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.

DEXAMETHASONE IMPLANT FOR DIABETIC MACULAR EDEMA IN NAIVE COMPARED WITH REFRACTORY EYES: The International Retina Group Real-Life 24-Month Multicenter Study. The IRGREL-DEX Study.

PURPOSE: To investigate efficacy and safety of repeated dexamethasone (DEX) implants over 24 months, in diabetic macular edema (DME) eyes that were treatment naive compared with eyes refractory to anti-vascular endothelial growth factor treatment, in a real-life environment. METHODS: This multicenter international retrospective study assessed best-corrected visual acuity and central subfield thickness (CST) of naive and refractory eyes to anti-vascular endothelial growth factor injections treated with dexamethasone implants. Safety data (intraocular pressure rise and cataract surgery) were recorded. RESULTS: A total of 130 eyes from 125 patients were included. Baseline best-corrected visual acuity and CST were similar for naive (n = 71) and refractory eyes (n = 59). Both groups improved significantly in vision after 24 months (P < 0.001). However, naive eyes gained statistically significantly more vision than refractory eyes (+11.3 ± 10.0 vs. 7.3 ± 2.7 letters, P = 0.01) and were more likely to gain ≥10 letters (OR 3.31, 95% CI 1.19-9.24, P = 0.02). At 6, 12, and 24 months, CST was significantly decreased compared with baseline in both naive and refractory eyes; however, CST was higher in refractory eyes than in naive eyes (CST 279 ± 61 vs. 313 ± 125 µm, P = 0.10). CONCLUSION: Over a follow-up of 24 months, vision improved in diabetic macular edema eyes after treatment with dexamethasone implants, both in eyes that were treatment naive and eyes refractory to anti-vascular endothelial growth factor treatment; however, improvement was greater in naive eyes.

External limiting membrane as a predictor of visual improvement in diabetic macular edema after pars plana vitrectomy.

BACKGROUND: To evaluate the predictors of visual improvement using spectral-domain optical coherence tomography (SD-OCT) in eyes with resistant diabetic macular edema (DME) treated with pars plana vitrectomy. METHODS: Thirty-four eyes with resistant DME were evaluated in a retrospective manner. Several SD-OCT variables including photoreceptor inner segment/outer segment (IS/OS) junction, external limiting membrane (ELM) integrity, and central macular thickness (CMT) before and after the surgery, were evaluated by two experienced observers, masked to visual acuity. The visual improvement was used as the outcome measure for a stepwise regression, while the OCT factors were used as predictors. RESULTS: The strongest predictor of vision improvement was pre-operative damage to the ELM (p = 0.0277) compared to IS/OS junction (p = 0.03). Pretreatment central macular thickness was a very weak predictor (p = 0.18) of visual improvement. For each percentage increase of ELM integrity there was a 0.13 letter gain in vision. ELM integrity explained 16% of the visual acuity improvement after treatment, which rose to 21% with the addition of CMT. The addition of IS/OS junction in the model did not add predictive information. CONCLUSIONS: Evaluation of ELM preoperatively predicts the vision improvement more accurately than the IS/OS junction and CMT in eyes with DME.

Correlation between retinal sensitivity and cystoid space characteristics in diabetic macular edema.

