INTERNAL DRAINAGE OF SUBRETINAL FLUID DURING CHANDELIER-ASSISTED SCLERAL BUCKLING.

PURPOSE: To describe the surgical technique of internal drainage of subretinal fluid as an adjunct to chandelier-assisted scleral buckling for the repair of rhegmatogenous retinal detachment. METHODS: The technique of internal drainage with a sharp needle or cannula through a trocar is described and shown in a Supplemental Digital Content 1 (see Video, http://links.lww.com/ICB/A87). RESULTS: Three patients (3 eyes) underwent scleral buckling for rhegmatogenous retinal detachment repair. Subretinal fluid was drained using the internal drainage approach in all cases. All three patients had successful reattachment of retina with improvement in visual function. No complications were reported related to vitreous loss, retinal incarceration, or redetachment following primary surgery. CONCLUSION: Internal drainage of subretinal fluid during chandelier-assisted scleral buckling is a useful technique that can be considered for repairing rhegmatogenous retinal detachment.

Comparative Outcomes of Primary Vitrectomy Versus Tap and Inject for Endophthalmitis Following Phacoemulsification Cataract Surgery.

PURPOSE: To compare functional and anatomical outcomes, rates of culture positivity and number of procedures in eyes with endophthalmitis following phacoemulsification surgery, treated with either primary vitrectomy and intravitreal antibiotics or vitreous tap and antibiotic injection (T&I). METHODS: Patients developing endophthalmitis after phacoemulsification surgery between 2007 and 2016 were identified, and outcomes were compared between the two treatment groups. RESULTS: 19 patients underwent a primary vitrectomy and 22 underwent a T&I. There was a significant improvement in visual acuity after T&I (p=.003) and primary vitrectomy (p=.00005). The median improvement in visual acuity was significantly greater for the primary vitrectomy group than the T&I group (p=.024). 64% of eyes were culture positive with the initial T&I, and 63% with primary vitrectomy (p=1.00). Two eyes initially culture negative with a T&I, and three eyes that were culture positive with a T&I were subsequently culture positive with a vitrectomy 24-72 hours later. 68% of patients who underwent a T&I required an additional procedure, compared to 26% of the vitrectomy group (p=.01). The T&I group underwent a mean of 2.3 procedures each, and the primary vitrectomy group underwent 1.5 (p=.03). CONCLUSIONS: Eyes with endophthalmitis treated with a primary vitrectomy demonstrated greater visual improvement and needed fewer procedures than those initially treated with a T&I. Viable bacteria were only seen in subsequent procedures in the T&I group, indicating that primary vitrectomy was superior at sterilizing the eye.

Better visual outcome associated with early vitrectomy in the management of endophthalmitis.

AIMS: To examine the role of early vitrectomy in the management of endophthalmitis from all causes. METHODS: Retrospective study of 290 consecutive subjects diagnosed with endophthalmitis at Auckland District Health Board between 1 January 2006 and 31 July 2019. Main outcome measure was visual acuity at 9-month follow-up and proportion of subjects with severe vision loss (≤20/200). RESULTS: Median age at presentation was 70.4 years and 151 subjects (52.1%) were women. Cataract surgery was the most common cause of endophthalmitis in 92 subjects (31.7%) followed by intravitreal injection in 57 (19.7%), endogenous endophthalmitis in 48 subjects (16.6%), non-surgical trauma in 42 subjects (14.5%), glaucoma surgery in 24 subjects (8.3%), vitrectomy in 22 subjects (7.6%) and corneal in 5 subjects (1.7%). Culture was positive in 136 (46.9%) with gram-positive organisms most common (76.5%). Early vitrectomy was performed in 82 subjects (28.3%). Median visual acuity at 9 months was 20/100 (IQR 20/30 to light perception), and severe vision loss occurred in 100 (43.5%). Retinal detachment occurred in 35 eyes (12.1%) and 26 eyes were enucleated. On multivariate analysis, younger age, poor presenting visual acuity and culture-positive endophthalmitis were associated with worse outcomes, and early vitrectomy was associated with better outcomes. CONCLUSIONS: Early vitrectomy (within 24 hours) is associated with better visual outcomes at 9 months, while younger age, poor presenting visual acuity and culture-positive endophthalmitis are associated with poorer visual acuity outcomes.

