Epiretinal membranes in patients with uveitis: an update on the current state of management.

PURPOSE: This review aims to summarize the current knowledge concerning the clinical features, diagnostic work-up, and therapeutic approach of uveitic epiretinal membranes (ERM). METHODS: A thorough investigation of the literature was conducted using the PubMed database. Additionally, a complementary search was carried out on Google Scholar to ensure the inclusion of all relevant items in the collection. RESULTS: ERM is an abnormal layer at the vitreoretinal interface, resulting from myofibroblastic cell proliferation along the inner surface of the central retina, causing visual impairment. Known by various names, ERM has diverse causes, including idiopathic or secondary factors, with ophthalmic imaging techniques like OCT improving detection. In uveitis, ERM occurrence is common, and surgical intervention involves pars plana vitrectomy with ERM peeling, although debates persist on optimal approaches. CONCLUSIONS: Histopathological studies and OCT advancements improved ERM understanding, revealing a diverse group of diseases without a unified model. Consensus supports surgery for uveitic ERM in progressive cases, but variability requires careful consideration and effective inflammation management. OCT biomarkers, deep learning, and surgical advances may enhance outcomes, and medical interventions and robotics show promise for early ERM intervention.

Diagnostic and therapeutic considerations in patients with bilateral diffuse uveal melanocytic proliferation.

PURPOSE: This review aims to summarize the current knowledge concerning the clinical features, diagnostic work-up, and therapeutic approach of bilateral diffuse uveal melanocytic proliferation (BDUMP). METHODS: A meticulous literature search was performed in the PubMed database. A supplementary search was made in Google Scholar to complete the collected items. Our search strategy utilized the following keywords: "bilateral diffuse uveal melanocytic proliferation", "BDUMP", and "Paraneoplastic Syndrome". Articles were considered based on their relevance, with the search spanning publications up to 2023. Studies were excluded if they did not contribute pertinent information or lacked methodological rigor. A critical appraisal of included studies was conducted, assessing study design, sample size, methodology, and potential bias, ensuring a thorough and transparent review process. RESULTS: BDUMP is a rare and potentially sight-threatening condition characterized by the bilateral proliferation of melanocytes within the uvea. BDUMP is typically observed in middle-aged or elderly individuals and is often associated with an underlying malignancy, most commonly of gastrointestinal origin. BDUMP is frequently misdiagnosed as a benign nevus or choroidal metastasis, leading to delayed diagnosis and treatment. The ophthalmic symptoms and signs typically precede the diagnosis of a systemic malignancy, emphasizing the crucial role of ophthalmologists in the recognition of BDUMP. Several diagnostic modalities can aid in the diagnosis of BDUMP, including ophthalmic examination, imaging studies such as optical coherence tomography, fluorescein angiography, and indocyanine green angiography, and biopsy of the uveal tissue. Treatment of BDUMP is directed towards the underlying malignancy and may include chemotherapy, radiotherapy, or surgical resection. Additionally, strict monitoring with regular follow-ups may contribute to the detection of new lesions and the reduction in the size of existing ones. CONCLUSIONS: BDUMP can be considered a potential biomarker in the management of malignancies, especially when the primary underlying tumor has not been detected. Further research is needed to better understand the pathogenesis of BDUMP and its association with malignancy.

Unexplained visual loss in retinal detachment repair: comparing gas, silicone oil and heavy silicone oil by multivariable regression.

