Correlation between metamorphopsia and disorganization of the retinal inner layers in eyes with diabetic macular edema.

PURPOSE: To investigate factors associated with the severity of metamorphopsia secondary to diabetic macular edema (ME) by evaluating optical coherence tomography (OCT) parameters including disorganization of the retinal inner layers (DRIL). METHODS: We retrospectively reviewed medical records of 37 eyes of 37 consecutive patients with diabetic ME or resolved diabetic ME, who underwent spectral-domain OCT examination and metamorphopsia assessment with M-CHARTS on the same day between November 2017 and March 2018. Age, sex, visual acuity, lens status, treatment history, and factors analyzed on OCT examination including DRIL length were evaluated in association with M-CHARTS scores. RESULTS: Metamorphopsia was detected in 20 eyes (54%). The patients with metamorphopsia were relatively older than those without it (P = 0.060), and DRIL length was relatively longer in eyes with metamorphopsia (P = 0.065), while visual acuity was significantly better in eyes without metamorphopsia (P = 0.048). In correlation analyses to the severity of metamorphopsia, the DRIL length was the only OCT parameter associated with the M-CHARTS score (P = 0.035), while age, visual acuity, and ME were not significantly associated with the severity of metamorphopsia (P = 0.051, 0.060, and 0.344, respectively). CONCLUSION: The DRIL length was significantly associated with the severity of metamorphopsia secondary to diabetic ME. The inner retinal layer plays a key role in the development of metamorphopsia in eyes with diabetic ME. Metamorphopsia should be carefully considered when treating diabetic ME since its severity has been found to be independent of visual acuity and ME status.

Disorganization of the Retinal Inner Layers after Anti-VEGF Treatment for Macular Edema due to Branch Retinal Vein Occlusion.

PURPOSE: To evaluate the association between disorganization of the retinal inner layers (DRIL) and visual acuity (VA) after anti-VEGF treatment for macular edema (ME) due to branch retinal vein occlusion (BRVO). METHODS: Sixty eyes of 60 patients were retrospectively investigated. Baseline characteristics and factors analyzed on optical coherence tomography (OCT) examination at the final visit were evaluated in association with VA at the final visit. RESULTS: DRIL was detected in 39 eyes at the final visit. The central subfield thickness was significantly higher in the eyes with DRIL. While DRIL length at the final visit showed a significant association with final VA on univariable analysis, only age and ellipsoid zone disruption on OCT at the final visit were found to be significantly associated with VA on multivariable analysis. CONCLUSIONS: DRIL had only a minor role in determining VA after anti-VEGF treatment for ME due to BRVO.

Floating flap of internal limiting membrane in myopic macular hole surgery.

PURPOSE: To evaluate the surgical results of macular hole (MH) in patients with high myopia treated with pars plana vitrectomy (PPV) leaving the internal limiting membrane (ILM) flap floating in vitreous fluid at the edge of the MH. METHODS: Nine highly myopic eyes with MH of nine consecutive patients who underwent PPV were retrospectively evaluated. Three eyes were accompanied by retinal detachment (RD). ILM peeling was performed around the MH and some part of the ILM flap was left attached to the edge of the MH. Further manipulation of the ILM flap to cover the MH was not performed. Fluid-gas exchange was performed to the retinal vessel arcade level. Patients maintained a face down position for 3 to 7 days postoperatively. RESULTS: Complete MH closure was confirmed using optical coherence tomography in all eyes and three eyes with RD showed reattachment of the retina after the initial surgery. Visual acuity significantly improved (P = 0.02) and no eyes experienced MH reopening or RD occurrence during the follow-up period of 8.33 ± 3.61 months after the surgery. CONCLUSIONS: MH with or without RD in highly myopic eyes could be successfully treated with PPV leaving ILM flap floating in vitreous fluid at the edge of the MH. After the ILM peeling, further manipulation of the ILM flap to cover the MH would not be necessary for the treatment of MH in high myopia.

A comparison of patient pain and visual outcome using topical anesthesia versus regional anesthesia during cataract surgery.