PURPOSE: To evaluate the correlation between retinal sensitivity and cystoid space characteristics in eyes with diabetic macular edema (DME). MATERIALS AND METHODS: Prospective cross-sectional study of 22 subjects with DME (32 treatment-naïve eyes). All study subjects underwent complete ophthalmic examination, including slit-lamp biomicroscopy and dilated fundus examination. All subjects underwent spectral domain optical coherence tomography (SD-OCT) and microperimetry (MP). Intraretinal cystoid space (ICS) volume was generated after manual delineation of cystoid space boundaries using the three-dimensional-OCT software. Various SD-OCT parameters, including retinal thickness, retinal volume, cystoid space volume, cystoid space intensity, and outer retinal structure integrity, were correlated with MP parameters and best-corrected visual acuity (BCVA). RESULTS: Subject's mean age was 57 ± 9 years. The mean logarithm of minimum angle of resolution BCVA was 0.4 ± 0.2. The intraclass correlation coefficient for inter- and intra-grader assessment of cystoid space volume by manual delineation was 0.99 and 0.99, respectively. Mean total ICS volume was 0.4 ± 0.4 mm 3 and for the foveal center, subfield was 0.1 ± 0.1 mm 3 . Mean retinal sensitivity was 12.89 ± 10 dB; however, foveal retinal sensitivity was 12.3 ± 11.1 dB. We found no significant correlation between BCVA and total cystoid space volume (r = 0.33, P = 0.06). Correlation between total retinal sensitivity and total ICS was negative and nonsignificant (r = -0.17, P = 0.36). Correlation between foveal retinal sensitivity and foveal cystoid space intensity was moderate and marginally significant (r = -0.43, P = 0.05). CONCLUSION: Total cystoid space volume was not significantly correlated with BCVA or total retinal sensitivity in subjects with DME. Foveal cystoid space optical intensity was negatively correlated with foveal retinal sensitivity. These findings suggest further investigation of cystoid space characteristics in the setting of DME may be of value.

Vitreous haemorrhage in massive hemorrhagic polypoidal choroidal vasculopathy: clinical characteristics and surgical outcomes: Vitreous hemorrhage in PCV.

BACKGROUND: To report the outcomes of vitreous hemorrhage (VH) associated with hemorrhagic polypoidal choroidal vasculopathy (PCV). METHODS: A retrospective study of 28 eyes of 27 consecutive patients of hemorrhagic PCV with VH, which were managed surgically between January 2003 and December 2011, was performed. All patients underwent pars plana vitrectomy for VH associated with PCV. The main outcome measure was best-corrected visual acuity (BCVA) at baseline, at 1, 3 and 6 months post operatively and at last follow up. RESULTS: The visual acuity measured on early treatment diabetic retinopathy study (ETDRS) chart improved in 16 eyes (57.1 %) by two or more lines, remained unchanged in nine eyes (32.1 %) and decreased in three (10.7 %) after surgery when compared to baseline VA. The mean baseline VA was 2.69 ± 0.57 logMAR units (<20/2000) which improved to 1.65 ± 0.93 logMAR units (20/800) at 1 month post operative visit and was sustained at 1.72 ± 1.12 (20/800) with an improvement of 0.96 logMAR units (p < 0.001, 95 % CI 0.54-1.37). The average postoperative follow up was for 14.2 months (range 1-84). The complications noted in postoperative follow up were cataract (n = 10), macular scaring (n = 9), organised dehemoglobinised blood (n = 7), retinal tear or detachment (n = 5), recurrent VH (n = 3) and choroidal detachment (n = 1). CONCLUSION: Majority of patients with loss of vision due to VH secondary to hemorrhagic PCV have sustained improvement in visual acuity following surgery.

Retrospective hospital-based analysis of age-related macular degeneration patterns in India: 5-year follow-up.

PURPOSE: To provide a detailed analysis of age-related macular degeneration (AMD) with a 5-year follow-up at a Tertiary Eye Care Center in India. METHODS: In this retrospective institutional study, 408 eyes of 204 subjects (100 males) with a diagnosis of AMD with minimum 5-year follow-up were included. Data collected included demographics, details of the ocular exam, special investigations performed, treatment offered, complications, and systemic diseases, if any. RESULTS: The median age was 74.24 ± 8.23 years. Median follow-up was 5.77 years. The visual acuity (VA) at baseline and last visit was 0.74 ± 0.12 (Snellen's equivalent 20/100) and 0.54 ± 0.12 logarithm of the minimum angle of resolution (Snellen's equivalent 20/50; P = 0.032) in patients with choroidal neovascular membrane (CNVM). The most common complaint was decreased vision (94.5%). AMD (any stage) was found to be bilateral in 93% of patients at baseline and 197 patients (96.56%) at 5 years. Seventeen eyes had active CNVM (12 of these were occult) at presentation. At baseline, 43 eyes had a disciform scar. Three hundred twenty-one eyes had dry AMD at baseline (geographic atrophy - 12 [3.7%] eyes). Five-year conversion rate into wet AMD and geographic atrophy was 2.87% and 3.12%. Median number of anti-vascular endothelial growth factor injections administered per patient was 2.8 ± 1.2. CNVM bilaterality was low (7.5%). CONCLUSION: Patients with AMD in India presented later in the course of the disease. Bilateral advanced AMD and geographic atrophy were uncommon. Five-year conversion rate into wet AMD and geographic atrophy was 2.87% and 3.12%.