PURPOSE: To measure the proportion of unexplained and all causes of visual loss following primary rhegmatogenous-retinal-detachment (RRD) repair, comparing gas tamponade (SF6, C2F6, C3F8), silicone oil (SO, 1000cs and 5000cs) and heavy silicone oil (Densiron). METHODS: Retrospective, continuous, comparative study from 01/1/2017-31/5/2021. All primary RRDs were included after successful removal of SO and Densiron. Primary failures were excluded. Visual loss was defined as reduction of ≥0.30 logMAR units. Multivariable binary-logistic and linear regression models to compare tamponade, and all cases of unexplained visual loss and logMAR gain were performed. Covariates included age, ocular co-morbidities, pre-op vision, macula-status, high-myopia, giant-retinal-tear (GRT), perfluorocarbon-use, combined buckle/PPV, PVR-C, retinectomy, tamponade agent and post-operative lens status. RESULTS: Of 1,012 primary RRDs, we found an incidence of unexplained visual loss in 15/1012 (1.5%, SF6:1/341[0.3%], C2F6:4/338[1.2%], C3F8:2/239[0.8%], Densiron:0/33[0.0%], SO-1000cs:5/43[11.6%] and SO-5000cs:3/18[16.7%]), and visual loss of all causes in 57/1012 (5.6%, SF6:13/341[3.8%], C2F6:14/338[4.1%], C3F8:15/239[6.3%], Densiron:2/33[6.1%], SO-1000cs:9/43[20.9%] and SO-5000cs:4/18[22.2%]). On multivariable binary-logistic regression, we report that macula-on RRD (Odds-Ratio[OR]5.7,95% Confidence-interval[CI]1.2-28.2, p=0.032), GRT (OR35.0,CI 2.0-617.3, p=0.015), combined buckle/PPV (OR37.7,CI 2.0-711.4, p=0.015), SO1000cs (OR86.6,CI 5.6-1,348.0), p=0.001) and 5000cs (OR37.2,CI 1.3-1,101.5, p=0.036) (Reference-tamponade:SF6) were associated with unexplained visual loss. Duration of oil tamponade was not linked to increase in unexplained visual loss (p=0.569). CONCLUSIONS: Correlation between SO in detachment repairs and unexplained visual loss has been established, however incidence with HSO has not been compared to other agents. This study demonstrates that although SO was linked with risk-adjusted increased unexplained visual loss relative to gas tamponade, no such association was found for Densiron, on multivariable analysis.

"Comparing outcomes of advanced nurse practitioners to ophthalmologists performing posterior YAG capsulotomy, a six-year study of 6308 eyes".

PURPOSE: To primarily report the baseline characteristics and visual acuity (VA) outcomes of advanced nurse practitioners (ANP) compared to ophthalmologists following YAG posterior capsulotomy (YAGPC). We secondarily looked to characterise the risk factors that lead to a repeated YAGPC. METHOD: Retrospective consecutive case series of 6,308 eyes attending the Birmingham and Midlands Eye Centre. RESULTS: ANPs performed 33.1% of YAGPC compared to 66.9% ophthalmologists. Compared to ophthalmologists, ANPs performed YAGPC in lower proportion of patients with ocular co-morbidities (p < 0.001) and had lower proportion of patients requiring further YAGPC compared to ophthalmologists (p < 0.001). Median pre, post-operative and LogMAR gain in VA of 0.48 (IQR 0.30-0.78), 0.18 (IQR 0.10-0.40) and 0.30 (0.08-0.48) LogMAR units, respectively. Multivariate regression showed that ANPs had a significantly lower rate of repeat YAGPC compared to ophthalmologists even when adjusting for age, ethnicity, training grade and ocular co-morbidities. No difference in visual outcomes was found between operator grade and ethnicity on multivariate analysis. CONCLUSION: YAGPC leads to excellent visual outcomes. ANPs can deliver safe and effective YAGPC.

Comparing the outcomes of YAG laser anterior capsulotomies performed by an advanced nurse practitioner to ophthalmologists in the management of anterior capsular contraction syndrome.

BACKGROUND: Anterior capsular contraction syndrome (ACCS) describes the progressive fibrotic phimosis of the anterior capsular bag that usually occurs a few months after cataract surgery. YAG laser anterior capsulotomy (YAGAC) is the most common treatment option due to the low-risk profile of this intervention. PURPOSE: In this series, we evaluated the outcomes of an advanced nurse practitioner (ANP) in conducting this laser intervention, comparing the results with those of ophthalmologists. METHODOLOGY: Our study represents a single-centre, retrospective, continuous case series of 108 eyes that underwent YAGAC due to ACCS between January 2017 and July 2020 at the Birmingham and Midland Eye Centre, the second largest tertiary referral centre in the United Kingdom. RESULTS: The groups treated by ANPs and ophthalmologists were similar in respect to age, gender, and laterality of the laser procedure. Eyes treated by ophthalmologists had significantly more ocular comorbidities (p < .001), the most common of which was glaucoma. Although the complication rate was higher in the ophthalmologist group, it did not reach statistical significance. However, there was a trend toward significance in the retreatment rate, with 8.6% (7/81) of eyes lasered by ophthalmologists requiring further YAGAC, and no repeat procedure was needed in the ANP group. CONCLUSIONS: YAGAC leads to good visual outcomes and a low complication rate in both ophthalmologist and ANP groups. IMPLICATIONS: Advanced nurse practitioners can deliver results that are comparable with those of experienced ophthalmologists.

