SURGICAL OUTCOME AND PROGNOSTIC FACTORS AFTER OPHTHALMIC SURGERY IN ABUSIVE HEAD TRAUMA.

PURPOSE: To analyze the clinical characteristics, surgical outcomes, and risk factors associated with visual outcomes in patients with abusive head trauma (AHT). METHODS: We retrospectively reviewed surgical outcomes of patients with AHT who underwent vitrectomy from 2001 to 2019. The patients' demographics, comprehensive preoperative and postoperative ocular findings, surgical treatments, visual outcomes, and postoperative complications in the medical records were reviewed. Univariable and multivariable analyses were performed to identify the prognostic factors associated with visual outcomes. RESULTS: Fourteen children (18 eyes) diagnosed with AHT who underwent vitrectomy were evaluated. The most common surgical indication was vitreous hemorrhage (n = 6, 33%). Retinal attachment at the final visit was noted in 17 eyes (94%). Thirteen eyes (72%) had a best-corrected visual acuity less than 20/200 after vitrectomy. In the multivariable analysis, optic nerve atrophy (n = 9, 50%) was significantly associated with a poor visual prognosis (final best-corrected visual acuity worse than 20/200) after vitrectomy in children with AHT (95% confidence interval, 1.041-517.963, P = 0.0471). CONCLUSION: The general visual prognosis was poor for patients with AHT needing vitrectomy, although a high rate of retinal attachment was observed. Optic nerve atrophy is a prognostic factor for poor visual outcomes in patients with AHT who received ophthalmic surgery.

MicroRNA-126 inhibits pathological retinal neovascularization via suppressing vascular endothelial growth factor expression in a rat model of retinopathy of prematurity.

Vascular endothelial growth factor (VEGF) is the principal growth factor responsible for the retinal neovascularization in the pathogenesis of retinopathy of prematurity (ROP). Current therapies for ROP include laser ablation and intravitreal anti-VEGF injection. However, these treatments either destroy the peripheral retina or associate with problems of persistent peripheral avascular retina or later recurrence of ROP. In the present study we investigated a new therapeutic approach by exploring the potential role of a specific microRNA, miR-126, in regulating VEGFA expression and retinal neovascularization in a rat oxygen-induced retinopathy (OIR) model. We demonstrated that miR-126 mimic and plasmid effectively suppresses VEGFA mRNA expression in both human and rat retinal pigment epithelium cell lines, quantified with qRT-PCR. Animal experiments on rat OIR model revealed that intravitreal injection of miR-126 plasmid efficiently downregulated VEGFA expression in the intraocular fluid and retinal tissues measured by ELISA, and significantly suppressed retinal neovascularization, which was confirmed by calculating sizes of neovascularization areas on fluorescence microscopic images of flat mounted retina stained with Alexa Fluor 594-conjugated isolectin B4 to visualize blood vessels. Together, these results showed that intravitreal injection of miR-126 plasmid could inhibit retinal neovascularization by down-regulating VEGFA expression, suggesting a potential therapeutic effect for ROP.

Autologous Retinal Transplantation for Primary and Refractory Macular Holes and Macular Hole Retinal Detachments: The Global Consortium.

