Treatment for dry age-related macular degeneration: where we stand in 2024.

PURPOSE OF REVIEW: This review highlights treatment options, both under investigation and currently available, for the treatment of dry age-related macular degeneration (AMD). An update on current clinical studies for dry AMD has been summarized. RECENT FINDINGS: Advanced dry AMD, characterized by geographic atrophy (GA), is a leading cause of blindness in the developed world, though prior to 2023 there was no approved treatment. There are now two approved treatments in the United States for GA. Additionally, there are several studies and trials to investigate therapeutic potential and effects of therapies for earlier intervention in dry AMD. Approaches to therapy include inhibiting the complement system, utilizing gene therapy, stem cell therapy, laser therapy, and surgical implants. SUMMARY: While there has been notable prior advancement in the treatment for neovascular or wet AMD, for the first time there are Food and Drug Administration (FDA) approved treatments for GA. Clinical studies have shown promise for additional methods for managing dry AMD both medically and surgically.

CHARACTERISTICS OF PARTICIPANTS IN DIABETIC RETINOPATHY CLINICAL RESEARCH CLINICAL TRIALS WHO WERE LOST TO FOLLOW-UP.

PURPOSE: Our study describes the racial/ethnic composition and the broad health status/severity of disease of the cohorts of Diabetic Retinopathy Clinical Research clinical trials and compares the rates of noncompletion of the trial with the first data report (lost to follow-up). METHODS: This study is a retrospective cohort study of participants in Diabetic Retinopathy Clinical Research Retina Network clinical trials who met our inclusion criteria. The primary outcome was the lost to follow-up rates and their associated risk factors. RESULTS: Eight clinical trials with 3,492 participants met our inclusion criteria. Participants who were lost to follow-up were more likely to be younger, Hispanic or Black, had Type 1 diabetes mellitus, had worse baseline best-corrected visual acuity, had higher hemoglobin A1c, had higher blood pressure, and had proliferative diabetic retinopathy (PDR) (Diabetic Retinopathy Severity Score >66). CONCLUSION: Participants who were lost to follow-up during Diabetic Retinopathy Clinical Research clinical trials tended to be younger, Hispanic or Black, and had worse diabetes and hypertension. This study highlights the importance of ensuring that a representative population is maintained through the end of the study period.

Intraocular Fibrin Glue to Lower the Risk of Postoperative Vitreous Hemorrhage After Diabetic Pars Plana Vitrectomy.

PURPOSE: To investigate the use of intraocular fibrin glue to lower the risk of vitreous hemorrhage (VH) after pars plana vitrectomy (PPV) in eyes with diabetic VH or traction retinal detachment. METHODS: A matched, case-control, single-surgeon, pilot study of patients undergoing PPV for diabetic VH or traction retinal detachment with versus without fibrin glue was performed. RESULTS: Thirty-nine patients (13 glue and 26 control patients) were included. In the glue group, mean (SD) logarithm of the minimum angle of resolution visual acuity (Snellen) significantly improved from 1.53 (0.6) (20/678) to 0.99 (0.9) (20/195) at postoperative month 6 ( P = 0.03). In the control group, mean logarithm of the minimum angle of resolution visual acuity also improved from 1.45 (0.8) (20/564) to 1.17 (0.9) (20/296) at postoperative Month 6 ( P = 0.3). Persistent post-PPV VH was similar between the 2 groups (15.4% in both groups, P > 0.99). However, early recurrent VH (<3 months post-PPV) was seen in 34.6% in the control group and none in the glue group ( P = 0.02). No intraocular inflammatory events were seen in the glue group. CONCLUSION: Intraocular fibrin glue may be a safe adjuvant in diabetic vitrectomy and may reduce the rate of early recurrent postoperative VH.

EPIRETINAL MEMBRANE WITH FOVEAL HERNIATION: Visual and Surgical Outcomes.

