Intravitreous Cutaneous Metastatic Melanoma in the Era of Checkpoint Inhibition: Unmasking and Masquerading.

PURPOSE: Cutaneous melanoma metastatic to the vitreous is very rare. This study investigated the clinical findings, treatment, and outcome of patients with metastatic cutaneous melanoma to the vitreous. Most patients received checkpoint inhibition for the treatment of systemic disease, and the significance of this was explored. DESIGN: Multicenter, retrospective cohort study. PARTICIPANTS: Fourteen eyes of 11 patients with metastatic cutaneous melanoma to the vitreous. METHODS: Clinical records, including fundus photography and ultrasound results, were reviewed retrospectively, and relevant data were recorded for each patient eye. MAIN OUTCOME MEASURES: Clinical features at presentation, ophthalmic and systemic treatments, and outcomes. RESULTS: The median age at presentation of ophthalmic disease was 66 years (range, 23-88 years), and the median follow-up from diagnosis of ophthalmic disease was 23 months. Ten of 11 patients were treated with immune checkpoint inhibition at some point in the treatment course. The median time from starting immunotherapy to ocular symptoms was 17 months (range, 4.5-38 months). Half of eyes demonstrated amelanotic vitreous debris. Five eyes demonstrated elevated intraocular pressure, and 4 eyes demonstrated a retinal detachment. Six patients showed metastatic disease in the central nervous system. Ophthalmic treatment included external beam radiation (30-40 Gy) in 6 eyes, intravitreous melphalan (10-20 µg) in 4 eyes, enucleation of 1 eye, and local observation while receiving systemic treatment in 2 eyes. Three eyes received intravitreous bevacizumab for neovascularization. The final Snellen visual acuity ranged from 20/20 to no light perception. CONCLUSIONS: The differential diagnosis of vitreous debris in the context of metastatic cutaneous melanoma includes intravitreal metastasis, and this seems to be particularly apparent during this era of treatment with checkpoint inhibition. External beam radiation, intravitreous melphalan, and systemic checkpoint inhibition can be used in the treatment of ophthalmic disease. Neovascular glaucoma and retinal detachments may occur, and most eyes show poor visual potential. Approximately one quarter of patients demonstrated ocular disease that preceded central nervous system metastasis. Patients with visual symptoms or vitreous debris in the context of metastatic cutaneous melanoma would benefit from evaluation by an ophthalmic oncologist.

A Two Forceps Technique For Approaching Tractional Diabetic Membranes.

BACKGROUND AND OBJECTIVE: To describe a two-forceps bimanual approach for complex diabetic detachments. PATIENTS AND METHODS: Curved scissors were used to create a zone of decreased resistance within a thick fibrovascular membrane in a previously vitrectomized patient. Using two forceps, the linear defect was propagated into the periphery in a direction tangential to the retina. The tissue was repeatedly regrasped at the leading edge of the propagating tear, allowing for progressive separation of the hyaloid from the retinal surface. RESULTS: Separation of the diabetic membrane and hyaloid from the retinal surface in a previously vitrectomized patient. CONCLUSION: The authors describe a two-forceps approach for dense fibrovascular proliferation in the setting of persistently attached cortical vitreous that may be employed in cases of severe diabetic retinopathy with traction and fibrovascular membranes, even after previous vitrectomy. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e176-e178.].

LARGE RETINAL PIGMENT EPITHELIAL RIP ASSOCIATED WITH BULLOUS RETINAL AND CHOROIDAL DETACHMENT.

PURPOSE: To report a giant retinal pigment epithelium rip in a patient with a bullous retinal and choroidal detachment. METHODS: Case report with widefield imaging, fundus autofluorescence, and optical coherence tomography of the retina. RESULTS: This 62-year-old patient had a history of advanced glaucoma, trabeculectomy, blebitis, and endophthalmitis. He had cataract surgery 6 weeks before presentation. He was found to have a large bullous retinal and choroidal detachment with a large retinal pigment epithelium tear at the limit of the choroidal detachment. After vitrectomy for retinal detachment repair, the tear was observed to extend inferiorly at the margins of the choroidal detachment. CONCLUSION: This case report demonstrates that large retinal pigment epithelium rips can be found associated with large bullous choroidal and retinal detachments. These tears seem similar to tears that have been observed after trabeculectomy.

