Recovery of Vision in Open Globe Injury Patients with Initial No Light Perception Vision.

PURPOSE: To identify clinical characteristics of injured eyes associated with visual recovery in patients with open globe injuries (OGIs) and presenting with no light perception (NLP) vision. DESIGN: Retrospective chart review. SUBJECTS: All patients presenting to Massachusetts Eye and Ear with OGI and NLP vision from January 1999 to March 2022. METHODS: Manual data extraction to collect patient demographic characteristics, preoperative, intraoperative, and postoperative characteristics of OGI injury, laceration versus rupture, history of intraocular surgery, time from injury to repair, timing of vitrectomy, lensectomy, choroidal drainage, and silicone oil placement, visual acuity (VA) at last follow-up, and subsequent B-scan ultrasound findings of retinal detachment, choroidal hemorrhage, vitreous hemorrhage, and disorganized intraocular contents. Patients with >1 week of follow-up and a documented VA at most recent follow-up were included. Exclusion criteria included age <10 years. Multivariable regression was performed. MAIN OUTCOME MEASURES: Visual acuity recovery defined as light perception or better in patients with OGI and initial NLP vision. RESULTS: One hundred forty-seven eyes with NLP vision after OGI were included. Twenty-five (17%) eyes regained vision at last follow-up. The majority of patients recovered light perception vision (n = 15, 60%) followed by 20/500 or better (n = 5, 20%), hand motions (n = 3, 12%), and counting fingers (n = 2, 8%). Most injuries were zone III (n = 102, 69%) and presented with rupture (n = 127, 86%). The mean time from OGI to surgical repair was 0.85 ± 1.7 days. B-scan was obtained in 104 (71%) cases. Pars plana vitrectomy was performed in 9 eyes (6%) with NLP at time of vitrectomy. Disorganized intraocular contents on B-scan (odd ratio, 0.170; 95% confidence interval, 0.042-0.681; P = 0.012) was the only clinical variable significantly associated with visual recovery, corresponding to a lack of visual improvement. CONCLUSIONS: Recovery of vision in OGI with NLP vision at presentation cannot be predicted based on presenting clinical features. B-scan findings of disorganized intraocular contents after initial OGI repair was the only factor negatively associated with vision recovery in this patient population. Therefore, all eyes presenting with an OGI and NLP vision should undergo primary repair in hopes of subsequent visual recovery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

SILICONE OIL-FILLED FOLDABLE CAPSULAR VITREOUS BODY VERSUS SILICONE OIL ENDOTAMPONADE FOR TREATMENT OF NO LIGHT PERCEPTION AFTER SEVERE OCULAR TRAUMA.

PURPOSE: To compare the anatomical and functional outcomes of silicone oil (SO)-filled foldable capsular vitreous body (FCVB) and SO endotamponade in vitrectomy for patients with no light perception after ocular trauma. METHODS: A total of 64 patients (64 eyes) with no light perception caused by severe ocular trauma were divided into FCVB and SO groups based on the surgical treatment. The main outcome measurements were retinal reattachment rate, intraocular pressure, best-corrected visual acuity, and number of operations. RESULTS: Both the FCVB group (29 eyes) and the SO group (35 eyes) showed significant improvement in postoperative best-corrected visual acuity and intraocular pressure. The two groups showed no significant differences in final intraocular pressure and the retinal reattachment rate. The postoperative vision (≥LP) in the FCVB group was significantly worse than in the SO group (FCVB [4/29] vs. SO [18/35], P = 0.003). However, the number of surgeries in the FCVB group was significantly lower than in the SO group (FCVB [1.10] vs. SO [2.23], P < 0.001). CONCLUSION: Vitrectomy combined with SO endotamponade shows better short-term improvement in the treatment of no light perception caused by severe ocular trauma. However, SO-filled FCVB can effectively prevent many complications caused by direct SO endotamponade, such as secondary surgeries or SO dependence.

Psychological complexities of visual restoration.