PURPOSE: Foveal herniation occurs when neuroretinal tissue protrudes through and above the level of an epiretinal membrane. This study describes the visual symptoms and spectral domain optical coherence tomography findings associated with foveal herniation and evaluates the postoperative visual, anatomical, and surgical outcomes. METHODS: A multicenter retrospective review of patients diagnosed with epiretinal membrane identified 59 patients with preoperative foveal herniation on spectral domain optical coherence tomography. Data regarding visual symptoms, preoperative and postoperative best-corrected visual acuity (BCVA), central retinal thickness, macular volume, and size of foveal herniation were collected, and statistical analysis was performed. RESULTS: A total of 58 of the 59 patients with foveal herniation underwent surgical epiretinal membrane peeling, with foveal contour restored in 53.5% of patients after surgery. Average BCVA improved from 20/80 to 20/40 Snellen equivalent at most-recent postoperative visit (P < 0.0001). The average central retinal thickness decreased from 632 µm to 432 µm (P < 0.0001) and the average macular volume decreased from 11.3 mm3 to 9.5 mm3 (P < 0.0001) at 3 months postoperatively. Preoperatively, greater herniation height was associated with worse BCVA (P = 0.008), greater central retinal thickness (P = 0.01), retinoschisis, cystoid macular edema, foveolar detachment, ellipsoid zone abnormality, and external limiting membrane abnormalities (P < 0.05). Postoperatively, there was a decrease in retinoschisis, cystoid macular edema, foveolar detachment, ellipsoid zone, and external limiting membrane abnormality (P < 0.05) on spectral domain optical coherence tomography. CONCLUSION: Patients with larger foveal herniation height had greater preoperative central retinal thickness, worse preoperative and postoperative BCVA, and more intraretinal abnormalities on spectral domain optical coherence tomography. Surgical epiretinal membrane peeling in patients with foveal herniation resulted in a significant improvement in patients' BCVA and microstructural abnormalities.

VITRECTOMY FOR VITREOUS HEMORRHAGE ASSOCIATED WITH RETINAL VEIN OCCLUSION: Visual Outcomes, Prognostic Factors, and Sequelae.

PURPOSE: To report the outcomes of pars plana vitrectomy for vitreous hemorrhage (VH) associated with retinal vein occlusion and to identify prognostic indicators. METHODS: Interventional, retrospective consecutive case series between 2015 and 2021. RESULTS: The study included 138 eyes of 138 patients (64 female and 74 male); 81 patients had branch retinal vein occlusion and 57 had central retinal vein occlusion. The mean age was 69.8 years. The mean duration between the diagnosis of VH and surgery was 79.6 ± 115.3 (range, 1-572) days. The mean follow-up was 27.2 months. The logarithm of the minimum angle of resolution visual acuity significantly improved from 1.95 ± 0.72 (Snellen equivalent, 20/1782) to 0.99 ± 0.87 (20/195) at 6 months and to 1.06 ± 0.96 (20/230) at the final visit (both P < 0.001). The visual acuity at 6 months improved by three or more lines in 103 eyes (75%). Postoperative complications during follow-up included recurrent VH in 16 eyes (12%) (of which 8 eyes underwent reoperations), rhegmatogenous retinal detachment in six eyes (4%), and new neovascular glaucoma in three eyes (2%). Worse final visual acuity was significantly associated with older age ( P = 0.007), concurrent neovascular glaucoma ( P < 0.001), central retinal vein occlusion ( P < 0.001), worse preoperative visual acuity ( P < 0.001), postoperative new neovascular glaucoma ( P = 0.021), and postoperative retinal detachment ( P < 0.001). The duration of VH was not associated with visual outcomes ( P = 0.684). Preoperative antivascular endothelial growth factor injections and tamponade did not prevent postoperative recurrent VH. CONCLUSION: Pars plana vitrectomy is effective for VH associated with retinal vein occlusion, regardless of the duration of hemorrhage. However, pre-existing risk factors and postoperative sequelae may limit visual recovery.

Ocular posterior segment complications following COVID-19 vaccination.