The Effect of Supervision and Out-of-Hours Surgery on the Outcomes of Primary Macula-On Retinal Detachments Operated by Vitreoretinal Fellows: A Review of 435 Surgeries.

PURPOSE: During bank holidays and weekends (BHWE), many primary macula-on retinal detachments (RD) across the United Kingdom are performed unsupervised out-of-hours by experienced vitreoretinal (VR) fellows. We aimed to determine whether first-year (F1) and second-year (F2) fellows could safely operate out-of-hours independently with remote supervision on primary macula-on RDs. METHODS: This is a retrospective consecutive series of 435 patients attending the Birmingham and Midlands Eye Centre from January 2017 to July 2020. We evaluated (i) 6-month re-detachment rate and (ii) visual outcomes of F1, F2, and consultants during office hours and BHWE as well as the effects of supervision versus non-supervision. RESULTS: For the re-detachment rate, no difference was found between surgeon grade (p = 0.821), whether supervised (p = 1.000), whether BHWE (p = 1.000), unsupervised BHWE and supervised mid-week (p = 0.757), and unsupervised F1 and F2 (p = 1.000), with non-significance maintained on multivariate regression. No difference was detected in the level of supervision (15.7%) between fellow grades during BHWE (p = 0.761) or mid-week (p = 0.295) or between surgeon grade and logMAR letters gained pre-postoperatively (p = 0.834). CONCLUSION: Safe VR services can be provided by experienced VR fellows during office hours, BHWE, supervised, or unsupervised, with similar primary success and visual outcomes to consultants in this patient subgroup. Initial intensive supervision and feedback and a gradual increase in independence is fundamental for VR fellows to gain confidence and become safe independent surgeons.

Optic Disc Pit Maculopathy - Case Series, Clinical Approach, and Management.

PURPOSE: The purpose of this study was to analyze the diagnostic and therapeutic approach of five cases with optic disc pit (ODP) maculopathy. MATERIALS AND METHODS: This was a retrospective study of five patients diagnosed with ODP maculopathy. Four of these cases had unilateral involvement, whereas one case had bilateral findings. The medical notes of these individuals were reviewed in order to record the presenting symptoms, clinical signs, visual acuity (VA), imaging, management, and the final visual outcome on their last follow-up appointment. RESULTS: The first patient (53-year-old female) underwent a left pars plana vitrectomy (PPV) combined with inner retinal fenestration, endolaser, and perfluoropropane (C3F8) gas tamponade and her VA improved from 6/24 to 6/9 Snellen. A focal retinal laser treatment was carried out on our second patient leading to decrease of the subretinal fluid but had a poor visual outcome due to the underlying secondary glaucoma from iris melanoma treatment in the past. The third patient was an asymptomatic 7-year-old girl in which the maculopathy resolved spontaneously without any surgical intervention with a final VA of 6/5. The fourth and fifth patients were asymptomatic with good vision in both eyes and were, therefore, only monitored with follow-ups. CONCLUSION: ODP maculopathy remains a challenging clinical entity for a vitreoretinal surgeon. The current management for ODP maculopathy involves surgical procedures with PPV being a common treatment of choice. Spontaneous resolution of ODP maculopathy has also been reported. Our study highlights the contrasting management that can be adopted in the treatment of ODP maculopathy, and there is not one definite treatment for this condition.

The role of tele-ophthalmology in diabetic retinopathy screening.

Diabetic retinopathy (DR) is the leading cause of legal blindness in the United States. Considering the increasing incidence of DR, it is extremely important to detect the most cost-effective tools for DR screening, so as to manage this surge in demand and the socioeconomic burden it places on the health care system. Despite the advances in retinal imaging, analysis techniques are still superseded by expert ophthalmologist interpretation. Teleophthalmology presents an immense opportunity, with high rates of sensitivity and specificity, to manage the steadily increasing demand for eye care of patients with diabetes, but challenges remain in the delivery of practical, viable, and clinically proven solutions.