Heterozygous COL9A3 variants cause severe peripheral vitreoretinal degeneration and retinal detachment.

The COL9A3 gene encodes one of the three alpha chains of Type IX collagen, with heterozygous variants reported to cause multiple epiphyseal dysplasia, and suggested as contributory in some cases of sensorineural hearing loss. Patients with homozygous variants have midface hypoplasia, myopia, sensorineural hearing loss, epiphyseal changes and carry a diagnosis of Stickler syndrome. Variants in COL9A3 have not previously been reported to cause vitreoretinal degeneration and/or retinal detachments. This report describes two families with autosomal dominant inheritance and predominant features of peripheral vitreoretinal lattice degeneration and retinal detachment. Genomic sequencing revealed a heterozygous splice variant in COL9A3 [NG_016353.1(NM_001853.4):c.1107 + 1G>C, NC_000020.10(NM_001853.4):c.1107 + 1G>C, LRG1253t1] in Family 1, and a heterozygous missense variant [NG_016353.1(NM_001853.4):c.388G>A p.(Gly130Ser)] in Family 2, each segregating with disease. cDNA studies of the splice variant demonstrated an in-frame deletion in the COL2 domain, and the missense variant occurred in the COL3 domain, both indicating the critical role of Type IX collagen in the vitreous base of the eye.

Mortality after endophthalmitis following contemporary phacoemulsification cataract surgery.

IMPORTANCE: To determine if endophthalmitis following cataract surgery is linked to increased mortality. BACKGROUND: Increased mortality has been linked to patients with cataract and cataract surgery. We tested the hypothesis that post-cataract endophthalmitis has a greater risk of death than pseudophakes who do not develop this complication. DESIGN: Case-control study conducted in a tertiary public hospital. PARTICIPANTS: The study group comprised 50 consecutive patients with post-cataract endophthalmitis, and these were matched with selected controls. METHODS: Patients with endophthalmitis following cataract surgery were identified from a prospective electronic surgical database. Subsequently, it was determined if the patient was deceased at the time of sequestration (September 2015), and the date of death was recorded. A previously described population who had undergone cataract surgery in the same facility was selected as a control group, and the population was case-matched in terms age, gender, presence or absence of diabetes and/or hypertension. MAIN OUTCOME MEASURES: The median survival rates were determined for the control group and the patients with post-cataract endophthalmitis. RESULTS: Fifty patients were identified as undergoing endophthalmitis post-cataract surgery, and 48 (n = 48) met inclusion criteria (mean age 72 years ±12 SD with 30:18 F:M); 17% were diabetic, and 50% had systemic hypertension. No statistically significant difference in median survival between the study and control cases was identified (100 months (95% confidence interval 86-114) vs. 106 months (95% confidence interval 66-146), respectively, P = 0.756). CONCLUSIONS AND RELEVANCE: Post-cataract endophthalmitis was not associated with an increased rate of mortality in this study.

Comparative study of femtosecond laser-assisted cataract surgery and conventional phacoemulsification in vitrectomized eyes.