PURPOSE: To report the anatomic and functional outcomes of autologous retinal transplantation (ART). DESIGN: Multicenter, retrospective, interventional, consecutive case series. PARTICIPANTS: One hundred thirty eyes of 130 patients undergoing ART for the repair of primary and refractory macular holes (MHs), as well as combined MH-rhegmatogenous retinal detachment (MH-RRD), between January 2017 and December 2019. METHODS: All patients underwent pars plana vitrectomy and ART, with surgeon modification of intraoperative variables. A large array of preoperative, intraoperative, and postoperative data was collected. Two masked reviewers graded OCT images. Multivariate statistical analysis and subgroup analysis were performed. MAIN OUTCOME MEASURES: Macular hole closure rate, visual acuity (VA), external limiting membrane and ellipsoid zone (EZ) band integrity, and alignment of neurosensory layers (ANL) on OCT. RESULTS: One hundred thirty ART surgeries were performed by 33 vitreoretinal surgeons worldwide. Patient demographics were: mean age of 63 ± 6.3 years, 58% female, 41% White, 23% Black, 19% Asian, and 17% Latino. Preoperative VA was 1.37 ± 0.12 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, approximately 20/500), which improved significantly to 1.05 ± 0.09 logMAR (Snellen equivalent, approximately 20/225; P < 0.001) after surgery (mean follow-up, 8.6 ± 0.8 months). Autologous retinal transplantation was performed for primary MH repair in 27% of patients (n = 35), for refractory MH in 58% of patients (n = 76; mean number of previous surgeries, 1.6 ± 0.2), and for MH-RRD in 15% of patients (n = 19). Mean maximum MH diameter was 1470 ± 160 µm, mean minimum diameter was 840 ± 94 µm, and mean axial length was 24.6 ± 3.2 mm. Overall, 89% of MHs closed (78.5% complete; 10% small eccentric defect), with a 95% closure rate in MH-RRD (68.4% complete; 26.3% small eccentric defect). Visual acuity improved by at least 3 lines in 43% of eyes and by at least 5 lines in 29% of eyes. Reconstitution of the EZ (P = 0.02) and ANL (P = 0.01) on OCT were associated with better final VA. Five cases of ART graft dislocation (3.8%), 5 cases of postoperative retinal detachment (3.8%), and 1 case of endophthalmitis (0.77%) occurred. CONCLUSIONS: In this global experience, patients undergoing ART for large primary and refractory MHs and MH-RRDs achieved good anatomic and functional outcomes, with low complication rates despite complex surgical pathologic features.

Treatment of macular hole retinal detachment with macular plug in highly myopic eyes: three-year results.

PURPOSE: To investigate the long-term surgical outcomes of macular hole retinal detachment (MHRD) following vitrectomy with macular plug in highly myopic eyes. METHODS: Thirty-five cases of highly myopic eyes with MHRD in 35 patients who underwent an initially successful vitrectomy with macular plug and were followed up for at least 3 years were reviewed. The anatomical outcomes were evaluated by fundus examination, fundus photographs and optical coherence tomography (OCT). Myopic features after the surgery were differentiated according to recommendations of the Meta-analysis of Pathologic Myopia (META-PM) Study Group. The best-corrected visual acuities (BCVAs) before and after surgery were analysed as the functional outcome. Main outcome measures time-course changes in BCVA and complications. RESULTS: The mean patient age was 61.0 ± 11.4 years. The follow-up was 45.2 ± 8.6 months (ranged from 36 to 71 months). The mean axial length was 29.3 ± 1.2 mm. All eyes demonstrated attached retina, but 2 eyes (5.7%) developed reopened macular holes until the last follow-up. Complications of postoperative rhegmatogenous retinal detachment were detected in 2 eyes (5.7%) within 1 year and retina reattached after the secondary vitrectomy. Three cases (8.6%) of prolonged subretinal fluid lasting more than 1 year were detected but finally absorbed completely. Comparing 1-3 years postoperatively, myopic features showed significant progression of myopic maculopathy category (p = 0.035). Functionally, significantly improved BCVA could be maintained postoperatively between 6 months and 3 years. However, vision of 14 eyes (40.0%) worsened within 1-3 years postoperatively, and visual deterioration was associated with progression of myopic maculopathy (p = 0.004) and pre-existing disease of glaucoma (p = 0.006). CONCLUSIONS: A vitrectomy combined with macular plug provided favourable outcomes in the long term, over the ≥3-year follow-up period.

Sub-perfluoro-n-octane injection of ocular viscoelastic device assisted inverted internal limiting membrane flap for macular hole retinal detachment surgery: a novel technique.

