SEQUENTIAL PARS PLANA VITRECTOMY AND INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR RHEGMATOGENOUS RETINAL DETACHMENTS WITH PERIPHERAL BREAKS AND CONCOMITANT NONCAUSATIVE MACULAR HOLE IN NONHIGHLY MYOPIC PATIENTS.

PURPOSE: To present the anatomical and functional results of sequential pars plana vitrectomy for treating rhegmatogenous retinal detachment with peripheral breaks and concomitant noncausative macular holes (MHs) in nonhighly myopic patients. METHODS: Medical records of patients who underwent rhegmatogenous retinal detachment surgical repair between 2017 and 2023 were reviewed. Of 980 patients with rhegmatogenous retinal detachment, 10 had concurrent MH and underwent sequential pars plana vitrectomy for rhegmatogenous retinal detachment repair and air endotamponade, followed by MH repair using the inverted internal limiting membrane flap technique and C2F6 endotamponade after a minimum of 1 week. The main outcomes measured were best-corrected visual acuity change, retinal reattachment rate, MH closure rate, and closure type. RESULTS: The retinal reattachment rate was 90% after the primary surgery and 100% after subsequent surgery. Macular hole closure was achieved in all cases. Macular hole diameters ranged from 291 to 702 µm. Anatomical recovery showed mainly 1A closure types (90%). Functional recovery demonstrated significant best-corrected visual acuity improvement, with a mean visual acuity gain of 1.58 ± 0.41 the logarithm of the minimum angle of resolution. CONCLUSION: For this infrequent pathology, sequential surgery using the inverted internal limiting membrane flap technique and air/gas endotamponade yielded favorable anatomical and functional outcomes. This controlled and standardized approach using sequential surgeries contributes to the achievement of consistent results.

Investigation of Risk Factors Predicting Cataract Surgery Complications in Patients with Pseudoexfoliation Syndrome: A Systematic Review.

(1) Background: The present review aims to identify risk factors with predictive value for differentiating between pseudoexfoliation patients at risk of developing intra- or postoperative complications and those without operative risk during cataract surgery. (2) Methods: The review protocol was registered at PROSPERO, registration no. CRD42023417721. The following databases were searched for studies between 2000 and 2023: PubMed/Medline, Scopus, Springer, Science Direct, Web of Science, Cochrane Database of Systematic Reviews, TRIP database, LILACS, Clinical Trials, and reference lists of articles. We included analytical studies of any design examining cataract surgery complications in pseudoexfoliation patients across two population groups, one who underwent uneventful cataract surgery and the other who experienced intra- or postoperative complications. The paper will follow PRISMA 2020 criteria for reporting. Effect measure was assessed using odds ratios (ORs) and corresponding 95% confidence interval (CI) for qualitative variables and means with their respective standard deviation (SD) for quantitative variables. The risk of bias was assessed using the method presented in the Cochrane Handbook for Systematic Reviews. The GRADE scale was used for quality of evidence and certainty. (3) Results: The initial search of published and gray literature databases retrieved 1435 articles, six of which were included in this report. A total of 156 intra- or postoperative incidents were reported in 999 eyes with pseudoexfoliation. The identified predictive factors were a shallow anterior chamber, cataract grade, neutrophil-to-lymphocyte ratio, preoperative intraocular pressure, and symmetry of the exfoliation material. Limitations include heterogeneity of data and limited number of studies identified in our search. (4) Conclusions: These findings suggest the potential to refine risk stratification protocols in clinical settings and assist surgeons in personalized decision-making among individuals with pseudoexfoliation syndrome.

Central serous chorioretinopathy in pregnancy.

Objective: The objective of this work was to present two unusual cases of central serous chorioretinopathy (CSC) and the chosen therapeutic method. Materials and methods: In this article, two cases of CSC in pregnant patients were described. Results: The first case was a 35-year-old patient in the 16th week of pregnancy and the second one was a 26-year-old patient in the 20th week of pregnancy. Due to the contraindications associated to pregnancy, the therapeutic method chosen was subthreshold micropulse laser photocoagulation. The functional and anatomical evolution was very good in both patients. Discussion: In both cases, treatment of the disease was preferred to prevent important photoreceptor losses. After the treatment, very good anatomical and functional results were obtained. Conclusions: The micropulse laser is an effective solution for treating CSC. It is the only safe therapeutic solution during pregnancy. CSC can be associated with pregnancy, without necessarily suggesting pre-eclampsia. Abbreviations: CSC = central serous chorioretinopathy, SRF = subretinal fluid.

Uveal melanoma diagnosis and current treatment options (Review).