LARGE RETINAL PIGMENT EPITHELIAL RIP ASSOCIATED WITH BULLOUS RETINAL AND CHOROIDAL DETACHMENT.

PURPOSE: To report a giant retinal pigment epithelium rip in a patient with a bullous retinal and choroidal detachment. METHODS: Case report with widefield imaging, fundus autofluorescence, and optical coherence tomography of the retina. RESULTS: This 62-year-old patient had a history of advanced glaucoma, trabeculectomy, blebitis, and endophthalmitis. He had cataract surgery 6 weeks before presentation. He was found to have a large bullous retinal and choroidal detachment with a large retinal pigment epithelium tear at the limit of the choroidal detachment. After vitrectomy for retinal detachment repair, the tear was observed to extend inferiorly at the margins of the choroidal detachment. CONCLUSION: This case report demonstrates that large retinal pigment epithelium rips can be found associated with large bullous choroidal and retinal detachments. These tears seem similar to tears that have been observed after trabeculectomy.

Adherence to European Society for Cataract and Refractive Surgery recommendations among Italian cataract surgeons: a survey.

PURPOSE: To survey the surgical routines with regards to prophylactic strategies in a sample of Italian hospitals and compare these with European Society for Cataract and Refractive Surgery (ESCRS) guidelines. METHODS: Six private and 18 public hospitals were included in this clinical-based retrospective study. The overall volume of cataract operations in the 24 centers in 2013 was 43,553. Main outcome measure was incidence of endophthalmitis per 1,000. An incidence of less than 0.13% was considered acceptable. RESULTS: Our study provides the first Italian data on the use of intracameral antibiotics in cataract surgery as recommended by the ESCRS. Thirteen centers (54%) used intracameral cefuroxime at the end of surgery. Of the 13 centers that used cefuroxime, 8 (62%) had an incidence of endophthalmitis less than 0.13%. Of the 7 (29%) centers that did not use intracameral cefuroxime, all had an endophthalmitis rate of greater than 0.13%. This difference was statistically significant (p<0.05). Among the 4 centers not included, 2 used vancomycin in the infusion bottle, 1 a fluoroquinolone, and the last a combination of antibiotics. The majority of surgeons (71%) used preoperative antibiotic eyedrops, but this measure was not shown to be significantly protective. CONCLUSIONS: Slightly more than half of the centers surveyed in this study adhered to the recommendations of the ESCRS and routinely employed prophylactic intracameral cefuroxime. An incidence of endophthalmitis greater than 0.13% was encountered significantly more frequently among centers that did not employ intracameral cefuroxime.

OCULAR INVOLVEMENT IN HEMOPHAGOCYTIC SYNDROME: A NOVEL FUNDUSCOPIC MANIFESTATION AND REVIEW OF THE LITERATURE.

PURPOSE: Hemophagocytic syndrome (HS) is a rare disease with a spectrum of ocular findings. The authors report a unique funduscopic presentation of HS in a neonate and a discussion of diagnosis, typical features, management, and outcome. METHODS: Single case report with retrospective analysis of the published literature of patients with HS and ocular findings from 1950 to present using the key terms hemophagocytic, lymphohistiocytosis, ocular, and ophthalmic. Literature search from 1950 to the present was performed through PubMed/MEDLINE and the Cochrane database. Requirement for inclusion was that the article or abstract was written in English. RESULTS: A 4-week-old neonate with HS demonstrated bilateral discrete white dots within the retina, which resolved incompletely over the course of the next months but showed increased pigmentation. CONCLUSION: With so few documented ophthalmic cases of HS in existence, the ocular findings at this point can be seen as diverse and variable. However as more cases are reported, hopefully this will allow for increased recognition of the ophthalmic manifestations and sequelae and in turn lead to improved treatment of this disease.

Pars plana vitrectomy in patients with myopic macular retinoschisis.