BACKGROUND: To evaluate the feasibility of a surgical technique using a sub-perfluoro-n-octane (PFO) injection of ocular viscoelastic device (OVD) to stabilize inverted internal limiting membrane (ILM) flap for the treatment of macular hole retinal detachment (MHRD). METHODS: This study was a retrospective, consecutive, interventional case series. Patients who underwent MHRD surgery with sub-PFO injection of OVD to stabilize inverted ILM flap onto the macular hole (MH) were reviewed. The color fundus and optical coherence tomography (OCT) images were collected and evaluated. The best-corrected visual acuity (BCVA) before and after surgery were compared as the functional outcome. RESULTS: The study included 8 eyes of 8 consecutive patients (mean age: 61.8 ± 7.1 years; mean follow-up period: 9.0 ± 2.5 months). All eyes (100%) achieved successful MH closure; 7 eyes (87.5%) demonstrated complete retinal reattachment, and 1 eye (12.5%) had minimal residual subretinal fluid parafoveally. Of the 8 patients, 7 patients (87.5%) had achieved improvement in BCVA after the primary surgery, whereas 1 eye remained stable. The average BCVA before and after the surgery at the last visit improved from 20/843 (1.63 ± 0.48 logMAR) to 20/200 (1.00 ± 0.39 logMAR) (P = 0.016). Anatomically, near-normal foveal contour was noted in five (62.5%) eyes at the final follow-up. CONCLUSIONS: The use of sub-PFO injection of OVD in MHRD surgery could stabilize inverted ILM flaps, achieve good anatomical results and improve postoperative BCVA.

Perfluoro-n-octane-assisted autologous internal limiting membrane plug for refractory macular hole surgery.

PURPOSE: To evaluate a surgical technique using a perfluoro-n-octane (PFO)-assisted autologous internal limiting membrane (ILM) plug for refractory macular holes (MHs). METHODS: This study was a retrospective, consecutive, interventional case series. Patients with refractory MHs following PFO-assisted autologous ILM plugs were reviewed between October 1, 2017, and February 28, 2018. The anatomical results of MH preoperatively and postoperatively were evaluated by fundus examination and optical coherence tomography (OCT). The best-corrected visual acuities (BCVAs) before and after surgery were compared as the functional outcome. RESULTS: Six eyes of six consecutive patients with refractory MH were enrolled in this study. Successful MH closure and BCVA improvement after the surgeries were obtained in all eyes. There were four male and two female patients, and the mean age was 63.7 ± 11.1 years. Intraoperatively, the average number of autologous ILM grafts we harvested was 2.2 ± 0.4. The mean follow-up was 6.0 ± 1.7 months. The averaged BCVA before and after the surgery at the last visit improved from 20/356 to 20/153. The ILM graft tissue was still visible, as shown by OCT, in all 6 of 6 (100%) eyes during the follow-up period. CONCLUSIONS: This surgical technique using PFO-assisted autologous ILM plug may provide an option for the treatment of refractory MH.

Nomogram for prediction of non-proliferative diabetic retinopathy in juvenile-onset type 1 diabetes: a cohort study in an Asian population.

The need for screening for retinopathy in patients with type 1 diabetes mellitus (T1DM) has been emphasised, but diagnostic delays were reported when screening was done at fixed intervals. To establish an individualised risk-prediction model to assist screening non-proliferative diabetic retinopathy (NPDR) in T1DM, we performed a retrospective cohort study enrolling participants in the Chang Gung Juvenile Diabetes Eye Study. There were 413 patients with 12 381 records analysed from 2005 to 2015. A time-dependent Cox proportional hazard analysis was used to evaluate the risks of NPDR development and a nomogram with risk-stratification indicators was established based on the results. During 97 months of follow-up, 43 of 413 patients (10.4%) developed NPDR. Male sex (HR: 0.4, 95% CI: 0.19-0.85), age 5-14 years at onset of T1DM (6.38, 2.41-16.87), duration of diabetes (1.57, 1.41-1.75), and hemoglobin A1c level (1.56, 1.35-1.80) were independently associated with NPDR. Using the nomogram offers a quick method in the clinical setting to interpret the risk of NPDR development. Based on its weighting, each of the independent factors is allocated a score, and the total points indicate the probabilities of NPDR occurring within 6 months, 1 year, and 3 years.