BACKGROUND: The SARS-CoV-2 pandemic has had a significant impact on healthcare, including eye care, worldwide. Effective and safe vaccines have been developed using both conventional and novel technologies to combat SARS-CoV-2 infection. While vaccination has been shown to be remarkably effective in reducing the spread and associated morbidity and mortality of COVID-19 disease, there have been reports of complications to the posterior segment of the eye. METHODS: We present a case-based analysis of reported complications of COVID-19 vaccination to the posterior segment of the eye. The study aims to highlight the diversity of possible complications and discuss the plausible involved pathophysiologic mechanisms. RESULTS: The most significant complications reported were retinal macro or microvascular occlusions, uveitis, and central serous chorioretinopathy. These complications are rare but require prompt diagnosis and management to prevent serious visual morbidity. CONCLUSIONS: Our study highlights the need for ophthalmologists to be aware of possible complications related to COVID-19 vaccination and the importance of prompt diagnosis and management. The findings of this study may help ophthalmologists to better understand and manage these rare complications.

Utility of blood as the clinical specimen for the diagnosis of ocular toxoplasmosis using uracil DNA glycosylase-supplemented loop-mediated isothermal amplification and real-time polymerase chain reaction assays based on REP-529 sequence and B1 gene.

BACKGROUND: Ocular infection with Toxoplasma gondii is a major preventable cause of blindness, especially in young people. The aim of the present study was to assess detection rate of T. gondii DNA in blood samples of clinically diagnosed of ocular toxoplasmosis using uracil DNA glycosylase-supplemented loop-mediated isothermal amplification (UDG-LAMP) and real-time quantitative PCR (qPCR) based on REP-529 and B1. METHODS: One hundred and seventeen patients with clinically diagnosed ocular toxoplasmosis (OT) were participated in the study as well as 200 control patients. Peripheral blood samples were assessed using UDG-LAMP and qPCR techniques targeting REP-529 and B1. RESULTS: Detection limits of qPCR using REP-529 and B1 were estimated as 0.1 and 1 fg of T. gondii genomic DNA, respectively. The limits of detection for UDG-LAMP using REP-529 and B1 were 1 and 100 fg, respectively. In this study, 18 and 16 patients were positive in qPCR using REP-529 and B1, respectively. Based on the results of UDG-LAMP, 15 and 14 patients were positive using REP-529 and B1, respectively. Results of the study on patients with active ocular lesion showed that sensitivity of REP-529 and BI targets included 64 and 63%, respectively using qPCR. Sensitivity of 62 and 61%, were concluded from UDG-LAMP using REP-529 and B1 in the blood cases of active ocular lesion. qPCR was more sensitive than UDG-LAMP for the detection of Toxoplasma gondii DNA in peripheral blood samples of patients with clinically diagnosed toxoplasmic chorioretinitis. Furthermore, the REP-529 included a better detection rate for the diagnosis of ocular toxoplasmosis in blood samples, compared to that the B1 gene did. Moreover, the qPCR and UDG-LAMP specificity assessments have demonstrated no amplifications of DNAs extracted from other microorganisms based on REP-529 and B1. CONCLUSIONS: Data from the current study suggest that qPCR and UDG-LAMP based on the REP-529 are promising diagnostic methods for the diagnosis of ocular toxoplasmosis in blood samples of patients with active chorioretinal lesions.

Indications for surgical management of retained lens fragments.

PURPOSE OF REVIEW: Retained lens fragments are a relatively rare occurrence after cataract surgery. While no definite guidelines for the surgical management or timing of surgery of this complication exist, surgery is indicated for patients with large lens fragments, persistent inflammation, secondary glaucoma, corneal edema, retinal tears or detachments, and associated endophthalmitis. The aim of this review is to summarize the current surgical management of retained lens material. RECENT FINDINGS: The Intelligent Research in Sight registry database of 2.26 million patients who underwent cataract surgery in the US indicated that 0.18% (1 in 563) had secondary removal of retained lens fragments in the anterior chamber in the operating room within 1 year of the original cataract surgery. The risk of returning to the operating room for retained lens material removal was greater among men, smokers, patients with Medicaid or military insurance, and those who had complex cataract surgery. Medical management with topical corticosteroids or observation may be considered for small lens fragments, but surgical removal remains the mainstay of the treatment for large lens fragments. SUMMARY: Retained lens fragments following cataract surgery may result in various vision-threatening complications. Understanding the risk factors, diagnosis, and surgical management of retained lens fragments are critical to preserving good visual outcomes. Vitrectomy is effective in patients with posterior nuclear fragments, retinal detachment, endophthalmitis, or uncontrolled glaucoma not responding to medical management. The best timing for surgery for retained lens fragments should be further investigated in a prospective study.