BACKGROUND/AIMS: To report the outcomes of patients undergoing pars plana vitrectomy (PPV) for myopic macular retinoschisis. METHODS: Retrospective, non-randomised case series of patients who underwent PPV for myopic macular retinoschisis. Macular holes and foveal retinal detachments that occurred with myopic macular retinoschisis were also included in the series. Myopic macular retinoschisis was confirmed with optical coherence tomography. Visual acuity (VA) and central foveal thickness (CFT) were measured at baseline and 6 months following surgery. RESULTS: A total of 41 eyes were identified that met the inclusion criteria. The mean follow-up time was 192 days (range 132-272). The mean preoperative VA was 20/130, and the mean VA at 6 months was 20/70 (p=0.02). Following surgery, 14 (34.1%) eyes had VA of 20/40 or better. In 15 (36.6%) eyes, VA was 20/50-20/100 and in 12 (29.2%) eyes, VA was 20/200 or worse. CFT improved from a mean of 558 microns at baseline to 265 microns at 6 months (p<0.001). CONCLUSIONS: PPV generally resulted in stable or improved VA for eyes with myopic macular retinoschisis. Eyes with concurrent macular hole or foveal retinal detachment often had improved VA, but to a lesser extent than eyes with myopic macular retinoschisis alone.

Immunogammopathies and acquired vitelliform detachments: a report of four cases.

PURPOSE: To describe the nature and evolution of acquired macular detachments in patients with immunogammopathies and to propose a mechanism for their development. DESIGN: Retrospective observational case series. METHODS: Three patients with multiple myeloma and 1 with light chain deposition disease were diagnosed with vitelliform macular detachments based on clinical examination, fundus autofluorescence, fluorescein angiography, and optical coherence tomography. These patients were followed over time and their clinical examinations and imaging studies were compared and contrasted. RESULTS: Three patients (5 eyes) with multiple myeloma and 1 patient (2 eyes) with light chain deposition disease presented with acquired macular yellowish subretinal deposits on funduscopic examination that corresponded to hyperautofluorescent lesions on fundus autofluorescence imaging and subretinal hyperreflective material on spectral-domain optical coherence tomography. One patient (2 eyes) had diffuse serous retinal detachments involving not only the macular region but also the midperiphery of the retina. These acquired macular vitelliform detachments were not associated with signs of hyperviscosity retinopathy in 5 eyes and resolved after successful treatment of the multiple myeloma in 6 eyes. CONCLUSION: Patients with an immunogammopathy such as multiple myeloma or light chain deposition disease may develop serous elevations of the macula that we classify as acquired vitelliform detachments using multimodal imaging. Appropriate evaluation including serum protein electrophoresis and hematology consultation should be considered in the management of patients with acquired vitelliform detachments of uncertain etiology.

Polypoidal choroidal vasculopathy: simultaneous indocyanine green angiography and eye-tracked spectral domain optical coherence tomography findings.

PURPOSE: To describe simultaneous scanning laser ophthalmoscope indocyanine green angiographic and eye-tracked spectral-domain optical coherence tomography findings in eyes with polypoidal choroidal vasculopathy (PCV). METHODS: Eighteen eyes of 18 patients with PCV because of a variety of different diagnoses were imaged with simultaneous scanning laser ophthalmoscope indocyanine green angiography and eye-tracked spectral-domain optical coherence tomography to localize the polyps and their associated vascular structures with respect to the retinal layers. RESULTS: Regardless of the underlying diagnosis, simultaneous scanning laser ophthalmoscope indocyanine green angiography and eye-tracked spectral-domain optical coherence tomography imaging localized the polypoidal structures of PCV to within larger Type 1 neovascular complexes occurring within or above Bruch membrane. In 8 eyes, PCV appeared to adhere to the undersurface of an elevated retinal pigment epithelial detachment. In 1 eye, a PCV lesion was detected within the neurosensory retina having apparently eroded through the overlying retinal pigment epithelium. CONCLUSION: Simultaneous scanning laser ophthalmoscope indocyanine green angiography and eye-tracked spectral-domain optical coherence tomography demonstrate that a majority of PCV represents a variant of the Type 1 neovascular growth pattern, which can occur in a variety of different neovascularized maculopathies. Polypoidal choroidal vasculopathy lesions appear to originate from long-standing choroidal neovascularization, rather than from the choroidal vasculature itself. Given these observations, PCV would be more accurately described as a neovasculopathy rather than as a choroidal vasculopathy.