In this paper, we report the psychological and emotional experience of a patient who regained vision after over a decade of vision loss. The negative psychological implications of blindness are well recognised and there is a robust link between visual impairment and low mood and depressive symptoms. Although uncommon, low mood and depressive symptoms have been reported in patients whose sight has been restored, and lack of research gives rise to the possibility their prevalence may be grossly under-recognised in such patient groups. The effects can be so severe that patients may revert to living in darkness in mimicry of their previous lifestyle, effectively obviating the sight-restoring surgery. Healthcare professionals have a responsibility to address this traditionally neglected need by facilitating social, psychological and medical interventions that may ease the return to vision.

Case Report: Effect of a Retinal Prosthesis System on Charles Bonnet Visual Hallucinations.

SIGNIFICANCE: Charles Bonnet syndrome is commonly encountered and diagnosed in low-vision patients. It can be distressing for some of them, as there is no known effective treatment of this condition. Although there is a growing interest in retinal implants for blind patients with severe retinal diseases, the effect of these devices on Charles Bonnet syndrome visual hallucinations remains undocumented. PURPOSE: The aim of this study was to report changes in the Charles Bonnet syndrome of a patient with retinitis pigmentosa after implantation of the Argus II retinal prosthesis. CASE REPORT: A 65-year-old patient with retinitis pigmentosa and no light perception was frequently experiencing Charles Bonnet syndrome. In the hope of improving his vision, he received an Argus II retinal prosthesis in 2018 and participated in a 10-week rehabilitation program at the Institut Nazareth et Louis-Braille. The nature and the frequency of his Charles Bonnet syndrome were documented with the Questionnaire de repérage du syndrome de Charles Bonnet (a French questionnaire used to screen for Charles Bonnet syndrome) before the surgery and for 70 weeks after it. The patient's visual acuity and visual fields were monitored during the same period. Additional tests were administered to document the visual, psychological, and cognitive states of the patient throughout the study. CONCLUSIONS: Although this case report confirmed that Argus II retinal prosthesis improves the performance of blind patients in visual tests, the improvement was not associated with a decrease in the symptoms of Charles Bonnet syndrome.

Surgical outcomes of macular hole and epimacular membrane treatment in patients with intraoperative amaurosis under sub-Tenon's anesthesia.

OBJECTIVE: Some patients have been found to develop intraoperative amaurosis under sub-Tenon's anesthesia. We explored whether these patients have poor surgical outcomes during mid- to long-term postoperative follow-up. METHODS: In this case series, 74 of 85 patients with macular diseases who underwent phacoemulsification combined with vitrectomy under sub-Tenon's anesthesia developed intraoperative amaurosis. The surgical outcomes at the 2- and 4-month follow-ups in these patients were investigated and compared with the outcomes in patients without amaurosis using best-corrected visual acuity (BCVA), optical coherence tomography (OCT), and pattern visual evoked potential (PVEP). RESULTS: Both BCVA and the OCT-based macular structure in patients with intraoperative amaurosis showed significant postoperative improvement comparable with that of patients without amaurosis. The presence of intraoperative amaurosis was not associated with either macular hole closure or macular edema regression. PVEP revealed no significant changes in the wave latency or amplitude before and after surgery. CONCLUSION: Intraoperative amaurosis following sub-Tenon's block is commonly seen but does not predict a poor surgical prognosis. When a patient develops amaurosis during surgery, the surgeon should increase patient comfort through verbal communication rather than perform an additional intervention to help relieve the patient's anxiety.

[Functional results and prognostic factors in open-globe ocular trauma with presenting visual acuity of no-light perception]. / Résultats fonctionnels et facteurs pronostiques des traumatismes oculaires à globe ouvert avec acuité visuelle initiale à perception lumineuse négative.

PURPOSE: To analyse the clinical ocular characteristics and determine prognostic factors for functional recovery in eyes presenting with no light perception (NLP) after open globe ocular trauma. MATERIALS AND METHODS: In this retrospective study were included all the patients with no light perception after open globe trauma who presented to Amiens University Hospital between October 2014 and June 2018. RESULTS: Fifteen eyes of 15 patients were included in this study. The main mechanism of the trauma was globe rupture (80 %, n=12). The most common location was zone III (66 %, n=10). The wound size was greater than 10mm in 9 patients (60 %). The ocular lesions included expulsion of the crystalline lens or posterior chamber intraocular lens, hyphema, retinal detachment, vitreous hemorrhage and ciliochoroidal lesions. Damage to the ciliary body was a negative prognostic factor for functional recovery (P=0.04). Nine patients remained with no light perception, whereas 6 patients experienced an improvement in visual acuity (2.3 logMAR in 3 patients, 0.7 logMAR in 1 patient, 0.4 logMAR in 1 patient and 0.2 logMAR in 1 patient). These 6 patients had undergone posterior vitrectomy due to vitreoretinal involvement (P<0.001). CONCLUSION: In the case of open globe trauma with no light perception on presentation, a functional recovery is possible if there is no irreversible anatomical damage.

