Open-angle glaucoma and Fuchs dystrophy.

A 62-year-old woman with a history of moderate myopia, long-standing open-angle glaucoma (OAG), and Fuchs dystrophy in both eyes was referred for consultative care. She had prior trabeculectomy in 1984 and 1992 in the left and right eyes, respectively. She is 3 months post-Descemet-stripping endothelial keratoplasty (DSEK) in the left eye, now referred with uncontrolled intraocular pressure (IOP) despite maximum tolerated medical therapy. Current medical therapy for IOP consists of acetazolamide 250 mg by mouth 2 times a day, brimonidine 2 times a day in the left eye, dorzolamide 2 times a day in the left eye, and timolol 2 times a day in the left eye. The patient has a history of presumed steroid response; however, her corneal surgeon has requested that the steroid be continued for the next several months because of the recent DSEK. The IOP in the left eye has ranged from the mid-20s to mid-30s since DSEK. The right eye has consistently had pressure in the low teens and below for many years without topical antihypertensive medications. Examination revealed stable visual acuity at 20/30 and 20/40 in the right and left eyes, respectively, IOP was 12 mm Hg in the right eye and 25 mm Hg in the left eye by Goldman applanation, irregular but reactive pupils without afferent defect, and full confrontational visual fields. Slitlamp examination showed superior low avascular bleb, moderate-to-severe guttae, and posterior chamber IOL in the right eye. The left eye showed superior low diffuse bleb, clear DSEK graft, quiet chamber, superonasal iridectomy, and posterior chamber IOL with an open posterior capsule. The conjunctiva was moderately scarred but a repeat trabeculectomy or Xen Gel stent (Abbvie) appeared possible. The angles were wide open in each eye. Fundus examination was normal aside from myopic, anomalous-appearing nerves with an approximate cup-to-disc ratio of 0.90 in both eyes. Humphrey visual field showed nonspecific changes on the right and moderate nasal defect on the left eye, stable to previous examinations dating back to 2018 (Figure 1JOURNAL/jcrs/04.03/02158034-202407000-00018/figure1/v/2024-07-10T174240Z/r/image-tiff and Figure 2JOURNAL/jcrs/04.03/02158034-202407000-00018/figure2/v/2024-07-10T174240Z/r/image-tiff). Optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL) revealed moderated thinning in both eyes that was also stable to prior examinations (Figure 3JOURNAL/jcrs/04.03/02158034-202407000-00018/figure3/v/2024-07-10T174240Z/r/image-tiff). Her axial length measured 25.23 and 26.34 mm in the right and left eyes, respectively. Central corneal thickness was 553 µm in the right eye and 563 µm in the left eye before her DSEK procedure. What would be your approach to management of this patient's left eye, addressing the following: Rationale for your procedure of choice? Would you over-rule the corneal surgeon and stop the steroid in an attempt to obviate the need for glaucoma surgery? Does the age of onset of glaucoma affect your surgical decision making? Note that patient age at the time of trabeculectomy was 22 years. Are some procedures better suited for patients after DSEK surgery?

Eplerenone for the treatment of chronic central serous chorioretinopathy: 3-year clinical experience.

BACKGROUND/AIMS: The efficacy of mineralocorticoid receptor antagonist eplerenone to treat chronic central serous chorioretinopathy (CSCR) has been established. However, previous studies have been limited by small cohort size and short follow-up duration. This study aims to report 3-year clinical outcomes of patients treated with eplerenone for chronic CSCR. METHODS: Institutional review board-approved retrospective chart analysis at a single institution from 2012 to 2018. Baseline best-corrected visual acuity and anatomical measurements related to degree of subretinal fluid (SRF) were collected at eplerenone initiation. Follow-up data were collected at the closest date to 12, 24 and 36 months. RESULTS: Data were obtained for 100 eyes of 83 patients at 1-year (mean 11.18 ± 4.00 months), 49 eyes at 2-year (24.01 ± 3.33 months) and 33 eyes at 3-year (mean 35.5 ± 7.89 months) follow-up visits. The rate of complete SRF resolution was 31%, 28% and 33%, respectively. At final follow-up, logarithm of the minimum angle of resolution visual acuity change from baseline was +0.10 ± 0.24 (p = 0.130). Average change from baseline at final follow-up for central subfield thickness was -97 ± 140.6 µm (p < 0.001), cube volume was -1.07 ± 1.71 mm3 (p < 0.001), macular thickness -28. 5 ± 47.5 µm (p < 0.001), maximum SRF height was -95.6 ± 160.5 µm (p < 0.001) and maximum SRF diameter was -1169.0 ± 1638.7 µm (p = 0.008). CONCLUSION: Anatomical improvement occurs primarily within the first year of eplerenone treatment for chronic CSCR.

Clinical Features and Management of Subretinal Abscesses Secondary to Methicillin-Resistant Staphylococcus aureus Endogenous Endophthalmitis.

BACKGROUND AND OBJECTIVE: To describe the clinical features, management, and immediate outcomes of patients with subretinal abscesses secondary to methicillin-resistant Staphylococcus aureus (MRSA) endogenous endophthalmitis. PATIENTS AND METHODS: Eleven eyes of seven patients were identified by retrospective chart review. Demographics, initial presentation, examination findings, imaging, cultures, treatments, and short-term outcomes were reviewed. RESULTS: Eleven eyes of seven patients presented with subretinal abscesses secondary to MRSA endogenous endophthalmitis. Four had history of recurrent MRSA infections or active soft-tissue ulceration. Six underwent vitreous tap for culture without growth. Three had positive blood cultures for MRSA. Six received empiric therapy with intravenous vancomycin, one received oral trimethoprim-sulfamethoxazole, and six received intravitreal vancomycin. Consolidation of abscesses was seen within days of initial treatment. Visual outcomes were contingent on abscess location and time to initial treatment. CONCLUSION: Prompt diagnosis and systemic antibiotic therapy is paramount in the treatment of this rare presentation. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:134-142.].

Intrasurgical assessment of subretinal tPA injection for submacular hemorrhage in the PIONEER study utilizing intraoperative OCT.

BACKGROUND AND OBJECTIVE: To assess the feasibility of intraoperative OCT (iOCT) during pars plana vitrectomy with subretinal tissue plasminogen activator (tPA) injection for subretinal hemorrhage. PATIENTS AND METHODS: Eyes that underwent vitrectomy and subretinal injection of tPA were identified from the PIONEER study, a prospective clinical study assessing the feasibility and utility of iOCT in ophthalmic surgery. A microscope-mounted spectral-domain OCT system was utilized for iOCT imaging. Standardized scan protocol and image acquisition were followed for intraoperative imaging. RESULTS: iOCT was successfully obtained in four of four eyes. In all cases, increased subretinal fluid was noted, with differential reflectivity visualized between the hemorrhage-tPA interface confirming appropriate localization of tPA injection. Image quality variability was significant. CONCLUSION: iOCT can successfully be performed during pars plana vitrectomy with subretinal tPA injection. Utilizing iOCT, appropriate placement of tPA solution and corresponding retinal architectural changes were visualized.