Uveal melanoma is a rare condition accounting for only 5% of all primary melanoma cases. Still, it is the most frequently diagnosed primary intraocular malignant tumor in adults. Almost 90% of the tumors involve the choroid and only a small percentage affects the ciliary body or the iris. There is a consistent difference in incidence between different regions with individuals of northern European descent having a significantly higher risk as compared to Hispanics, Asians, and Blacks. Among the many risk factors, mutations in the G protein subunit alpha Q (GNAQ) or G protein subunit alpha 11 (GNA11) genes and different receptors are highly suggestive. While iris melanoma can easily be noticed by the patient itself or diagnosed at a routine slit-lamp evaluation, a consistent percentage of posterior uveal tumors are incidentally diagnosed at funduscopic evaluation as they can evolve silently for years, especially if located in the periphery. Uveal melanoma classifications rely on the tumor size (thickness and basal diameter) and also on intraocular and extraocular extension. The differential diagnosis with pseudomelanomas is carried out according to the tumor aspect and position. Iris melanoma has a better prognosis and a lower mortality rate as compared to choroidal melanoma that has a much higher rate of metastasis (50% of the patients) and a subsequent limited life expectancy from 6 to 12 months. While conservative therapeutic options for the primary tumor, relying on different surgical excision techniques and/or irradiation therapies, offer good local tumor control, the treatment options for metastatic disease, although numerous, are still inadequate in preventing a fatal outcome.

Cumulative visual impact of two coagulability disorders: A case report.

Cumulative visual impact of two coagulability disorders were reviewed by presenting a case of a young female patient with a spontaneous abortion and two thromboembolic events in 8 years, whose visual function was severely affected. The particularities of her genetic constellation regarding the retinal circulation are also discussed. The patient developed a central retinal artery occlusion in the right eye during pregnancy in 2010, which led to an extended hematological workup that revealed presence of MTHFR C677T and MTHFR A1298C heterozygote mutations. The screening for myeloproliferative disorders showed JAK2 V617F gene mutation. Test results confirmed the diagnosis of thrombophilia and essential thrombocythemia and she was recommended permanent treatment with low molecular weight heparin, platelet antiaggregant, peripheral vasodilator and neuroprotectors. Despite the treatment, the patient developed central retinal vein occlusion in the fellow eye 8 years after the first thromboembolic event. The visual acuity for the right eye (0.9 logMAR) remained poor and the visual acuity for the left eye recovered completely (from 0.3 logMAR to 0 logMAR). However, new retinal artery or vein occlusions could occur in the future and there is also a risk of thrombosis in other areas, such as cerebral, pulmonary or renal, due to the general coagulability imbalance.

Intraocular pressure changes during and after silicone oil endotamponade (Review).

Silicone oil (SIO) has rapidly become an indispensable adjunct in vitreoretinal surgery. Constant improvements in purity and also in viscosity have not totally prevented specific complications that may occur during endotamponade. Results of in vitro studies that suggested that higher viscosity silicone oil might be superior in terms of stability and safety are confirmed in real life only if endotamponade lasts for more than 6 months. Intraocular pressure changes induced by the silicone oil endotamponade or oil extraction are documented from its very first use and are potentially threatening vision. The purpose of this review is to update current knowledge on the incidence, risk factors, pathogenesis, and management of secondary silicone oil glaucoma. Also, in a retrospective evaluation on cases with complex retinal detachments that underwent 23G vitrectomy and high viscosity SIO endotamponade, we have noticed that a considerable number of cases developed significant intraocular pressure changes during SIO endotamponade and after SIO removal, especially in early postoperative period.

Subretinal alteplase injections in massive subretinal hemorrhage due to age-related macular degeneration: A case report series.

This report describes a series of cases with massive subretinal hemorrhage (SRH) due to age-related macular degeneration (AMD) treated by subretinal alteplase injections. In all cases, the surgical technique consisted in 25-gauge pars plana vitrectomy (PPV) and alteplase injection under the retina using a 38-gauge cannula. After the fluid-gas exchange, bevacizumab injection was performed in all patients. Three cases of SRH in which this technique was used, as well as their evolution at one week and one month postoperatively are described. Visual acuity was hand motion in all three cases at presentation. After surgery, a significant anatomical and functional improvement was noted in all cases. One month postoperatively, none of the patients had blood under the macula, and visual acuities significantly improved to 0.8, 0.2 and 0.16 (decimal fraction). A consistent reduction of central retinal thickness was observed on optical coherence tomography (OCT) from the first week postoperatively. No intra and postoperative complications were noted. Subretinal alteplase injection proved as a viable solution in these severe SRH with early presentation. There was no need to change the systemic anticoagulant and antiaggregant therapy. Bevacizumab intravitreal injection at the end of surgery has an important role in preventing further bleeding.