Stellate nonhereditary idiopathic foveomacular retinoschisis and an approach to the differential diagnosis of macular star.

PURPOSE OF REVIEW: This review aims to introduce stellate nonhereditary idiopathic foveomacular retinoschisis (SNIFR) and its differential diagnosis. We summarize findings from case reports and series published in the last few years on the clinical and imaging findings in SNIFR. RECENT FINDINGS: SNIFR presents as either a unilateral or bilateral macular star on fundus examination without clinical or imaging evidence of exudation or frank vitreomacular traction. optical coherence tomography (OCT) imaging shows schisis cavities in the Henle fibre and outer plexiform layers that correspond to the stellate en face findings. Visual acuity is usually minimally affected, and the presence of significant vision loss should prompt high clinical suspicion for alternate diagnoses. SUMMARY: SNIFR is a recently characterized clinical entity that serves as an important addition to the differential diagnosis of a macular star. It is a diagnosis of exclusion and should be distinguished from other causes of macular star such as neuroretinitis, vitreomacular traction, ocular manifestations of malignant hypertension, congenital juvenile X-linked macular schisis, myopic maculopathy, optic pit maculopathy, nicotinic acid maculopathy or taxane maculopathy among others.

Outcomes after switching eyes that were stable on aflibercept to ranibizumab versus continuing aflibercept in neovascular age-related macular degeneration.

PURPOSE: To describe outcomes of neovascular age-related macular degeneration (nAMD) eyes that were stable on aflibercept but switched to ranibizumab compared to eyes maintained on aflibercept over the same period. METHODS: In this retrospective cohort study, eyes switched from aflibercept to ranibizumab due to intraocular inflammation (IOI) concerns with aflibercept were identified. Data was gathered from 3 visits pre-switch, switch visit (Sw), and 3 visits post-switch (P1, P2, P3). Similar data was gathered on eyes eligible to switch but continued on aflibercept with the middle visit considered the "presumed switch." Outcome measures included visual acuity (VA) and central foveal thickness (CFT). RESULTS: A total of 142 eyes were analyzed with 71 in each of the switch and aflibercept groups. In the switch group, mean CFT increased from 165.7 µm at Sw to 184.7 µm at P1 (p = 0.009), 180.9 µm at P2 (p = 0.007), and 183.3 µm at P3 (p = 0.004). VA changed from logMAR 0.43 (20/54) at Sw to 0.49 (20/61) at P1 (p = 0.02), 0.54 (20/69) at P2 (p = 0.008), and 0.53 (20/68) at P3 (p = 0.04). In the aflibercept group, no significant change in CFT was found over the same period. VA changed from logMAR 0.56 (20/72) at the "presumed switch" to 0.58 (20/76) at P1 (p = 0.085), 0.62 (20/83) at P2 (p = 0.001), and 0.59 (20/77) at P3 (p = 0.14). CONCLUSIONS: nAMD eyes that were stable or improving on aflibercept but were switched to ranibizumab worsened, while those in a comparable group maintained on aflibercept remained fairly stable, suggesting a potential efficacy difference between the two drugs.

REFRACTIVE ERROR CHANGE DURING TREATMENT OF DIABETIC MACULAR EDEMA: A Post Hoc Analysis of the Diabetic Retinopathy Clinical Research Protocol T Trial.