Posterior Scleritis as a Paraneoplastic Syndrome in Colon Cancer: A Case Report

This study presents a rare case of unilateral posterior scleritis as an ophthalmic manifestation of a paraneoplastic syndrome. A 61-year-old man presented to our department complaining of gradual worsening of vision in his left eye. Visual acuity was 10/10 and 3/10 in his right and left eye, respectively. He also mentioned that he experienced posterior ocular pain while sleeping at night, but was otherwise asymptomatic. His past ophthalmic and medical history were clear. A thorough clinical, imaging (fundus photography, optical coherence tomography, fluorescein angiography, and B-scan), and laboratory investigation was carried out. A diagnosis of posterior scleritis was made, but no obvious cause or underlying disease was identified even after a thorough systematic assessment. Regular follow-up within the next few months did not reveal any further pathological findings. Finally, 6 months after the initial presentation, the patient was diagnosed with colon cancer. Posterior scleritis can present as an ophthalmic manifestation of a paraneoplastic syndrome in patients with an underlying malignancy, even months before the presentation of systemic symptoms and diagnosis of the underlying disease. In conclusion, in patients (especially older adults) with posterior scleritis, the possibility of a malignant neoplasia must not be ignored or underestimated (paraneoplastic syndrome).

The Management of Uveitic Glaucoma in Children

Children comprise a unique population of patients in regard to the diagnostic and therapeutic approach of uveitic glaucoma. The management of glaucoma secondary to uveitis in children is extremely challenging and presents various difficulties, which are associated both with the underlying uveitis and the young age of the patients. The treatment of uveitic glaucoma calls for a thorough and individualized approach, involving both pharmacotherapeutic and surgical modalities. It appears that the efficient control of inflammatory activity plays a significant role in the final visual outcome of these patients. This study aims to review the current literature about the management of uveitic glaucoma in pediatric patients.

Primary vitreoretinal lymphoma.

Primary vitreoretinal lymphoma (PVRL) is a rare ocular lymphoid malignancy, which consists a subset of primary central system lymphoma (PCNSL) and the most common type of intraocular lymphoma. The involvement of eyes is estimated to be approximately 20% of PCNSL, but the brain involvement may be up to 80% of PVRL. Typically, PVRL is a high grade B-cell malignancy of the retina and needs to be assorted from choroidal low-grade B-cell lymphomas. Very often PVRL masquerades and can be erroneously diagnosed as chronic uveitis, white dot syndromes or other neoplasms. Establishing an accurate diagnosis may involve cytology/pathology, immunohistochemistry, flow cytometry, molecular pathology and cytokine profile analysis. There is inadequate information about PVRL's true incidence, ethnic/geographical variation and pathogenetic mechanisms. The therapeutic approach of PVRL involves aggressive chemotherapy and radiation therapy. Although PVRL tends to have a good response to the initial treatment, the prognosis is poor and the survival restricted due to the high relapse rates and CNS involvement.

Bartonella henselae- and quintana-associated uveitis: a case series and approach of a potentially severe disease with a broad spectrum of ocular manifestations.

PURPOSE: To evaluate the clinical manifestations of intraocular inflammation associated with Bartonella infection and describe the assessment and management of patients with cat-scratch disease (CSD). METHODS: This is a retrospective review of the clinical records of patients diagnosed with Bartonella henselae and Bartonella quintana intraocular inflammation from 2011 to 2018 in the Department of Ocular Inflammations and Infections of the University Eye Clinic of Ioannina (Greece). An analysis of the current literature concerning Bartonella-related intraocular infections was also carried out. RESULTS: This is a retrospective study of 13 patients (7 males and 6 females) with a mean age of 39.2 years that were diagnosed with unilateral intraocular inflammation, except one case with bilateral affection, attributed to Bartonella (either henselae or quintana). Twelve (12) patients (92.3%) had a positive history of traumatic cat contact. The main ocular clinical findings with regard to the type of uveitis included neuroretinitis in 5 eyes (38.5%), vasculitis in 3 eyes (23.1%), iridocyclitis in 2 eyes (15.4%), intermediate uveitis in 2 eyes (15.4%), posterior uveitis in 1 eye (7.7%), panuveitis in 2 eyes (15.4%), retinochoroiditis in 2 eyes (15.4%), vitritis in 1 eye (7.7%), peripheral choroidal granuloma in 1 eye (7.7%). Immunoglobulin (Ig) G was positive in all cases. All patients were treated with antibiotics (mainly rifampicin, doxycycline and azithromycin). The visual acuity was noted to be improved in all patients after treatment, but some of them experienced disturbing complications. CONCLUSION: CSD may manifest with various ocular pathological findings. Taking into consideration the increasing frequency of infections by B. henselae and B. quintana, clinicians should always incorporate CSD in the differential diagnosis of such presentations of uveitis. Educating vulnerable groups (children, immunosuppressed, etc.) and also general population, the appropriate preventing measures can contribute in limiting the risk of infection.