Polypoidal choroidal vasculopathy: a review.

More than a quarter century has passed since the original description of polypoidal choroidal vasculopathy (PCV) in 1982 as a peculiar hemorrhagic disorder involving the macula characterized by recurrent subretinal pigment epithelial bleeding. In the ensuing years, numerous reports have described the expanded clinical spectrum of this entity. PCV is the principal vascular composition of patients of pigmented races experiencing neovascular maculopathies, particularly African Americans and Asians. This form of neovascularization is now known to occur in white patients with or without concomitant drusen, and the site of involvement has extended from the peripapillary area to the peripheral fundus. Indocyanine green angiography has made detection of these abnormal vascular changes more reliable and definitive. More precise diagnosis has also led to a better understanding of specific clinical features that distinguish PCV from more typical proliferations of abnormal choroidal vessels. We review the nature of PCV, including its genetic basis, demographic features, histopathology, clinical manifestations, natural course, response to treatments, and the histopathological and genetic bases. We emphasize multimodal ophthalmic imaging of these vessels, in particular fluorescein and indocyanine green angiography and optical coherence tomography.

Long-term follow-up for type 1 (subretinal pigment epithelium) neovascularization using a modified "treat and extend" dosing regimen of intravitreal antivascular endothelial growth factor therapy.

PURPOSE: The purpose of the study was to analyze long-term outcomes for the treatment of type 1 (subretinal pigment epithelium) neovascularization using a modified "treat and extend" antivascular endothelial growth factor dosing regimen. METHODS: We performed a retrospective, noncomparative analysis of visual acuity, funduscopic, and optical coherence tomography data for 18 eyes of 16 consecutive patients with newly diagnosed type 1 neovascularization treated with intravitreal bevaci-zumab and/or ranibizumab with at least 24-month follow-up. Three monthly injections were followed by continued treatment at intervals increasing by 2 weeks per visit to a maximum of 10 weeks. The interval was shortened if clinical or optical coherence tomography evidence of recurrent fluid at the foveola or increased extrafoveolar fluid was detected. RESULTS: Median baseline logarithm of the minimum angle of resolution visual acuity was 0.53 (20/69 Snellen equivalent) and remained stable at 24 months (logarithm of the minimum angle of resolution 0.52, P = 0.84) after an average of 12 injections (range, 8-19 injections) and at 36 months (logarithm of the minimum angle of resolution 0.52, P = 0.68) after an average of 20 injections (range, 18-25 injections). Although most eyes (15 of 18 [83%]) continued to manifest extrafoveolar subretinal fluid throughout the course of treatment, only 1 eye developed geographic atrophy overlying the areas of choroidal neovascularization. During a cumulative observation period of 540 months, no eyes developed a sight-threatening submacular hemorrhage. CONCLUSION: A modified "treat and extend" dosing regimen of intravitreal antivascular endothelial growth factor therapy reduces the need for monthly visits and imaging and allows for stable long-term visual acuity in eyes with type 1 neovascularization.

Staphylococcus aureus endophthalmitis: antibiotic susceptibilities, methicillin resistance, and clinical outcomes.

