The effect of ethnicity on anatomic success following macular hole surgery: a multicentre cohort study.

PURPOSE: The purpose is to assess the effect of ethnicity on surgical macular hole closure. METHODS: A retrospective cohort study was undertaken in five UK National Health Service Hospitals. We included all patients with known ethnicity undergoing vitrectomy, internal limiting membrane peel, and gas/oil tamponade for all stages of primary full-thickness macular hole (FTMH). The primary outcome was anatomic success, defined as FTMH closure with one operation. The secondary outcome was mean change in best-corrected visual acuity (BCVA) comparing baseline with final review. RESULTS: Of 334 operations, the ethnicity profile comprised 78.7% White patients, 11.7% Black patients, 8.1% Asian patients, and 1.5% in mixed/other ethnicities. Mean age was 69.7 years with 68.5% females. Overall, 280 (83.8%) had anatomic success. Anatomic failure occurred in 38.5% of Black patients versus 12.6% of White patients (relative risk: 1.788; 95% CI: 1.012 to 3.159; P = 0.045). Overall, baseline logarithm of the minimum angle of resolution BCVA improved by 0.34, from 0.95 (95% CI: 0.894 to 1.008) to 0.62 (95% CI: 0.556 to 0.676). Mean BCVA improved by 0.35 in White patients, 0.37 in Black patients, 0.23 in Asian patients, and 0.38 in mixed/other ethnicity (P = 0.689). Greater FTMH minimum linear diameter was associated with an increased risk of anatomic failure (relative risk: 1.004; 95% CI: 1.002 to 1.005; P < 0.0001), whereas better pre-operative BCVA (F [1,19] = 162.90; P < 0.0001) and anatomic success (F [1,19] = 97.69; P < 0.0001) were associated with greater BCVA improvement. Socio-economic status did not significantly influence anatomic success or BCVA change. CONCLUSIONS: Black ethnicity is associated with an approximately twofold greater risk of failed FTMH surgery. The reasons for this difference warrant further study.

New application of membrane blue-dual dye for retinal or iatrogenic break staining in retinal detachment surgery.

INTRODUCTION: The principles of surgery for managing primary rhegmatogenous retinal detachment (RRD) are to precisely identify and correctly treat all causative retinal breaks. Estimates regarding unidentified breaks complicating RRDs vary from 2.2%-22.5%. PURPOSE: To evaluate the efficacy of membrane blue-dual heavy dye solution for staining of undetected preoperatively retinal and iatrogenic breaks. SUBJECTS, MATERIAL AND METHODS: 1. This is a prospective interventional study. 23 and 27-gauge vitrectomy surgeries were evaluated for primary repair of 5 patients with rhegmatogenous retinal detachment (RRD). No breaks where identified prior to surgery despite meticulous pre-operative examination using binocular indirect ophthalmoscopy with indentation. 0.1ml of MembraneBlue-Dual™ was applied onto the vitreous cavity, while it was completely filled with fluid, and all excess dye was immediately aspirated with a blunt backflush instrument. In all eyes with RRD, the surgery was completed by gas tamponade (C3F8 or SF6). Follow up was 6 months. RESULTS: We compared the number of breaks identified when examined intraoperative with internal peripheral indentation before and after injection of the dye and found that in all cases (100%) at least one more break was found after injection of dye which was subsequently treated with cryotherapy or endolaser. At last follow up six months after surgery the success rate was 100% and none of our cases re-detached. CONCLUSIONS: The greatest advantage of use of this "heavy" dye solution membrane blue-dual is improved intraoperative identification of ILM at the edges of retinal breaks and the discrimination of them from surrounding intraocular structures. Due to its increased molecular weight and viscosity properties it eliminates the need for fluid-air exchange, injection of PFCL or subretinal injection.

Association of serum lipid levels with retinal hard exudate area in African Americans with type 2 diabetes.

PURPOSE: Previous studies have yielded conflicting results regarding whether serum lipid levels are associated with retinal hard exudates in diabetic retinopathy. The majority of studies have assessed hard exudates only as a dichotomous trait (presence vs. absence) and included limited numbers of African Americans (AA). The purpose of this study was to determine if there are any associations between serum lipid levels and hard exudates in AA with type 2 diabetes (T2D). METHODS: 890 AA participants with T2D were enrolled from 5 sites. Macular fundus photographs were graded by masked ophthalmologist investigators. Hard exudate areas were measured using a semi-automated algorithm and ImageJ software. Multivariate regression models were used to determine the association between serum lipid levels and (1) presence of hard exudate and (2) area of hard exudate. RESULTS: Presence of hard exudates was associated with higher total cholesterol [(odds ratio (OR) = 1.08, 95 % confidence interval (CI) 1.03-1.13, P = 0.001)] and higher low-density lipoprotein (LDL) cholesterol (OR = 1.08, 95 % CI 1.03-1.14, P = 0.005) in models controlling for other risk factors. Hard exudate area was also associated with both higher total and LDL cholesterol levels (P = 0.04 and 0.01, respectively) in multivariate models controlling for other risk factors. CONCLUSIONS: Higher total and LDL cholesterol were associated with the presence of hard exudates and a greater hard exudate area in AA with T2D. This information can be used to counsel diabetic patients regarding the importance of lipid control to decrease the risk of macular hard exudates.