Management of retinal detachment in retinoblastoma with globe conserving treatment.

PURPOSE: To investigate the features and outcomes of retinoblastoma (Rb) patients complicated by development of retinal detachment (RD) following systemic chemotherapy with or without local focal consolidation treatment and without external beam radiotherapy (EBRT). METHODS: A retrospective study of all Rb patients between April 2002 and April 2012 at a tertiary hospital center (Birmingham Children's Hospital and Birmingham Midlands Eye Centre, United Kingdom). All eyes that had developed RD during or after systemic treatment with or without local focal consolidation treatment were included in the study. The time interval between the type of treatment of Rb, development of RD and relevant surgical intervention were analyzed. Patients with exudative RD were treated conservatively through observation and patients with rhegmatogenous RD were treated with scleral buckling. Final anatomical retinal reattachment rate and visual acuity outcomes were analyzed. RESULTS: A total of 258 patients were treated for Rb over the 10-year period. One hundred sixty-nine patients were managed with globe conserving treatment. Ten (5.92%) eyes of 10 patients were complicated with RD. Five eyes were exudative or presumed exudative type of RD while the other five eyes were rhegmatogenous or presumed rhegmatogenous RD. In the exudative group, two patients achieved visual acuity (VA) of 0.2 Single Kays (20/32 Snellen), and the other two patients achieved 0.85 and 0.86 Crowded Kays (20/142 and 20/145 Snellen), respectively, after the RD had resolved. The last patient in the group had to be enucleated due to tumor recurrences. The median time for the exudative RD to resolve is 15 weeks (range, 4-36 weeks). In the rhegmatogenous group, 3 of the 4 operated patients achieved retinal reattachment. The final postoperative VA ranged between 0.05 Crowded Kays to 1.84 Crowded Kays (20/22 to 20/1384 Snellen). The other patient was treated conservatively as no retinal breaks were found with previous cryotherapy and thermotherapy. The final VA in this patient was hand movement, and the RD did not reattach. The median time for the rhegmatogenous RD to reattach is 6 weeks (range, 4-8 weeks). There were no intra- and postoperative complications. CONCLUSIONS: With long-term conservative management through observation, exudative Rb after systemic treatment of Rb will tend to resolve by itself. However, supplementary local treatment with cryoretinopexy or laser photocoagulation during the systemic treatment of Rb can lead to an increased risk of rhegmatogenous RD. In these cases, most rhegmatogenous RD are successfully repaired with non-drainage scleral buckling and cryoretinopexy.

The Role of Histone Deacetylase Inhibitors in Uveal Melanoma: Current Evidence.

Uveal melanoma is the most common intraocular malignancy in adults, representing approximately 3% of all melanoma cases. Despite progress in chemotherapy, radiation and surgical treatment options, the prognosis and survival rates remain poor. Acetylation of histone proteins causes transcription of genes involved in cell growth, DNA replication and progression of cell cycle. Overexpression of histone deacetylases occurs in a wide spectrum of malignancies. Histone deacetylase inhibitors block the action of histone deacetylases, leading to inhibition of tumor cell proliferation. This article reviewed the potential therapeutic effects of histone deacetylase inhibitors on uveal melanoma. MEDLINE database was used under the key words/phrases: histone deacetylase, inhibitors, uveal melanoma and targeted therapies for uveal melanoma. A total of 47, English articles, not only referring to uveal melanoma, published up to February 2018 were used. Valproic acid, trichostatin A, tenovin-6, depsipeptide, panobinostat (LBH-589), vorinostat (suberanilohydroxamic acid) entinostat (MS-275), quisinostat, NaB, JSL-1, MC1568 and MC1575 are histone deacetylase inhibitors that have demonstrated promising antitumor effects against uveal melanoma. Histone deacetylase inhibitors represent a promising therapeutic approach for the treatment of uveal melanoma.