IMPORTANCE: To compare the safety and outcomes of femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification in post-vitrectomy eyes. BACKGROUND: To compare visual outcomes and adverse outcomes of FLACS and conventional phacoemulsification in vitrectomized eyes. DESIGN: Single surgeon, retrospective study set in a private clinic in Auckland, New Zealand. Patients selected in a chronological manner, without masking or randomization. PARTICIPANTS: Only patients undergoing cataract extraction following vitrectomy were included. METHODS: The last 25 surgeries performed prior to acquisition of the femtosecond laser and the first 25 surgeries performed following acquisition of the femtosecond laser were included. Patient demographic data, preoperative and postoperative visual acuities were collected. Intraoperative and postoperative complications were compared. Follow-up ranged from 1 to 74 months. MAIN OUTCOME MEASURES: The main outcome measures are postoperative visual outcomes and intra- and postoperative complications for both groups. RESULTS: Results of FLACS compared to conventional phacoemulsification are as follows: preoperative logMAR best corrected visual acuity (BCVA) (0.63 vs. 0.69), postoperative logMAR BCVA (0.17 vs. 0.19), posterior capsule complications (0% vs. 12%, P = 0.235), cystoid macular oedema (CMO) (12% vs. 20%, P = 0.705) and postoperative neodymium-doped yttrium aluminium garnet (Nd:YAG) capsulotomy (16% vs. 48%, P = 0.032). CONCLUSIONS AND RELEVANCE: FLACS demonstrates comparable visual outcomes to conventional phacoemulsification. Whilst outcomes measured were not statistically significant, except postoperative YAG capsulotomy, FLACS showed a trend towards a better intraoperative and postoperative safety profile. Femtosecond laser offers a theoretical advantage in reducing complication rates in post-vitrectomy eyes, further larger studies are needed.

Removal of subfoveal perfluorocarbon liquid: Report of 3 cases.

PURPOSE: To report removal of retained subfoveal perfluorocarbon liquid (PFCL) after vitrectomy for retinal detachment. METHODS: Three patients underwent 3-port 23-gauge vitrectomy in an attempt to remove retained subfoveal PFCL bubble secondary to retinal detachment surgery. In two patients, removal was achieved via a 23-G needle whereas the third patient with multiple small subfoveal droplets, multiple punctures were required and in that case a small 40-G needle was used.We assessed best corrected visual acuity (BCVA), fundus imaging, and spectral domain optical coherence tomography (SD-OCT) of all patients before and after surgery. RESULTS: The subfoveal PFCL was successfully removed in all 3 eyes and although a functional improvement was documented, outer retinal atrophy and photoreceptor loss was observed in all our cases. CONCLUSIONS: SD-OCT allows early recognition of retained subfoveal PFCL. Surgical removal may lead to retinal morphologic restoration and functional improvement. While we achieved complete removal of PFCL with both 23-G and 40-G instrumentation, we believe the versatility and ease justifies the universal usage of 40-G retinotomy needles.

A Study Investigating a Possible Link Between Lens Protein in the Vitreous Fluid of Eyes After Uncomplicated Cataract Surgery and Chronic Cystoid Macular Edema.

PURPOSE: This study aimed to determine if the lens protein aquaporin 0 (AQP0) is present in the vitreous of pseudophakic eyes of patients presenting with chronic cystoid macular edema (CME). DESIGN: A case-control study was conducted. METHODS: Ten patients undergoing therapeutic vitrectomy for chronic CME after uncomplicated cataract surgery were enrolled in this study. Fourteen patients with pseudophakia undergoing vitrectomy surgery for indications other than CME acted as the comparison group.The vitreous fluid from the 2 groups was analyzed for the presence of the lens protein AQP0 and type II collagen (used as a positive control). RESULTS: Type II collagen was detected in all the vitreous samples, whereas AQP0 was documented in 50% of eyes with chronic CME but was not found in the vitreous of any eyes without a documented history of CME. CONCLUSIONS: Aquaporin 0 is found in some eyes with chronic CME after uncomplicated cataract surgery, suggesting contamination of the vitreous by lens protein may have a role in the pathogenesis of this disorder.

Amino acid immunoreactivity in normal human retina and after brachytherapy.

We localised amino acids in the mid-peripheral aged human retina and a retina that had undergone radiation treatment 10 years earlier. The distribution pattern of glutamate, γ-amino butyric acid (GABA), glycine, glutamine and taurine, reflected patterns established in the primate retina. The retina that had undergone radiation exposure displayed both anatomical and neurochemical remodelling. The proximal retina comprised around 40 to 45 per cent of the total retina and neuronal kinesis and aberrant neuronal projections were also present. Amino acid neurochemistry was strikingly different with Müller cells displaying GABA loading, glycinergic neurons displaced and displaying a very high level of glycine labelling. We conclude that radiation exposure triggered these changes in the human retina and likely reflects general remodelling of structure and function following ischaemic damage to endothelial cells.