OPTICAL COHERENCE TOMOGRAPHY CHARACTERISTICS OF MACULAR EDEMA AND HARD EXUDATES AND THEIR ASSOCIATION WITH LIPID SERUM LEVELS IN TYPE 2 DIABETES.

PURPOSE: To determine whether hyperreflective foci (HF) and macular thickness on spectral domain ocular coherence tomography are associated with lipid levels in patients with Type 2 diabetes. METHODS: Two hundred and thirty-eight participants from four sites had fundus photographs and spectral domain ocular coherence tomography images graded for hard exudates and HF, respectively. Regression models were used to determine the association between serum lipid levels and 1) presence of HF and hard exudates and 2) central subfield macular thickness, central subfield macular volume, and total macular volume. RESULTS: All patients with hard exudates on fundus photographs had corresponding HF on spectral domain ocular coherence tomography, but 57% of patients with HF on optical coherence tomography did not have hard exudates detected in their fundus photographs. Presence of HF was associated with higher total cholesterol (odds ratio = 1.13, 95% confidence interval = 1.01-1.27, P = 0.03) and higher low-density lipoprotein levels (odds ratio = 1.17, 95% confidence interval = 1.02-1.35, P = 0.02) in models adjusting for other risk factors. The total macular volume was also associated with higher total cholesterol (P = 0.009) and triglyceride (P = 0.02) levels after adjusting for other risk factors. CONCLUSION: Higher total and low-density lipoprotein cholesterol were associated with presence of HF on spectral domain ocular coherence tomography. Total macular volume was associated with higher total cholesterol and triglyceride levels.

Ipilimumab-induced Ocular and Orbital Inflammation--A Case Series and Review of the Literature.

PURPOSE: Ipilimumab, a monoclonal antibody directed against the immune protein cytotoxic T-lymphocyte antigen-4 (CTLA-4), characteristically induces side effects called "immune-related adverse events" (IRAE). Although ophthalmic involvement is rare, we report 7 cases of eye and orbit complications related to ipilimumab therapy. METHODS: We performed a retrospective review of patients with metastatic melanoma who developed ipilimumab-related ocular or orbital inflammation who were seen at our institutions. RESULTS: Seven patients were identified: 4 patients had orbital inflammation, 2 had uveitis, and 1 had peripheral ulcerative keratitis. Four patients developed inflammation after the second ipilimumab infusion, 2 after the third infusion and 1 after the first infusion. All 4 patients with orbital inflammation were treated with systemic corticosteroids. Two patients with uveitis were treated with topical steroids, but were also treated with systemic corticosteroids for other IRAE, including colitis and hypophysitis. The patient with keratitis was treated with topical corticosteroids alone with resolution of inflammation. All 7 patients discontinued ipilimumab therapy, 5 due to systemic IRAE and 2 due to tumor progression. Five of 7 patients had tumor progression on ipilimumab therapy. CONCLUSIONS: Ocular and orbital inflammation may occur in patients with metastatic melanoma receiving ipilimumab, is frequently accompanied by other IRAEs, and resolves with corticosteroid treatment, often leaving no long-term sequelae.

SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN CONVALESCENT PHASE OF TREATED SARCOID CHOROIDAL GRANULOMAS.

PURPOSE: To report swept-source optical coherence tomography findings of sarcoid choroidal granulomas in the posttreatment convalescent stage of disease. PATIENTS/METHODS: The authors retrospectively reviewed charts from patients with sarcoid-related choroidal granulomas and recorded pertinent examination and imaging findings. Swept-source optical coherence tomography was performed using the DRI 3D-OCT-1 Atlantis (Topcon) over the areas of previous choroidal granulomas after the patients had been treated. RESULTS: Three patients with sarcoid choroidal granulomas were imaged with swept-source optical coherence tomography. Findings included loss or alteration of choroidal architecture, subretinal fibrosis, and outer retinal tubulations in the areas of the sarcoid granulomas after treatment. In one case with an associated choroidal neovascular membrane, there was also disruption of Bruch membrane and loss of normal choroidal vascular network in the area of the lesion. CONCLUSION: Swept-source optical coherence tomography demonstrated significant anatomical sequelae that persisted after treatment of sarcoid granulomas. To the best of the authors' knowledge, this is the first report of outer retinal tubulations over healed sarcoid granulomas.