PURPOSE: To evaluate the impact of anti-vascular endothelial growth factor therapy on the refractive error in eyes with diabetic macular edema. METHODS: Post hoc analysis of Diabetic Retinopathy Clinical Research protocol T. Spherical equivalent (SE) was calculated for study and fellow eyes at baseline, 1-year, and 2-year visits. The SE change of the eyes with edema was compared with those with resolved edema. The correlation between refractive error changes and central subfield thickness was evaluated. RESULTS: Among 543 study eyes, SE changed from -0.17 (2.04) D at baseline visit to -0.16 (2.14) D at 2 years giving a hyperopic shift of 0.04 (0.82) D (P = 0.022). Among fellow eyes, mean (SD) SE changed from -0.19 (2.1) D at baseline to -0.11 (2.1) D at 2 years, giving a hyperopic shift of 0.12 (0.84) D (P = 0.001). No significant difference in SE shift was found between eyes with and without edema at 2 years in phakic (0.12D and 0.08 D, P = 0.87) and pseudophakic eyes (-0.24D and -0.08D, P = 0.30). The SE shift was not correlated with central subfield thickness change at the end of the second year (r = 0.02, P = 0.62). CONCLUSION: Diabetic macular edema patients have minimal changes in refractive error. The correction of refractive error may be considered during treatment, regardless of the presence of edema.

SECONDARY EPIRETINAL MEMBRANE AFTER LASER RETINOPEXY FOR RETINAL TEAR OR LOCALIZED RETINAL DETACHMENT: Surgical Outcomes and Optical Coherence Tomography Structural Analysis.

PURPOSE: To assess visual acuity and optical coherence tomography outcomes after repair of secondary epiretinal membrane (ERM) after prior laser retinopexy for retinal tear with or without localized retinal detachment. METHODS: Retrospective, consecutive series. A previously described optical coherence tomography grading scheme was used for imaging analysis. RESULTS: Forty-two eyes of 42 patients were included, of which 16 (38.1%) had a concurrent localized retinal detachment. Mean logMAR visual acuity prelaser retinopexy was 0.15 ± 0.13 (Snellen 20/28), which worsened to 0.56 ± 0.42 (Snellen 20/72) before ERM surgery (P < 0.001). The mean visual acuity improved to 0.36 ± 0.30 (Snellen 20/45, P < 0.001) 3 months postsurgery and to 0.31 ± 0.32 (Snellen = 20/40, P < 0.001) at the final follow-up. Most eyes exhibited advanced ERM characteristics (n = 19 [45.2%] Stage 3 and n = 15 [35.7%] Stage 4 characteristics). The presence of inner microcystic changes (P = 0.008) and ellipsoid zone disruption (P = 0.009) at postoperative Month 3 were associated with worse final visual acuity. Eyes undergoing ERM surgery ≤180 days from laser retinopexy (n = 16, 38.1%) were younger (P = 0.024) and more likely to have Stage 4 ERM characteristics (P = 0.001). CONCLUSION: Secondary ERM after laser retinopexy may occur rapidly (<180 days) and exhibit significant anatomic alterations. The presence of inner microcystic changes and ellipsoid zone disruption postoperatively were optical coherence tomography features associated with worse final visual acuity.

CLINICAL OUTCOMES OF PATIENTS WITH ENDOPHTHALMITIS AFTER DEXAMETHASONE INTRAVITREAL IMPLANT.