The first deaf-blind patient in Russia with Argus II retinal prosthesis system: what he sees and why.

OBJECTIVE: In this study, we propose a new method for evaluating the functional results based on the sizes of phosphenes that the patient drew which were then digitalized. We also describe the methodology of psychological testing and support for a deaf-blind patient. APPROACH: A 59-year-old man with retinitis pigmentosa and hearing loss (clinical Usher syndrome) underwent surgery to implant the Argus II retinal prosthesis system in his right eye. MAIN RESULTS: Correlation analysis showed a weak dependency between the size of a phosphene and the perceptual threshold. Significant correlations between a phosphene and the height of the interface, impedance or retinal thickness was not found. The patient with the retinal prosthesis felt more independent and confident, and more healthy. This is the first case of retinal implant surgery in Russia. SIGNIFICANCE: The results of this study add to the understanding in the field of retinal implants functioning. The experience of the successful rehabilitation of the deaf-blind patient after implantation of Argus II allowed us to design a methodology that can be used in future similar cases.

The individual and household impacts of cataract surgery on older blind adults in ethiopia.

PURPOSE: To comprehensively measure the impacts of cataract surgery on patients' activities and mental and physical health, caregivers' well-being, and household incomes in a resource-poor setting Methods: One thousand two hundred thirty-four bilaterally blind older adults in Amhara region, Ethiopia, were interviewed at baseline and 1030 (83%) re-interviewed at follow-up 1 year later. Six hundred ninety three (45%) at baseline were diagnosed with cataracts and offered free surgery, of which 484 (73%) were operated. Difference-in-difference was used to estimate impacts of surgery, using surgery-ineligible, mostly non-cataract blind as controls. RESULTS: For patients, surgery resulted in a 0.31 standard deviation increase in an index of social participation (p < 0.001), a 30% proportional increase in ability to perform activities of daily living (p < 0.001), and a 17% proportional reduction in Center for Epidemiologic Studies Depression Scale (CES-D) depression score (p < 0.001). A small (6%) increase in work participation occurred among men (p = 0.093) in this elderly sample. No change occurred in individual or household food insecurity, household consumption, or assets. Caregivers' mental health improved slightly (7.3% proportional reduction in CES-D; p = 0.024). Estimates show no change in caregiver work participation or social participation; however, subjective responses regarding changes from surgery suggest that reduced caregiving time was an important benefit to households. CONCLUSION: Cataract surgery significantly improved the vision as well as mental health, social engagement, and physical functioning of older adults. However, increases in work participation were very limited, likely reflecting the advanced age of the patients (mean = 76 years); in addition, possibly, to cumulative impacts of blindness on ability to work or on household assets. Earlier surgery may lead to larger economic effects.

Pediatric Corneal Transplant Surgery: Challenges for Successful Outcome.

Visual rehabilitation of pediatric corneal blinds is a major challenge to corneal transplant surgeons. Penetrating keratoplasty (PKP) is the only way to restore vision and prevent irreversible blindness due to amblyopia in children. Performing penetrating corneal grafts in children poses difficulty in evaluation, technical difficulties during surgery and problems during follow-up. Younger children do not cooperate for proper slit-lamp examination and need to be examined under general anaesthesia. In addition, the complications encountered post PKP, including allograft rejection, post PKP astigmatism and post PKP glaucoma are more frequent in pediatric group as compared to adult recipients. Even after a successful graft, the child requires rigorous treatment for amblyopia. Parents need to be counselled before surgery and possible visual outcome and chances of obtaining clear graft should be discussed.