PURPOSE: To investigate the antibiotic susceptibility and clinical outcomes of endophthalmitis caused by methicillin-sensitive Staphylococcus aureus (MSSA) versus methicillin-resistant (MRSA) S. aureus. DESIGN: Retrospective, consecutive case series. METHODS: Charts of 32 patients with culture-proven S. aureus endophthalmitis seen at the Bascom Palmer Eye Institute from January 1, 1995, through January 1, 2008, were reviewed. Antibiotic susceptibility profiles, identified using standard microbiologic protocols, and visual acuity at 1 and 3 months were the main outcome measures. RESULTS: MSSA was recovered from 19 (59%) of 32 patients and MRSA was recovered from 13 (41%) of 32 patients. Causes included cataract surgery in 18 (56%) of 32 patients, endogenous in 5 (16%) of 32 patients, bleb association in 4 (13%) of 32 patients, pars plana vitrectomy and ganciclovir implantation in 3 (9%) of 32 patients, and trauma in 2 (6%) of 32 patients. All isolates were sensitive to vancomycin. MSSA isolates were sensitive to all tested antibiotics, except one that exhibited fluoroquinolone resistance. In the MRSA group, frequent resistance occurred with the fourth-generation fluoroquinolones (moxifloxacin, 5 of 13 patients [38%]; gatifloxacin, 5 of 13 patients [38%]). The median presenting visual acuity was approximately hand movements for both MSSA and MRSA eyes. All eyes received intravitreal antibiotics. Pars plana vitrectomy was performed on 47% of MSSA and 61% of MRSA patients. A final visual acuity of 20/400 or better at 3 months was achieved in 59% of MSSA and 36% of MRSA patients (P = .5). CONCLUSIONS: Although all MSSA and MRSA isolates were sensitive to vancomycin, fewer than half of MRSA isolates were sensitive to the fourth-generation fluoroquinolones. Visual acuity outcomes between MRSA and MSSA eyes were not significantly different.

Evaluation of safety for bilateral same-day intravitreal injections of antivascular endothelial growth factor therapy.

PURPOSE: To explore the incidence of complications after bilateral same-day intravitreal injections of antivascular endothelial growth factor pharmacotherapies in this retrospective interventional case series. METHODS: An electronic review of billing records was performed to identify all bilateral same-day intravitreal antivascular endothelial growth factor injections performed within a single group retina practice between January 6, 2006 and June 1, 2009. The charts were reviewed to identify the complications of endophthalmitis, intraocular inflammation, retinal tear, and retinal detachment. RESULTS: A total of 1,534 bilateral intravitreal injections (326 bevacizumab and 1,208 ranibizumab: 3,068 injections total) were performed in 367 patients. Three complications were identified. Two cases of unilateral culture-proven endophthalmitis occurred after bilateral intravitreal ranibizumab, and one case of unilateral acute intraocular inflammation occurred after bilateral intravitreal bevacizumab. In all three of these eyes, visual acuity returned to its preinjection level. No cases of retinal tear or retinal detachment were identified. The incidence of culture-proven endophthalmitis was 0.065%, and the incidence of acute intraocular inflammation was 0.033%. CONCLUSION: The complication rates after bilateral same-day intravitreal antivascular endothelial growth factor injections seem to be similar to those after unilateral injections. Severe acute intraocular inflammation can occur unilaterally after same-day bilateral injections of bevacizumab.

"Treat and extend" dosing of intravitreal antivascular endothelial growth factor therapy for type 3 neovascularization/retinal angiomatous proliferation.

PURPOSE: The purpose of this study was to analyze long-term outcomes for the treatment of type 3 neovascularization/retinal angiomatous proliferation using a "Treat and Extend" dosing regimen for antivascular endothelial growth factor therapy. METHODS: This was a retrospective analysis of visual acuity and optical coherence tomography data of 11 eyes of 10 consecutive patients with newly diagnosed type 3 neovascularization/retinal angiomatous proliferation treated with intravitreal bevacizumab and/or ranibizumab with at least a 12-month follow-up. Three monthly injections were followed by continued treatment at intervals increasing by 2 weeks per visit, to a maximum of 10 weeks, unless clinical or optical coherence tomography evidence of persistent or recurrent fluid was present, in which case, the interval was shortened. RESULTS: Mean baseline Snellen visual acuity was 20/80, improved to 20/40 at 1 month, and was maintained throughout the 36-month period (n = 11 at 12 months, n = 10 at 24 months, and n = 8 at 36 months) (P < 0.04, paired t-test). The mean center point optical coherence tomography thickness decreased from 320 microm to 180-230 microm, and was maintained during the study period (P < 0.02). The mean number of injections was seven in the first year, six in the second year, and seven in the third year. CONCLUSION: "Treat and Extend" antivascular endothelial growth factor dosing in type 3 neovascularization/retinal angiomatous proliferation delivers promising outcomes at a reduced burden for the patient and health care system compared with monthly and optical coherence tomography-guided dosing regimens.