Conjunctival flap surgery in the management of ocular surface disease (Review).

Literature regarding conjunctival flap surgery was reviewed to describe and discuss the rationale for this type of procedure. The conjunctival flap is an acknowledged surgery for the treatment of various corneal diseases with a chronically compromised ocular surface, such as severe dry eye, neurotrophic or neuroparalytic disease, or bullous keratopathy. The purpose of this surgery is to restore the integrity of the corneal surface and thus to prevent gradual corneal ulceration and secondary infection, as well as to ameliorate pain, reduce the need for frequent medications, improve cosmetic appearance, and offer an alternative to invasive surgery or enucleation. Since the introduction of more effective methods of treating severe ocular surface diseases, conjunctival flap surgery has rarely been the primary modality of treatment and has usually followed a range of medical and surgical treatments. The availability of improved ocular lubricants, more effective antimicrobials, bandage contact lenses, tissue adhesives, and other corneal and conjunctival surgical interventions, has reduced the need for conjunctival flaps. However, conjunctival flaps remain extremely useful in selected cases and deserve a place in the ophthalmologist's repertoire for the management of ocular surface disease.

Ocular cicatricial pemphigoid (Review).

Ocular cicatricial pemphigoid is a particular form of mucous membrane pemphigoid and it is characterized by a chronic bilateral conjunctivitis with relapsing-remitting periods. Without therapy 75% of the cases develop visual loss due to major ocular complications (e.g. severe dry-eye syndrome, corneal erosions, corneal keratinization, entropion, symblepharon). Pathogenesis remains uncertain and probably linked to an autoimmune type II hypersensitivity response in patients with a genetic predisposition and exposure to different environmental triggers. With a worldwide distribution, no racial predilection and an estimated incidence that largely varies from 1/10,000-1/60,000, ocular cicatricial pemphigoid predominantly affects women aged ~60 years. Conjunctival biopsy with direct immunofluorescence is the gold standard in diagnosis confirmation, but up to 40% of the patients have a negative biopsy result that does not rule out the diagnosis. The skin and many other mucous membranes (e.g. oral, trachea, esophagus, pharynx, larynx, urethra, vagina and anus) may be involved. The disease grading relies on Foster staging system (based on clinical signs) and Mondino and Brown system (based on the inferior fornix depth loss). The differential diagnosis includes atopy, allergies, trauma, chemical burns, radiation, neoplasia, infectious, inflammatory and autoimmune etiologies. The main goals of the treatment are to stop disease progression, to relieve symptoms and to prevent complications. With long-term systemic therapy 90% of the cases can be efficiently controlled. While Dapsone is the first-line treatment in mild to moderate disease in patients without G6PD deficiency, more severe cases require immunosuppressant therapy with azathioprine, mycophenolate mofetil, methotrexate or cyclosporine. Cyclophosphamide, biologics (etanercept or rituximab) and intravenous immunoglobulin therapy are usually reserved for recalcitrant disease and unsatisfactory results to conventional therapy. Dry eye syndrome requires constant lubricating medication and topical steroids, cyclosporine-A and tacrolimus. Surgery should be planed only in quiescent phase as minor conjunctival trauma can significantly worsen the disease.

The Management of Lamellar Macular Holes: A Review.

This literature review aims to provide the retina specialist with answers to patient's questions related to the management of lamellar macular holes (LMHs). Most LMHs are stable over time, but 13-21% present an anatomic decline after 18-24 months of follow-up. Nineteen point five percent of the eyes may experience a visual acuity (VA) loss of more than 5 letters after 3 years. Many surgeons choose to perform surgery when there is significant metamorphopsia or documented decline in VA over time. The typical surgery is phacovitrectomy with the epiretinal membrane and the internal limiting membrane peeling in previously phakic eyes (41.9 to 85.3% of the eyes). In the eyes that remained phakic, cataract surgery was often necessary within the first year of follow-up (19.2 to 40% of eyes). After surgery, a VA gain was recorded in 63-94% of eyes, but some eyes (between 0 and 20%) suffered some VA loss. Progression to full-thickness macular hole may occur after surgery, and thus a second surgical intervention may be needed.

High-resolution imaging of diabetic retinopathy lesions using an adaptive optics retinal camera.