Simultaneous Keratolimbal Autograft and Penetrating Autokeratoplasty: A Single-Stage Procedure to Restore Monocular Vision of a Blind Patient With Limbal Stem Cell Deficiency.

PURPOSE: To describe the technique of simultaneous keratolimbal autograft and penetrating autokeratoplasty to restore monocular vision of a blind patient with limbal stem cell deficiency (LSCD). METHODS: A patient with acquired monocular vision due to loss of the left eye owing to LSCD postblast injury presented with acute loss of vision in the right eye due to central retinal artery occlusion. Simultaneous keratolimbal autograft and penetrating autokeratoplasty were performed in attempt to restore his vision in the left eye. RESULTS: Postoperatively, the anterior chamber was well formed along with mild graft edema on day 1. Topo-guided suture removal was started at 4 months. The graft maintained clear transparency at 1-year follow-up, and the best-corrected visual acuity improved from hand movement to 20/50. CONCLUSIONS: Keratolimbal autograft and penetrating autokeratoplasty, as a one-stage procedure, proved to be effective in restoring monocular vision in a patient with LSCD.

The Boston keratoprosthesis.

PURPOSE OF REVIEW: The Boston keratoprosthesis (BKPro) is often the only hope for visual rehabilitation in severe corneal disease. Since Food and Drug Administration approval of the device in 1992, there have been a series of advances in its design, surgical techniques, and postoperative care, which have widened its applicability and decreased associated complications. The purpose of this review is to highlight the indications, management, outcomes, and advances in the BKPro literature. RECENT FINDINGS: With more surgeons reporting long-term data, it is evident that modifications to the device and perioperative care have led to higher rates of device retention and improved visual outcomes. Recent data also suggest that BKPro may be superior to traditional corneal transplant in the setting of a previously failed graft. There may be advantages to implantation of the device earlier in the course of some diseases without an increased risk of postoperative complications. Devices to reliably measure intraocular pressure and imaging modalities to provide improved visualization of intraocular structures have the potential to further improve outcomes. SUMMARY: The current indications for implantation of the BKPro have broadened. Initially considered a surgery of last resort, the clinical indications for use of the BKPro continue to grow. Early detection and management of postoperative complications can mitigate vision loss and improve outcomes.

Electronic retinal implant surgery.

Blindness due to outer retinal degeneration still remains largely untreatable. Photoreceptor loss removes light sensitivity, but the remaining inner retinal layers, the optic nerve, and indeed the physical structure of the eye itself may be unaffected by the degenerative processes. This provides the opportunity to restore some degree of vision with an electronic device in the subretinal space. In this lecture I will provide an overview of our experiences with the first-generation retinal implant Alpha IMS, developed by Retina Implant AG and based on the technology developed by Eberhart Zrenner as part of a multicentre clinical trial (NCT01024803). We are currently in the process of running a second NIHR-funded clinical trial to assess the next-generation device. The positive results from both studies to date indicate that the retinal implant should be included as a potential treatment for patients who are completely blind from retinitis pigmentosa. Evolution of the technology in future may provide further opportunities for earlier intervention or for other diseases.

The global state of cataract blindness.

PURPOSE OF REVIEW: Cataracts are a significant cause of blindness and visual impairment worldwide. The present article reviews the literature and describes the current extent of cataracts globally, barriers to treatment, and recommendations for improving the treatment of cataracts. RECENT FINDINGS: Prevalence and absolute number of blind because of cataracts remain high, although rates are declining in many areas globally. The age-standardized prevalence of blindness in adults older than 50 remains highest in western sub-Saharan Africa, with a rate of 6.0%. The greatest declines in age-standardized blindness because of cataracts in adults older than 50 between 1990 and 2010 were in East Asia, tropical Latin America, and western Europe. Recent studies have largely found higher rates of cataracts in women than in men. A new simulator for training ophthalmologists in manual small-incision cataract surgery holds promise for the future. SUMMARY: The rates of cataract surgery are increasing and postoperative outcomes are improving worldwide, yet challenges to reducing the cataract burden further remain. Cost, an insufficient number of ophthalmologists, and low government funding remain significant barriers but investment in further eye care infrastructure and training of additional ophthalmologists would improve the current situation.

Whole-eye transplantation: a look into the past and vision for the future.

