Displacement of Submacular Hemorrhage Using Subretinal Cocktail Injection versus Pneumatic Displacement: A Real-World Comparative Study.

INTRODUCTION: The objective of this study was to compare the outcome of submacular hemorrhage (SMH) displacement using pneumatic displacement with intravitreal expansile gas versus pars plana vitrectomy (PPV) with subretinal injection of tissue plasminogen activator (tPA), anti-vascular endothelial growth factor (VEGF) agent, and air as primary surgery. METHODS: Retrospective interventional case series of 63 patients who underwent surgical displacement of SMH secondary to neovascular age-related macular degeneration (nAMD) or polypoidal choroidal vasculopathy (PCV) from May 1, 2015, to October 31, 2022. Medical records were reviewed for diagnosis, logMAR visual acuity (VA), central subfield thickness (CST), and postoperative displacement rates and complications up to 12 months after operation. RESULTS: The diagnosis was nAMD in 24 (38.1%) and PCV in 39 (61.9%) eyes. There were 40 (63.5%) eyes in the pneumatic displacement group (38 received C3F8, 2 received SF6) and 23 (36.5%) eyes in the subretinal cocktail injection. Mean baseline VA was 1.46 and 1.62, respectively (p = 0.404). The subretinal injection group had more extensive SMH (p = 0.005), thicker CST (1,006.6 µm vs. 780.2 µm, p = 0.012), and longer interval between symptom and operation (10.65 vs. 5.53 days, p < 0.001). The mean postoperative VA at 6 months was 0.67 and 0.91 (p = 0.180) for pneumatic displacement and subretinal injection groups, respectively, though VA was significantly better in the pneumatic group at 12-month visit (0.64 vs. 1.03, p = 0.040). At least 10 mean change in VA were >10 letters gain in both groups up to 12 months. Postoperative CST reduction was greater (625.1 µm vs. 326.5 µm, p = 0.008) and complete foveal displacement (87.0% vs. 37.5%), p < 0.001, odds ratio [OR] = 11.1) and displacement to arcade or beyond (52.5% vs. 17.5%, p = 0.009, OR = 5.15) were more frequent in the subretinal injection group. Two patients with failed pneumatic displacement were successfully treated with subretinal cocktail injection as a second operation. CONCLUSION: Surgical displacement of SMH leads to clinically meaningful improvement in VA. PPV with subretinal cocktail injection is more effective than pneumatic displacement in displacing SMH with similar safety profile despite longer interval before operation, higher CST, and more extensive SMH at baseline. Retinal surgeons could consider this novel technique in cases with thick and extensive SMH or as a rescue secondary operation in selected cases.

A Multitask Deep-Learning System to Classify Diabetic Macular Edema for Different Optical Coherence Tomography Devices: A Multicenter Analysis.

OBJECTIVE: Diabetic macular edema (DME) is the primary cause of vision loss among individuals with diabetes mellitus (DM). We developed, validated, and tested a deep learning (DL) system for classifying DME using images from three common commercially available optical coherence tomography (OCT) devices. RESEARCH DESIGN AND METHODS: We trained and validated two versions of a multitask convolution neural network (CNN) to classify DME (center-involved DME [CI-DME], non-CI-DME, or absence of DME) using three-dimensional (3D) volume scans and 2D B-scans, respectively. For both 3D and 2D CNNs, we used the residual network (ResNet) as the backbone. For the 3D CNN, we used a 3D version of ResNet-34 with the last fully connected layer removed as the feature extraction module. A total of 73,746 OCT images were used for training and primary validation. External testing was performed using 26,981 images across seven independent data sets from Singapore, Hong Kong, the U.S., China, and Australia. RESULTS: In classifying the presence or absence of DME, the DL system achieved area under the receiver operating characteristic curves (AUROCs) of 0.937 (95% CI 0.920-0.954), 0.958 (0.930-0.977), and 0.965 (0.948-0.977) for the primary data set obtained from CIRRUS, SPECTRALIS, and Triton OCTs, respectively, in addition to AUROCs >0.906 for the external data sets. For further classification of the CI-DME and non-CI-DME subgroups, the AUROCs were 0.968 (0.940-0.995), 0.951 (0.898-0.982), and 0.975 (0.947-0.991) for the primary data set and >0.894 for the external data sets. CONCLUSIONS: We demonstrated excellent performance with a DL system for the automated classification of DME, highlighting its potential as a promising second-line screening tool for patients with DM, which may potentially create a more effective triaging mechanism to eye clinics.