PURPOSE: To report a case series of endophthalmitis associated with intravitreal dexamethasone injections in a single practice and to discuss the clinical findings and visual outcomes of each case. METHODS: All endophthalmitis cases following intravitreal dexamethasone injections performed from January 1, 2014 to October 20, 2020 were identified using Wills Eye/MidAtlantic billing records. The diagnosis, clinical information, and microbiology were confirmed for each case. Data were analyzed using Excel (Microsoft Excel, Redmond, WA). RESULTS: Four cases of endophthalmitis were identified from 3,925 intravitreal dexamethasone injections in a single practice and one case was referred from an outside institution, resulting in an incidence of 0.102% (1 in 981 injections). Mean age was 82.3 years (range, 63-88 years) with a mean of 11.3 intravitreal dexamethasone injections performed (range, 2-30 injections) before endophthalmitis. Cases presented with endophthalmitis a mean (SD) of 3.6 (1.64) days after causative injection. Three cases grew gram-positive organisms. All patients responded to intravitreal antibiotics. Mean logarithm of the minimal angle of resolution visual acuity at causative injection, endophthalmitis presentation, 3 months, and last follow-up was 0.44 (20/55), 2.22 (20/3,319), 1.18 (20/303), and 1.46 (20/577), respectively. CONCLUSION: Endophthalmitis following intravitreal steroid injections may occur more frequently than other intravitreal injections. Dexamethasone-attributed endophthalmitis remains uncommon, and prompt intravitreal antibiotic treatment seems to be effective in this series.

Survey of Vitreoretinal Specialists in the United States Regarding Telemedicine During the COVID-19 Pandemic.

Objective: To evaluate the attitudes, beliefs, and practice patterns of vitreoretinal specialists regarding the utilization of telemedicine during the COVID-19 pandemic, and to identify features which may predict future telemedicine use. Methods: An 11-question anonymous survey was completed electronically in July 2020 by vitreoretinal specialists practicing in the United States. Results: The survey response rate was 13.0% (361/2,774). Thirty-five respondents (9.7%) had used telemedicine before March 1, 2020; after March 1, 2020, 170 (47.1%) reported using telemedicine (p < 0.001). Of the 170 respondents who reported telemedicine use, a majority (65.3%;111/170) performed 0-5 patient visits per week. Female retina specialists, younger physicians, and those with prior telemedicine usage were more likely to use telemedicine. Barriers to telemedicine use included concern for misdiagnosis (332/361, 92.0%), inability to obtain optical coherence tomography imaging (330/361, 91.4%), inability to obtain fundus imaging (327/361, 90.6%), lack of access to and/or comfort with the technology (261/361, 72.3%), potential legal liability (229/361, 63.4%), and low reimbursement (227/361, 62.9%). The majority of respondents (225/361; 62.3%) reported that telemedicine without ancillary imaging was not an acceptable way to evaluate patients. However, 59.2% (214/361) would find telemedicine acceptable if remote imaging was available. Conclusions: The pandemic led to a rapid adoption of telemedicine by vitreoretinal specialists. The majority of specialists using telemedicine performed five or fewer visits per week. The availability of remote imaging may increase confidence in clinical outcomes with a subsequent increase in utilization of telemedicine by vitreoretinal specialists.

Emerging treatments for geographic atrophy in age-related macular degeneration.

PURPOSE OF REVIEW: This review describes therapeutic research programs for geographic atrophy (GA) due to age-related macular degeneration (AMD). We highlight clinical trial data from phase I, II, and III studies. RECENT FINDINGS: There are currently no treatments for GA, a form of advanced AMD that causes significant visual morbidity. Currently, therapeutic candidates are being developed to delay further progression of GA or even attempt to reverse some of the damage. The approaches to therapy range from molecular targets to cell transplantation. Studies of these novel treatment approaches have demonstrated varying degrees of success. The progress in understanding the disease pathophysiology as well as clinical trial data is reviewed. SUMMARY: There are promising new treatments to prevent GA progression as well as some that may reverse the disease course.

Full-thickness macular holes after surgical repair of primary rhegmatogenous retinal detachments: incidence, clinical characteristics, and outcomes.