PURPOSE: The purpose of this study was to compare the level of patient pain during the phacoemulsification and implantation of foldable intraocular lenses while under topical, intracameral, or sub-Tenon lidocaine. PATIENTS AND METHODS: This was a retrospective study. Three hundred and one eyes subjected to cataract surgery were included in this study. All eyes underwent phacoemulsification surgery and intraocular lens implantation using topical, sub-Tenon, or intracameral anesthesia. The topical group received 4% lidocaine drops, and the intracameral group received a 0.1-0.2 cc infusion of 1% preservative-free lidocaine into the anterior chamber through the side port combined with topical drops of lidocaine. The sub-Tenon group received 2% lidocaine. Best-corrected visual acuity, corneal endothelial cell loss, and intraoperative pain level were evaluated. Pain level was assessed on a visual analog scale (range 0-2). RESULTS: There were no significant differences in visual outcome and corneal endothelial cell loss between the three groups. The mean pain score in the sub-Tenon group was significantly lower than that in the topical and intracameral groups (P=0.0009 and P=0.0055, respectively). In 250 eyes without high myopia (< -6D), there were no significant differences in mean pain score between the sub-Tenon and intracameral groups (P=0.1417). No additional anesthesia was required in all groups. CONCLUSION: Intracameral lidocaine provides sufficient pain suppressive effects in eyes without high myopia, while sub-Tenon anesthesia is better for cataract surgery in eyes with high myopia.

Efficacy of inverted internal limiting membrane flap technique for the treatment of macular hole in high myopia.

PURPOSE: To determine the effect of pars plana vitrectomy (PPV) with inverted internal limiting membrane (ILM) flap technique for macular hole with or without retinal detachment in highly myopic eyes. DESIGN: Retrospective, interventional case series. METHODS: Ten eyes of 10 patients with macular hole with (4 eyes) or without (6 eyes) retinal detachment in high myopia (axial length more than 26.5 mm) were treated by PPV with inverted ILM flap technique. RESULTS: Macular hole closure was observed in 8 eyes (80%) following the initial surgery (in 5 eyes without retinal detachment and in 3 eyes with retinal detachment). In 4 eyes with retinal detachment caused by macular hole, retinas of 3 eyes were reattached by the initial surgery. Postoperative best-corrected visual acuity improved by more than 2 lines in 5 eyes (50%), was unchanged in 4 eyes (40%), and worsened by more than 2 lines in 1 eye (10%). CONCLUSIONS: Inverted ILM flap technique might contribute to a high closure rate of macular hole and be a preferable adjuvant to the treatment of macular hole in high myopia with or without retinal detachment.

Features and surgical outcome of retinal nerve fiber layer alterations associated with epiretinal membrane.

PURPOSE: In this study, the authors aimed to investigate structural abnormalities in the retinal nerve fiber layer (RNFL) using spectral-domain optical coherence tomography (SD-OCT) and study the surgical outcomes in eyes with such alterations by comparing ultrastructure findings of the surgically excised epiretinal membrane (ERM) and inner limiting membrane (ILM) in patients with idiopathic ERM. METHODS AND PATIENTS: Vitreous surgery was performed on four eyes with idiopathic ERM, of which three had columnar alterations of the nerve fiber layer. The ERM and ILM were dissected and removed, and ultrathin sections were analyzed and imaged completely by using electron microscopy. All the patients underwent a comprehensive ophthalmologic examination, including SD-OCT, fundus-monitoring microperimetry, and red-free scanning laser ophthalmoscopic imaging. RESULTS: Preoperatively, SD-OCT revealed the presence of columnar structures only in the RNFL. Transmission electron microscopy showed that all samples contained retinal cell debris on the outer surface of the ILM. However, adhesion of retinal nerve fibers on the outer surface of the ILM was not observed in any specimen. The columnar alterations in the RNFL observed via SD-OCT resolved completely within 1 month in all eyes. At 6 months after surgery, no eyes showed scotoma on microperimetry. Further, no dissociated nerve fiber layer appearance was identified. CONCLUSION: Vitrectomy with ILM peeling can be safely performed for ERMs with RNFL alterations, detected preoperatively by SD-OCT, without any structural or functional disturbances. The columnar alterations of the RNFL on SD-OCT may be inner retinoschisis.

Post-cataract surgery visual disturbance in a retinitis pigmentosa patient with asteroid hyalosis.

A patient with retinitis pigmentosa showed visual disturbances following successful cataract surgery. He had a dense asteroid hyalosis in the eye before cataract surgery. After the surgery he noticed that his vision became worse. The visual disturbance was explained as being caused by the progression of retinal degeneration. Although the electroretinogram was non-recordable, the degeneration of macular area appeared relatively small. We considered that dense asteroid hyalosis was responsible for his visual disturbances, and pars plana vitrectomy (PPV) was performed to remove the asteroid hyalosis. After the PPV, rapid improvement of his visual acuity was observed. Cataract surgery may affect the status of asteroid hyalosis and cause rapid visual loss. PPV should be considered for retinitis pigmentosa patients with dense asteroid hyalosis, especially when a large decrease in visual acuity is noted shortly after cataract surgery.