. Vitreomacular adhesions may promote neovascular AMD and may have an impact on the efficacy and frequency of intravitreal vascular endothelial growth factor (VEGF) inhibition. Therefore, vitreomacular surgery may be considered as a treatment option in selected cases. Peeling of epimacular membranes and the internal limiting membrane (ILM) may contribute to stabilizing visual acuity and reducing the treatment burden of current intravitreal pharmacotherapy. At present, surgical interventions in AMD are mainly performed in cases of submacular hemorrhage involving the fovea. The treatment is not standardized and consists of liquefaction of the blood using recombinant tissue plasminogen activator (rTPA) and its pneumatic displacement, potentially combined with VEGF inhibition. Other submacular surgical strategies, such as choroidal neovascularization (CNV) extraction, macular translocation or transplantation of retinal pigment epithelium (RPE) are currently limited to selected cases as a salvage treatment; however, the development of these submacular surgical interventions has formed the basis for new approaches in the treatment of dry and neovascular AMD including submacular or intravitreal gene and stem cell therapy.