PURPOSE: Full-thickness macular hole (FTMH) formation following rhegmatogenous retinal detachment (RRD) repair may limit post-operative visual acuity and often requires a return to the operating room, but little is known about this phenomenon. METHODS: This study included all patients with a FTMH that developed after RRD repair from January 1, 2015-July 31, 2020. The main outcome was the rate of FTMH formation following RRD repair as well as characteristics of FTMH following RRD repair that spontaneously close. RESULTS: There were 470 eyes with a diagnosis of both a FTMH and a RRD during the study period. Of these, 27 (0.28%) developed a FTMH following RRD repair. The median time to FTMH diagnosis was 91 days (25th, 75th quartiles 40, 204 days). The mean minimum hole diameter was 514.5 ± 303.6 microns. There were 4 FTMHs (14.8%) that spontaneously closed without surgical intervention. The spontaneous closure was noted from 4 to 12 weeks after the initial diagnosis of the FTMH. These holes were smaller than the holes that did not close spontaneously (mean minimum diameter 161.8 ± 85.2 vs 588.7 ± 279.3 microns, p = 0.0058). Of the 27 post-operative FTMHs, there were 23 eyes (85%) that underwent surgical intervention with pars plana vitrectomy and internal limiting membrane peeling. Nineteen eyes (83%) closed with one surgery, 20 eyes (87%) ultimately closed, while 3 eyes (11.1%) did not close. CONCLUSIONS: FTMH is relatively uncommon to occur following RRD repair with a prevalence of 0.28% in our series with 87% of these holes achieving closure following surgery or spontaneously. Approximately 15% of FTMHs following RRD repair closed spontaneously and these holes were significantly smaller.

SURGICAL FAILURES AFTER PRIMARY SCLERAL BUCKLING FOR RHEGMATOGENOUS RETINAL DETACHMENT: Comparison of Eyes With and Without Proliferative Vitreoretinopathy.

PURPOSE: To compare proliferative vitreoretinopathy (PVR)-related surgical failure and non-PVR-associated failure after scleral buckling for primary rhegmatogenous retinal detachment. METHODS: In this single-center, retrospective, consecutive case series, eyes with surgical failure after scleral buckling for primary rhegmatogenous retinal detachment were identified. Eyes with surgical failure were categorized as PVR-associated and non-PVR-associated failure, and these groups were compared. RESULTS: Of the 530 scleral buckling procedures performed, 69 were surgical failures (13%), of which 27 of the 530 (5%) were due to PVR and 42 of the 530 (8%) were from non-PVR causes. Patients with PVR-associated failure were more likely to be smokers (P < 0.001), have a delayed presentation after symptoms (P = 0.011), have preoperative vitreous hemorrhage (P = 0.004), and have preoperative PVR (P = 0.002). Multivariate logistic regression models showed that the odds of PVR-associated failure were greater in eyes with preoperative vitreous hemorrhage (odds ratio, 8.2; P = 0.048), preoperative PVR (odds ratio, 22.7; P = 0.023), and among previous smokers (odds ratio, 28.8; P < 0.001). Thirty-two of 69 patients (46%) required one additional surgical intervention, and 37 of the 69 patients (53%) required two or more additional interventions to achieve final reattachment. CONCLUSION: Proliferative vitreoretinopathy-related surgical failure after primary scleral buckling was 5%. Risk factors for PVR-associated failure parallel those commonly referenced for pars plan vitrectomy, including smoking history, preoperative vitreous hemorrhage, and preoperative PVR.

Solitary neurofibroma of the orbit with intracerebral extension associated with ocular surface melanocytoma: a case report.

Solitary or isolated neurofibroma is uncommonly observed in the orbit. Neurofibromas typically involve peripheral nerves and occasionally the cranial nerves. A 29-year-old man presented with recent onset left eye proptosis and exotropia. Physical examination was positive for hyperpigmented lesions of the ipsilateral ocular surface and hard palate. Imaging revealed an infiltrative orbital mass with extension through superior orbital fissure into the brain. There was also bone defect of greater sphenoid wing. Medial orbitotomy was performed to obtain biopsies of the orbital mass and the pigmented ocular surface lesions. Histopathologic diagnosis of neurofibroma was confirmed for the former and melanocytoma for the latter. His symptoms and examinations remained stable during the follow up. This case is unique due to several features, including extensive intracerebral spread of orbital neurofibroma in a patient without definite diagnosis of neurofibromatosis type 1 and association with ipsilateral ocular surface melanocytoma and palatal pigmented lesions. ABBREVIATIONS: CT: computed tomography; GFAP: glial fibrillary acid protein; MRI: magnetic resonance imaging; NF-1: neurofibromatosis type 1.