Ocular adnexal marginal zone lymphoma of mucosa-associated lymphoid tissue.

Ocular adnexal lymphomas are a group of heterogeneous neoplasms representing approximately 1-2% of non-Hodgkin lymphomas and 8% of extranodal lymphomas. The incidence of primary ocular adnexal lymphoid tumors has raised over the last decades, and this could be probably attributed to the more sophisticated diagnostic techniques. Due to the wide spectrum of clinical manifestations, ocular tissue biopsy is important in order to set a precise diagnosis based on histological, immunophenotypical and, in some cases, molecular findings. The most common subtype, which may account for up to 80% of primary ocular adnexal lymphomas, is extranodal marginal zone lymphoma (EMZL) of mucosa-associated lymphoid tissue. This lymphoma is usually asymptomatic in the early phase of the disease causing a delay in the final diagnosis and prompt therapy. The pathogenesis of a proportion of these tumors has been linked to chronic inflammatory stimulation from specific infectious factors (e.g., Chlamydia psittaci) or to autoimmunity. The further improvement in diagnostic methods and the further understanding of the pathogenesis of ocular adnexal EMZL may contribute to the establishment of a more successful multidisciplinary therapeutic planning.

A Combination of Surgical Techniques to Repair a Giant Traumatic Macular Hole.

A 38-year-old man with a traumatic full-thickness macular hole (FTMH) presented to our eye casualty department with a sudden deterioration of his right eye vision to hand movements over the past one week. The suspected traumatic FTMH was present since he was 13 years old from a direct impact of a golf ball in his right eye and his best-corrected visual acuity (BCVA) has always remained at 1/60 Snellen vision. On examination, he had a very large FTMH measuring 1635 µm with central foveal retinal detachment. Pars plana vitrectomy combined with large inverted internal limiting membrane (ILM) peel flap, 5000 Cs silicone oil tamponade, and autologous platelets implantation was performed. Follow-up visits revealed that the FTMH was closed under silicone oil. The silicone oil was removed six months after the surgery and the FTMH remained close with the retina remaining attached. His BCVA was restored to his previous baseline level of 1/60 Snellen vision. With the advent of multiple techniques to repair FTMH such as the ILM flaps, we have combined this technique with older proven techniques such as silicone oil tamponade and autologous platelets implantation to close the giant traumatic FTMH. This case study demonstrates that combining techniques can help close a FMTH that is otherwise deemed impossible in the past.

New Therapeutic Perceptions in a Patient with Complicated Herpes Simplex Virus 1 Keratitis: A Case Report and Review of the Literature.

BACKGROUND Keratitis caused by herpes simplex virus (HSV) can have detrimental effects on the cornea leading to loss of vision. Modern therapies can contribute to the prevention of anatomical and functional damage. CASE REPORT An 80-year-old male with complicated HSV-1 keratitis of the left eye (confirmed diagnosis after microbiological investigation) presented three months after antiviral treatment with corneal blurring, severe epitheliopathy, thinning of the stroma, and neovascularization. At the time he was referred, the visual acuity of his left eye was very low, as he could only count fingers at a one-foot distance. He was initially started on oral acyclovir (800 mg once daily) and topical poly-carboxymethyl glucose sulfate; afterwards he underwent amniotic membrane (AM) transplantation and localized treatment with anti-VEGF factors. One month after the AM transplantation there was an obvious improvement of the corneal surface. Ophthalmic suspension of cyclosporine-A 1% was also added to his treatment. After three months, a transplantation of stem cells (deriving from the sclerocorneal junction of his right eye) was carried out at the sclerocorneal junction, as the corneal damage and neovascularization was more severe at this anatomical area. Four months after the last surgery, his visual acuity was 1/10 (note, he had a history of an old vascular episode) and the cornea was sufficiently clear with no signs of epitheliopathy and almost complete subsidence of the neovascularization. CONCLUSIONS Transplantation of AM and stem cells in combination with anti-VEGF factors and topical administration of cyclosporine-A 1% and poly-carboxymethyl glucose sulfate (a regenerative factor of corneal matrix) contributed substantially in the management of herpetic keratitis complications.