OCT Angiography Metrics Predict Progression of Diabetic Retinopathy and Development of Diabetic Macular Edema: A Prospective Study.

PURPOSE: To prospectively determine the relationship of OCT angiography (OCTA) metrics to diabetic retinopathy (DR) progression and development of diabetic macular edema (DME). DESIGN: Prospective, observational study. PARTICIPANTS: A total of 205 eyes from 129 patients with diabetes mellitus followed up for at least 2 years. METHODS: All participants underwent OCTA with a swept-source OCT device (DRI-OCT Triton, Topcon, Inc, Tokyo, Japan). Individual OCTA images of superficial capillary plexus (SCP) and deep capillary plexus (DCP) were generated by IMAGEnet6 (Basic License 10). After a quality check, automated measurements of foveal avascular zone (FAZ) area, FAZ circularity, vessel density (VD), and fractal dimension (FD) of both SCP and DCP were then obtained. MAIN OUTCOME MEASURES: Progression of DR and development of DME. RESULTS: Over a median follow-up of 27.14 months (interquartile range, 24.16-30.41 months), 28 of the 205 eyes (13.66%) developed DR progression. Of the 194 eyes without DME at baseline, 17 (8.76%) developed DME. Larger FAZ area (hazard ratio [HR], 1.829 per SD increase; 95% confidence interval [CI], 1.332-2.512), lower VD (HR, 1.908 per SD decrease; 95% CI, 1.303-2.793), and lower FD (HR, 4.464 per SD decrease; 95% CI, 1.337-14.903) of DCP were significantly associated with DR progression after adjusting for established risk factors (DR severity, glycated hemoglobin, duration of diabetes, age, and mean arterial blood pressure at baseline). Lower VD of SCP (HR, 1.789 per SD decrease; 95% CI, 1.027-4.512) was associated with DME development. Compared with the model with established risk factors alone, the addition of OCTA metrics improved the predictive discrimination of DR progression (FAZ area of DCP, C-statistics 0.723 vs. 0.677, P < 0.001; VD of DCP, C-statistics 0.727 vs. 0.677, P = 0.001; FD of DCP, C-statistics 0.738 vs. 0.677, P < 0.001) and DME development (VD of SCP, C-statistics 0.904 vs. 0.875, P = 0.036). CONCLUSIONS: The FAZ area, VD, and FD of DCP predict DR progression, whereas VD of SCP predicts DME development. Our findings provide evidence to support that OCTA metrics improve the evaluation of risk of DR progression and DME development beyond traditional risk factors.

Non-mydriatic ultrawide field scanning laser ophthalmoscopy compared with dilated fundal examination for assessment of diabetic retinopathy and diabetic macular oedema in Chinese individuals with diabetes mellitus.

AIMS: To evaluate the performance of ultrawide field scanning laser ophthalmoscopy (UWF-SLO) for assessing diabetic retinopathy (DR) and diabetic macular oedema (DME) in a Chinese population, compared with clinical examination. METHODS: This is a retrospective cohort study. A series of 322 eyes from 164 patients with DM were included. Each patient underwent both dilated fundal examination with DR and DME grading by retina specialist and non-mydriatic 200° UWF-SLO (Daytona, Optos, Dunfermline, UK). The severity of DR and DME from UWF-SLO images was further graded by ophthalmologists, according to both international clinical DR and DME disease severity scales and the standard 7-field Early Treatment Diabetic Retinopathy Study (ETDRS) scale. Any DR, DME and vision-threatening DR (VTDR) were treated as endpoints for this study. RESULTS: 23 out of 322 images (7.14%), including all four cases with proliferative DR on clinical examinations, were determined as ungradable. When the international scale was used for grading UWF-SLO images, the sensitivity of any DR, DME and VTDR was 67.7%, 67.4% and 72.6%, respectively; the specificity of any DR, DME and VTDR was 97.8%, 97.3% and 97.8%, respectively. The agreement with clinical grading in picking up any DR, DME and VTDR was substantial, with κ-values of 0.634, 0.694 and 0.707, respectively. The performance of UWF-SLO was shown to be lower when ETDRS scale was used for grading the images. CONCLUSION: The performance of non-mydriatic UWF-SLO is comparable in identifying DR with that of clinical examination in a Chinese cohort. However, whether UWF-SLO can be considered as tool for screening DR is still undetermined.