Multifocal electroretinogram in diabetic macular edema and its correlation with different optical coherence tomography features.

PURPOSE: To evaluate multifocal electroretinogram (mfERG) parameters in eyes with diabetic macular edema (DME) and its correlation with vision and optical coherence tomography (OCT) features. METHODS: Fifty-four eyes of 27 subjects with DME due to nonproliferative diabetic retinopathy were evaluated. MfERG responses were measured in three concentric rings. Macular thickness was measured by OCT in each segment of the three concentric rings, and mfERG rings were superimposed on the macular thickness map. The correlation between macular thickness in specific points of the thickness map and changes of the mfERG parameters in the corresponding points of the mfERG field map was evaluated and the relationship between the OCT and mfERG changes and changes of best-corrected visual acuity (BCVA) was investigated. The central foveal B-scans of SD-OCT were used to evaluate any correlation between the external limiting membrane (ELM) status, ellipsoid zone (EZ) status, presence of cysts or disorganization of retinal inner layers (DRIL), and mfERG parameters at the central corresponding area. RESULTS: The mean of BCVA was 0.5 ± 0.3 in logMAR, and the central macular thickness was 392.6 ± 123.4 microns. The central ring P1 and N2 amplitudes had a significant correlation with BCVA in univariate and multivariate analyses (P = 0.001 for both, r = - 0.346 and r = - 0.646, respectively). There was a significant correlation between retinal thickness and the N1 amplitude in the central ring (P = 0.02, r = - 0.343). Outer retinal layer disruption (ELM and EZ) correlated with prolonged P1 implicit time at the corresponding location (P = 0.005, r = 0.068). The presence of the DRIL was associated with reduced P1 and N2 amplitudes (P = 0.037, r = - 0.284 and P = 0.019, r = - 0.562, respectively). A significant correlation was also found between the presence of cysts and a lower central P1 amplitude (P = 0.033, r = - 0.376). CONCLUSION: In diabetic patients, discrete changes of some parameters in the central ring of the mfERG field map (e.g., P1 and N2 amplitudes) have a significant correlation with both structural OCT abnormalities in the corresponding points of the thickness map (like DRIL, intraretinal cyst and ELM/EZ disruption) and BCVA. Predictive models such as those described in this report may make it possible to identify the relationship between specific anatomical and functional characteristics in diabetic retinopathy.

Pseudo inferior oblique overaction, clinical findings, mechanism, and surgical outcomes.

PURPOSE: To investigate clinical findings of the pseudo inferior oblique overaction (IOOA) syndrome and the outcomes of strabismus surgery and to discuss the mechanisms proposed for this disease. METHODS: This syndrome is defined by Y pattern strabismus with exotropia in upgaze. There is marked abduction and hypertropia of the adducting eye when elevation is carried out in side gaze, but there is no hypertropia of the adducting eye in horizontal side gaze. Sixteen patients were included and surgery was performed in 14 patients. Success of the surgical intervention was defined as correction of the Y pattern, orthotropia in primary position, upgaze, and downgaze. RESULTS: Thirteen of the sixteen patients were female. The mean age was 9.6 ± 6.1 years. The mean follow-up time was 14.7 ± 16.9 months. Pre-operatively, 12 patients were orthophoric, and four patients were exophoric (4 to 8 PD) in primary position. In downgaze, all patients were orthophoric. Mean exotropic deviation in upgaze was 25.06 ± 5.9 (18 to 40 PD). Fourteen patients underwent surgery with 2-mm bilateral lateral rectus recession and full tendon supraplacement in seven cases, and 2/3 tendon supraplacement in the other seven patients. The success rate of surgery was 92.8% after the first operation, which reached 100% after a second surgical procedure was performed on one of the patients. CONCLUSIONS: Strabismus surgery is effective in correcting the Y pattern in patients with pseudo IOOA. A 2/3 tendon supraplacement combined with 2-mm recession of the lateral rectus muscles is the preferred treatment.