Ocular ischemic syndrome presenting as retinal vasculitis in a patient with moyamoya syndrome.

PURPOSE: To report a case of ocular ischemic syndrome presenting as retinal vasculitis in a patient with Moyamoya syndrome. METHODS: A retrospective chart review was conducted to record clinical data including fluorescein angiography, optical coherence tomography, and serologic testing. A review of the literature from 1969 to 2014 of ocular involvement in Moyamoya syndrome was performed. RESULTS: A 51-year-old woman with long history of bilateral retinal vasculitis and refractory cystoid macular edema was eventually diagnosed with Moyamoya syndrome after sustaining a perioperative cerebrovascular accident. Moyamoya syndrome has been associated in the literature with ocular ischemic syndrome, presenting with narrowed retinal arteries, dilated veins, and midperipheral retinal hemorrhages, but retinal vasculitis with cystoid macular edema has not been reported. CONCLUSION: Moyamoya-related ocular ischemic syndrome can present as retinal vascular leakage and macular edema. Ophthalmologists should be cognizant that signs of the disease may be first observed in the eye before manifestations in the cerebrovascular system.

Phacoemulsification surgery in eyes with neovascular age-related macular degeneration.

Purpose. To evaluate the visual outcomes and effect of phacoemulsification surgery on the progression of neovascular age-related macular degeneration (AMD). Methods. Retrospective, noncomparative, and interventional case series. Thirty eyes from 29 subjects with neovascular AMD treated with intravitreal antivascular endothelial growth factor (VEGF) injections who underwent phacoemulsification and had a postsurgery follow-up of 6 months were included. LogMAR best corrected visual acuity (BCVA) was assessed preoperatively; 1 month, 3 months, and 6 months postoperatively; and finally at the last visit. The frequency of anti-VEGF therapy, calculated as the number of intravitreal injections per month, and central macular thickness (CMT) before and after cataract surgery were determined. Results. Median (range) logMAR BCVA was 0.69 (0.16 to 1.32) preoperatively; 0.55 (-0.04 to 1.32) at 1 month, 0.52 (-0.1 to 1.32) at 3 months, and 0.50 (0.0 to 1.32) at 6 months postoperatively; and 0.6 (0.0 to 1.4) at final visit (P = 0.0011). There was no difference in the frequency of anti-VEGF injections between the immediate 6 months before and after phacoemulsification, which was equal to 0.1667 injections per month (P = 0.6377). Median CMT measured 203 µ m preoperatively, which temporarily increased to 238 µ m at 1 month after surgery (P = 0.0093) and then spontaneously returned to baseline, measuring 212.5 µ m at 3 months postoperatively (P = 0.3811). Conclusion. Phacoemulsification surgery significantly improved vision in patients with neovascular AMD, with no increased need for anti-VEGF injections to keep the macula dry postoperatively.

Intravitreal tissue plasminogen activator, perfluoropropane (C3F8), and ranibizumab or photodynamic therapy for submacular hemorrhage secondary to wet age-related macular degeneration.

PURPOSE: To report a combined intravitreal treatment for submacular hemorrhage. METHODS: This retrospective, noncomparative, interventional case series included 7 patients with neovascular age-related macular degeneration and 2 with idiopathic polypoidal choroidal vasculopathy, presenting with fovea-involving submacular hemorrhage ≥ 4 disk areas in size, of <10 days of duration. All patients received a single 0.05-mL intravitreal injection of 50 µg alteplase, 0.3 mL of 100% C3F8, and facedown positioning for 1 week. Patients with newly diagnosed age-related macular degeneration received 3 consecutive monthly intravitreal injections of 0.5 mg ranibizumab, followed by monthly retreatment as needed. Those with idiopathic polypoidal choroidal vasculopathy were treated with photodynamic therapy. RESULTS: Mean (± SD) logarithm of the minimum angle of resolution visual acuity improved from 0.75 ± 0.35 at presentation to 0.35 ± 0.30 at a mean final follow-up of 15.1 months (P = 0.0078). Median Snellen acuity improved from 20/200 to 20/32. Visual acuity was stable in one case and improved in eight. The average size of submacular hemorrhage was 6.8 disk areas at presentation, reducing to 2.6 within 1 month (P = 0.0039). Subfoveal hemorrhage was displaced in all cases within 9 weeks. The mean pretreatment central retinal thickness of 669 µm reduced to 528 µm (P = 0.0039). One case developed transiently elevated intraocular pressure. Two developed breakthrough vitreous hemorrhage. No adverse events were attributed to tissue plasminogen activator. CONCLUSION: Tissue plasminogen activator and C3F8, combined with intravitreal ranibizumab or photodynamic therapy, may result in anatomical clearance of submacular hemorrhage and improved visual acuity, in a condition with an otherwise poor visual prognosis.