Blindness afflicts ~39 million people worldwide. Retinal ganglion cells are unable to regenerate, making this condition irreversible in many cases. Whole-eye transplantation (WET) provides the opportunity to replace diseased retinal ganglion cells, as well as the entire optical system and surrounding facial tissue, if necessary. Recent success in face transplantation demonstrates that this may be a promising treatment for what has been to this time an incurable condition. An animal model for WET must be established to further enhance our knowledge of nerve regeneration, immunosuppression, and technical aspects of surgery. A systematic review of the literature was performed to evaluate studies describing animal models for WET. Only articles in which the eye was completely enucleated and reimplanted were included. Study methods and results were compared. In the majority of published literature, WET can result in recovery of vision in cold-blooded vertebrates. There are a few instances in which mammalian WET models demonstrate survival of the transplanted tissue following neurovascular anastomosis and the ability to maintain brief electroretinogram activity in the new host. In this study we review in cold-blooded vertebrates and mammalian animal models for WET and discuss prospects for future research for translation to human eye transplantation.

Intraoperative OCT Imaging of the Argus II Retinal Prosthesis System.

BACKGROUND AND OBJECTIVE: Optimal placement of the Argus II Retinal Prosthesis System (Second Sight Medical Products, Sylmar, CA) is critical. Intraoperative optical coherence tomography (OCT) allows for intrasurgical visualization and confirmation of array placement. In this study, two different OCT systems were evaluated to assess the feasibility and utility of this technology during Argus II surgery. PATIENTS AND METHODS: Intraoperative OCT was performed on five patients undergoing Argus II implantation at Cole Eye Institute from June 2015 to July 2016. The EnVisu portable OCT (Bioptigen, Morrisville, NC) and microscope-integrated RESCAN 700 (Zeiss, Oberkochen, Germany) intraoperative OCT systems were utilized. The EnVisu was used in three patients and the RESCAN 700 in three of the five patients. Following array tacking, intraoperative OCT was performed over the entire array including the edges and tack. RESULTS: Intraoperative OCT allowed for visualization of the array/retina interface. Microscope integration of the OCT system facilitated ease of focusing, real-time feedback, surgeon-directed OCT scanning to the areas of interest, and enhanced image quality at points of interest. CONCLUSIONS: Intraoperative imaging of the Argus II electrode array is feasible and provides information about electrode array-retina interface and distance to help guide a surgeon. Microscope integration of OCT appears to provide an optimal and efficient approach to intraoperative OCT during Argus II array placement. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:999-1003.].

Strategies to improve follow-up of children after surgery for cataract: findings from Child Eye Health Tertiary Facilities in sub-Saharan Africa and South Asia.

PurposeWe sought to conduct a systematic literature review on follow-up of children with ocular surgical management (primarily childhood cataract) in developing countries. Second, we sought to determine the current practices regarding follow-up for clinical, optical, low vision, rehabilitation, and educational placement among children receiving surgical services at Child Eye Health Tertiary Facilities (CEHTF) in sub-Saharan Africa (SSA) and South Asia.MethodsA systematic literature review was conducted. Separately, we conducted a cross-sectional study among CEHTF in SSA and South Asia (India, Nepal, and Bangladesh) to assess current capacities and practices related to follow-up and educational placement.ResultsThe articles that met the systematic review eligibility criteria could be grouped into two areas: factors and strategies to improve post-operative follow-up and educational placement of children after surgery. Among the 106 CEHTF in SSA and South Asia, responses were provided by 75 CEHTF. Only 59% of CEHTF reported having a Childhood Blindness and Low Vision Coordinator; having a coordinator was associated with having appropriate follow-up mechanisms in place. Educational referral practices were associated with having a low-vision technician, having low-vision devices, and having donor support for these services.ConclusionsThe systematic literature review revealed evidence of poor follow-up after surgical interventions for cataract and other conditions, but also showed that follow-up could be improved significantly if specific strategies were adopted. Approaches to follow-up are generally inadequate at most facilities and there is little external support for follow-up. Findings suggest that funding and supporting a coordinator would assist in ensuring that good practices for follow-up (cell phone reminders, patient tracking, and reimbursement of transport) were followed.