Retrospective review of the efficacy of topical bromfenac (0.09%) as an adjunctive therapy for patients with neovascular age-related macular degeneration.

PURPOSE: The purpose of this study was to assess the efficacy of topical bromfenac (0.09%) as an adjunctive therapy for patients with neovascular age-related macular degeneration demonstrating persistent exudation despite monthly intravitreal antivascular endothelial growth factor therapy. METHODS: Twenty-one patients (22 eyes) who manifested persistent subretinal and/or intraretinal fluid after at least 3 monthly intravitreal injections of ranibizumab or bevacizumab were prescribed topical bromfenac (0.09%) ophthalmic solution twice daily for 2 months. The efficacy of topical bromfenac was evaluated by comparing visual acuity (logarithm of the minimal angle of resolution and Snellen equivalent), masked readings of spectral domain optical coherence tomography center-point retinal thickness, and the height of pigment epithelial detachment (when present) at baseline and at 1 month and 2 months after the initiation of combined treatment. RESULTS: The mean visual acuity logarithm of the minimal angle of resolution (Snellen equivalent) at baseline was 0.55 +/- 0.35 (20/70), and it did not change significantly after 1 month (0.53 +/- 0.35; P = 0.41, paired Student's t-test) or 2 months (0.52 +/- 0.34; P = 0.26) after the initiation of combined treatment. The mean central retinal thickness was 311 microm at baseline, 308 microm (P = 0.73, paired Student's t-test) after 1 month, and 299 microm (P = 0.34) after 2 months. In 20 eyes of 19 patients manifesting a pigment epithelial detachment, the mean pigment epithelial detachment height was 275 microm at baseline, 271 microm (P = 0.33, paired Student's t-test) at 1 month, and 274 microm (P = 0.76) at 2 months. There were no adverse events associated with the extended administration of topical bromfenac. CONCLUSION: In patients with neovascular age-related macular degeneration manifesting persistent exudation despite monthly intravitreal antivascular endothelial growth factor therapy, we could not detect a beneficial effect of adding topical bromfenac (0.09%) twice daily over 2 months.

Prospective study of risk factors for conjunctival bacterial contamination in patients undergoing intraocular surgery.

PURPOSE: To determine whether a patient's age, gender, local or systemic risk factors affect the rate of preoperative bacterial contamination. METHODS: Consecutive 1,474 patients undergoing intraocular surgery were enrolled in this prospective masked study. Past medical history was noted and examinations were performed. The patients were divided into four groups: a control group (without local or systemic risk factors), those with local risk factors (chronic use of topical medications, contact lens wear, blepharitis, chronic eyelid or conjunctival inflammation), those with systemic risk factors (immunosuppression, diabetes, autoimmune conditions, and asthma), and those with both. Conjunctival cultures were obtained before surgery. RESULTS: Among the 1,474 patients, 914 bacteria were isolated from 214 (14.9%) patients. Advanced age was associated with a higher rate of positive conjunctival cultures (p<0.005). No statistical difference was found with regard to gender (p=0.7173). Among the 282 patients in the control group, 14 (5%) had a positive conjunctival culture. Compared to the control group, positive conjunctival cultures were found in 118 out of 503 patients (23.5%) with local risk factors (p<0.0001), 65 out of 545 patients (11.9%) with systemic risk factors (p=0.0019), and 22 out of 144 (15.3%) with both (p=0.0006). Two patients developed postoperative endophthalmitis (0.14%), one with both local risk and systemic factors and the other with a systemic risk factor. CONCLUSIONS: Patients with local or systemic risk factors or advanced age were found to have a higher rate of bacterial conjunctival contamination before intraocular surgery.