Functional and anatomical remodeling in human retinal detachment.

Rhegmatogenous retinal detachment is by far the most common indication for retinal surgery and a major cause of severe vision loss. Increased levels of glutamate found in the vitreous of human patients and persistent remodeling, even after reattachment, suggest substantial neurochemical, functional and anatomical changes have occurred in the detached retina. Therefore, this study was designed to characterize the morphological changes and glutamate receptor functionality in human rhegmatogenous retinal detachment. A cation channel permeating probe, agmatine (1-amino-4-guanidobutane; AGB), was employed to track endogenous and kainate (KA) driven channel functionality combined with immunocytochemical characterization of cellular remodeling. In the detached retina increased AGB permeability was identified in the outer retina while there was a decrease in the inner retina in basal conditions. KA receptors exhibited increased AGB permeability in ON bipolar cells and decreased permeability in calbindin labeled inner retinal cells. All retinal detachment samples demonstrated ectopic synaptic protein expression, photoreceptor processes extending toward the inner retina, and other remodeling features of retinal degeneration. These anatomical changes have been demonstrated in animal studies and are novel features unreported in primary cases of human retinal detachment. We conclude that deafferentation in retinal detachment leads to alteration of the glutamatergic pathway.

Combined cataract surgery and vitrectomy for vitreous haemorrhage secondary to age-related macular degeneration.

PURPOSE: To report on the functional outcome of surgery on patients with concurrent cataract and breakthrough vitreous haemorrhage from age-related macular degeneration (ARMD). METHODS: Retrospective case series. RESULTS: Five eyes were included in the study. The post operative follow-up interval ranged from 9 to 12 months. Preoperative visual acuity ranged from hand motion to perception of light. Two surgeries were complicated by iatrogenic breaks, and a further surgery was required to re-attach the retina in one of these eyes. Only one of the five eyes experienced an improvement in visual functioning. CONCLUSION: In this series, the outcome of surgery for combined cataract and breakthrough vitreous haemorrhage, secondary to ARMD was poor. The functional outcome of surgery for combined cataract and vitreous haemorrhage secondary to ARMD in this series was poor.

Endophthalmitis after pars plana vitrectomy: a New Zealand experience.

PURPOSE: To describe the clinical course and estimate the incidence of endophthalmitis after pars plana vitrectomy in New Zealand. METHODS: A retrospective analysis was performed on all cases of culture-positive endophthalmitis after vitreoretinal surgery over a 10-year period. RESULTS: Five cases of culture-positive endophthalmitis were identified between 1993 and 2002. During this interval, 10,397 vitrectomies were performed, equating to an overall incidence of 0.048%. All patients presented within 7 days of surgery. CONCLUSIONS: Endophthalmitis after pars plana vitrectomy is uncommon but is associated with a poor functional outcome.

History of retinal surgery in New Zealand.

The history of retinal surgery in New Zealand is relatively short but covers a period of transition from caustic cautery to laser retinopexy, from scleral shortening to 25 gauge vitrectomy. The practitioners of this craft include some of the notable figures in medicine in New Zealand, and in their own way each contributed to the welfare of those patients with surgical retinal disease.

Analysis of symptoms associated with rhegmatogenous retinal detachments.

AIM: The symptoms associated with rhegmatogenous retinal detachments are variable and can be associated with other vitreoretinal and neuro-ophthalmic entities. The present study sought to determine the frequency and type of symptoms associated with rhegmatogenous retinal detachment (RRD), and analyse any relationships with the premorbid state. METHODS: An observational case series was undertaken. A patient questionnaire together with clinical data was collected for patients presenting with RRD. RESULTS: The data on 141 patients presenting with RRD were evaluated prospectively. More than 90% of patients reported a variety of symptoms including visual loss, floaters and flashes. The speed of visual loss was not associated with the extent of retinal break. Rather unexpectedly, patients with a history of retinal pathology were not any more likely to be symptomatic either in their presenting or fellow eye. The absence of symptoms was not associated with age, high myopia or previous cataract surgery. CONCLUSION: Both patients and physicians need to be aware of the importance of the symptoms associated with RRD.