Purpose. Adaptive optics (AO) imaging is a promising high-resolution investigation technique in ophthalmology that can bring new information about the pathophysiology of diabetic retinopathy. Material and methods. Seven patients previously diagnosed with diabetic retinopathy were investigated with optical coherence tomography (OCT) scanning, OCT angiography, fundus photo, and AO retinal camera (rtx1TM, Imagine Eyes, Orsay, France). Results. The red lesions on fundus photos appeared on AO imaging as hyporeflective lesions. OCT angiography helped us to differentiate between microaneurysms and hemorrhages. Hard exudates had a heterogeneous granular appearance. Retinal oedema was proved to have a blurring effect on the AO images. In addition to this, cystic spaces were identified to have a hyporeflective demarcation line. Conclusions. AO imaging is offering a fine documentation of retinal lesions and might become an important instrument for early diagnosis of diabetic retinopathy and for explaining its pathophysiological mechanisms. Abbreviations: AO = adaptive optics, AOO = adaptive optics ophthalmoscopy, SS = swept source, OCT =optical coherence tomography, SLO = scanning laser ophthalmoscope.

Choroidal thickness increase after micropulse transscleral cyclophotocoagulation.

Glaucoma, the affliction that results in optic nerve damage and vision loss, is the main cause of irreversible blindness. The goal of this study was to describe our experience and OCT findings regarding glaucoma patients who underwent MicroPulse Transscleral Cyclophotocoagulation. A variety of glaucoma patients treated with MP-TSCPC were included in our study. LASER settings were 2000mW of 810nm infrared diode micropulse LASER, 31.3% duty cycle and the duration of treatment was between 80-130 s per hemisphere to each eye, at 3 mm of corneoscleral limbus, spearing the nasal and temporal clock hours and also the region with previous filtration surgeries (trabeculectomy). We conducted a prospective study in which twenty-two patients underwent MP-TSCPC under local anaesthesia and they were examined one week, one month, three months, and six months postoperatively. Mean IOP dropped from 35.23 mmHg preoperatively to 17.73mmHg (49.67%) at 1 week follow-up, to 21.81 mmHg (38.09%) at 1 month follow-up, to 22.34 mmHg at 3 months follow-up and to 23.56 mmHg at 6 months follow-up. Four patients (15.8%) underwent a second treatment (at 1 month after the initial treatment) due to insufficient IOP decrease, two of them with success in lowering the IOP postoperatively. By measuring the foveolar choroidal thickness via macular OCT scan, we noticed that all responsive patients had a thicker choroid one week after the laser treatment, with a steady increase of a mean 7.3% that was sustained at one and three months follow-up, while in non-responsive patients, the choroidal thickness remained the same postoperatively, or had a significant decrease. The increase in choroidal thickness in all patients in whom we observed IOP reduction was a significant correlation that supported the mechanism of increased uveoscleral outflow obtained from LASER treatment.

Submacular hemorrhage in neovascular age-related macular degeneration: A synthesis of the literature.

Large submacular hemorrhage, an uncommon manifestation of neovascular age-related macular degeneration, may also occur with idiopathic polypoidal choroidal vasculopathy. Submacular hemorrhage damages photoreceptors owing to iron toxicity, fibrin meshwork contraction, and reduced nutrient flux, with subsequent macular scarring. Clinical and experimental studies support prompt treatment, as tissue damage can occur within 24 hours. Without treatment the natural history is poor, with a mean final visual acuity (VA) of 20/1600. Reported treatments include retinal pigment epithelial patch, macular translocation, pneumatic displacement, intravitreal or subretinal tissue plasminogen activator, intravitreal anti-vascular endothelial growth factor (VEGF) drugs, and combinations thereof. In the absence of comparative studies, we combined eligible studies to assess the VA change before and after each treatment option. The greatest improvement occurred after combined pars plana vitrectomy, subretinal tissue plasminogen activator, intravitreal gas, and anti-vascular endothelial growth factor treatment, with VA improving from 20/1000 to 20/400. The best final VA occurred using combined intravitreal tissue plasminogen activator, gas, and anti-vascular endothelial growth factor therapy, with VA improving from 20/200 to 20/100. Both treatments had an acceptable safety profile, but most studies were small, and larger randomized controlled trials are needed to determine both safety and efficacy.

Surgical technique for repositioning subluxated previously scleral-fixated intraocular lenses.

PURPOSE: To describe a repositioning technique of a subluxated scleral-fixated rigid intraocular lens (IOL) with haptic holes in eyes with complete or anterior vitrectomy. DESIGN: Interventional case series. METHODS: Using a two-port pars plana vitrectomy, a 10-0 polypropylene suture with the free end fixated to a haptic hole cut from another artificial IOL is passed through a paracentesis, then through the hole of the haptic luxated in the vitreous cavity. It is then reanchored at the sclera, repositioning the IOL. RESULTS: In the two eyes, visual acuity was restored to pre-subluxation levels. During 6-month follow-up, anatomic and functional results were stable, and there were no complications. CONCLUSIONS: This technique enables repositioning of a subluxated, previously sutured rigid IOL without externalization of the lens or haptics and with good results.