Refractory macular hole repaired by autologous retinal graft and blood clot.

BACKGROUND: To evaluate the surgical technique using autologous retinal graft (ARG) and autologous blood clot (ABC) for the management of refractory macular holes (MHs). METHODS: This study was a retrospective, consecutive, interventional case series. Six eyes of 6 patients who underwent vitrectomy combined with ARG and ABC for the treatment of refractory MH were reviewed. Visual and anatomic outcomes were evaluated. RESULTS: The mean age was 59.0 ± 9.9 years. All cases had multiple vitreoretinal procedures including vitrectomy and gas fluid exchange before patient presentation. The average numbers of vitrectomies were 2.3 ± 0.5, and those of gas fluid exchange were 3 ± 1.7. Closure of the macular hole was achieved in four (66.7%) cases at last follow-up. The mean follow-up time was 25.2 ± 15.6 months. The averaged BCVA before and after 12 months of the surgery improved from 20/591 to 20/244. CONCLUSIONS: This surgical technique using ARG and ABC provide an option for the treatment of refractory MHs.

Anti-VEGF for ROP and Pediatric Retinal Diseases.

Vascular endothelial growth factor (VEGF) is an important mediator of the pathological neovascularization and vascular permeability of the eye. The increasing use of intravitreal therapies targeting VEGF has revolutionized the treatment of pediatric vitreoretinal diseases. In retinopathy of prematurity (ROP), the role of VEGF in pathogenesis has been well recognized and the use of anti-VEGF treatment in phase 2 ROP has demonstrated promising results, particularly in severe cases of posterior disease. This has made VEGF an established target in the treatment of pediatric retinal diseases known to have abnormal vascular activity. However, questions remain about late systemic and neurodevelopmental effects after anti-VEGF therapy for children because intravitreal injection of anti-VEGF may result in systemic circulation of anti-VEGF agent and a corresponding suppression of systemic VEGF. We do not currently know whether the short-term suppression of systemic VEGF affects long-term neurodevelopmental outcomes because VEGF is a vital supporting factor during neurodevelopment. This review article focuses on the evidence for the use of anti-VEGF treatment in certain pediatric ocular diseases, including ROP, Coats disease, and retinoblastoma. More extensive and prospective studies are warranted to further elucidate the role of anti-VEGF therapy in these diseases and illustrate how we can optimally use these agents in pediatric patients.

Clinical Characteristics of Stenotrophomonas maltophilia Keratitis.

PURPOSE: Stenotrophomonas maltophilia is an important opportunistic pathogen but an uncommon cause of corneal infections. This study aimed to report the clinical features, antibiotic susceptibility, treatments, and visual outcomes of S. maltophilia keratitis. METHODS: The medical records of 21 patients with culture-proven S. maltophilia-associated infectious keratitis in our hospital between January 1, 2003, and December 31, 2014, were retrospectively reviewed. The clinical features of patients with S. maltophilia keratitis were compared with those of patients from 17 previously reported cases. RESULTS: The most common risk factors for S. maltophilia keratitis were preexisting corneal disease or previous corneal surgery (16), followed by soft contact lens wear (9). Nine patients (42.9%) were multifactorial. Polymicrobial infections was detected in 12 eyes (57.1%). All S. maltophilia isolates were susceptible to levofloxacin and moxifloxacin. A total of 17 of 21 patients (81.0%) had favorable responses to topical antimicrobial treatment, and 10 (47.6%) required surgical intervention for promotion of reepithelialization (6) and corneal perforation (4). Final vision ranged from light perception to 20/20. The clinical features of S. maltophilia keratitis in our cases and in previously reported cases were similar. CONCLUSIONS: S. maltophilia keratitis primarily affects patients with compromised ocular surfaces. S. maltophilia demonstrates in vitro susceptibility and a strong clinical response to fluoroquinolones.