Impact of virtual reality simulation on learning barriers of phacoemulsification perceived by residents.

OBJECTIVE: To identify residents' perceived barriers to learning phacoemulsification surgical procedures and to evaluate whether virtual reality simulation training changed these perceptions. DESIGN: The ophthalmology residents undertook a simulation phacoemulsification course and proficiency assessment on the Eyesi system using the previously validated training modules of intracapsular navigation, anti-tremor, capsulorrhexis, and cracking/chopping. A cross-sectional, multicenter survey on the perceived difficulties in performing phacoemulsification tasks on patients, based on the validated International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric (ICO-OSCAR), using a 5-point Likert scale (1 = least and 5 = most difficulty), was conducted among residents with or without prior simulation training. Mann-Whitney U tests were carried out to compare the mean scores, and multivariate regression analyses were performed to evaluate the association of lower scores with the following potential predictors: 1) higher level trainee, 2) can complete phacoemulsification most of the time (>90%) without supervisor's intervention, and 3) prior simulation training. SETTING: The study was conducted in ophthalmology residency training programs in five regional hospitals in Hong Kong. RESULTS: Of the 22 residents, 19 responded (86.3%), of which 13 (68.4%) had completed simulation training. Nucleus cracking/chopping was ranked highest in difficulty by all respondents followed by capsulorrhexis completion and nucleus rotation/manipulation. Respondents with prior simulation training had significantly lower difficulty scores on these three tasks (nucleus cracking/chopping 3.85 vs 4.75, P = 0.03; capsulorrhexis completion 3.31 vs 4.40, P = 0.02; and nucleus rotation/manipulation 3.00 vs 4.75, P = 0.01). In multivariate analyses, simulation training was significantly associated with lower difficulty scores on these three tasks. CONCLUSION: Residents who had completed Eyesi simulation training had higher confidence in performing the most difficult tasks perceived during phacoemulsification.

Intraocular lens explantation in Chinese patients: different patterns and different responses.

The aim of the study was to evaluate the indications and outcomes of intraocular lens (IOL) explantation in Chinese patients. The medical records of all Chinese patients who underwent IOL explantation in Hong Kong Eye Hospital, from January 2008 to March 2013, were reviewed. A total of 98 IOLs were explanted over the study period. The main reasons for lens removal included lens malposition (71.4%), isolated uveitis-glaucoma-hyphema (UGH) syndrome (9.1%), refractive surprise (6.1%), and pseudophakic bullous keratopathy (4.1%). "In-the-bag" IOL malposition was associated with intraocular complications during cataract extraction (28.9%) and high myopia (22.2%). Sulcus implantation of a single-piece acrylic (SPA) IOL resulted in UGH syndrome in all cases, while sulcus-fixated 3-piece lenses had such complication in only 7.1% of cases. Importantly, the problem persisted despite the removal of the SPA IOL from the ciliary sulcus. Majority of the patients had resolution of the original problems after lens removal or exchange and had the same or improved visual acuity after surgery. Lens malposition was the major indication of intraocular lens explantation in our case series. Resolution of symptoms and visual acuity can be achieved with IOL explantation. Implantation of SPA in ciliary sulcus is not recommended.

Hybrid treatment for ruptured diverticulum of kommerell: a minimally invasive option.

Although aberrant right subclavian artery is the commonest aortic arch anomaly, it is a rare entity in clinical practice. While mostly asymptomatic, the rupture of an aneurysm of an aberrant right subclavian artery or Kommerell's diverticulum can be life threatening. A conventional open surgical approach involving sternotomy and resection of the abnormal vessels under circulatory support carries significant morbidity and mortality. We report a case of a ruptured diverticulum of Kommerell that was successfully treated with a hybrid debranching surgery, Amplatzer device embolization of the subclavian vessels, and thoracic aortic endovascular stenting.