Choroidal thickness in diabetic patients of Indian ethnicity.

PURPOSE: To evaluate choroidal thickness (CT) change in various grades of diabetic retinopathy (DR) in comparison to age-matched healthy subjects. METHODS: This prospective observational study included 227 eyes of 125 subjects with diabetes (study group: 58 females) and 197 eyes of 110 age-matched healthy subjects (control group: 66 females). Collected data included age, gender, duration of diabetes, glycemic control, comprehensive ocular examination, fundus photography, and CT measurement on spectral domain ocular coherence tomography using enhanced depth imaging. RESULTS: Mean age in the study group was 57.0 ± 9.37 years (43-73 years). The mean age was 41.48 ± 5.43 years in the control group. Subjects with diabetes with (252.8 ± 55.6 microns) and without (261.71 ± 51.8 microns) retinopathy had significantly thinner choroids when compared to the control group (281.7 ± 47.7 microns; P = 0.032). Seventy-four of 227 eyes did not have any evidence of DR, 89 eyes had features of nonproliferative diabetic retinopathy (NPDR), and 33 eyes had treatment naïve proliferative diabetic retinopathy (PDR). Thirty-one PDR eyes had received previous laser photocoagulation. Subjects with diabetes without retinopathy had a greater subfoveal choroidal thickness (SFCT) than subjects with diabetes with retinopathy (P < 0.001). Eyes with PDR (243.9 ± 56.2 microns) had thinner SFCT than those with NPDR (238.98 ± 111.23 microns). There was no difference in the SFCT between treated (laser photocoagulation done; 251.784 ± 103.72 microns) and treatment naïve PDR (258.405 ± 89.47 microns, P = 0.23). CONCLUSIONS: Control eyes had greater SFCT compared to subjects with diabetes, with and without retinopathy. The thinning progressed with increasing severity of DR. Choroidal thinning may contribute to DR pathogenesis.

Choroidal thickness profile in healthy Indian children.

PURPOSE: The purpose was to study choroidal thickness and its profile based on location in healthy Indian children using enhanced depth spectral-domain-optical coherence tomography (SD-OCT). METHODS: In this cross-sectional observational study 255 eyes of 136 children with no retinal or choroidal disease were consecutively scanned using enhanced depth SD-OCT. Eyes with any ocular disease or axial length (AXL) >25 mm or < 20 mm were excluded. A single observer measured choroidal thickness from the posterior edge of the retinal pigment epithelium to the choroid/sclera junction at 500-microns intervals up to 2500 microns temporal and nasal to the fovea. Generalized estimating equations were used to evaluate the correlation between choroidal thickness at various locations and age, AXL, gender and spherical equivalent (SEq). RESULTS: Mean age of the subjects was 11.9 ± 3.4 years (range: 5-18 years). There were 62 Females and 74 males. The mean AXL was 23.55 ± 0.74 mm. Mean subfoveal choroidal thickness was 312.1 ± 45.40 µm. Choroid was found to be thickest subfoveally, then temporally. Age, AXL and SEq showed a significant correlation with choroidal thickness, whereas gender did not affect choroidal thickness. CONCLUSION: Our study provides a valid normative database of choroidal thickness in healthy Indian children. This database could be useful for further studies evaluating choroidal changes in various chorioretinal disorders. Age and AXL are critical factors, which negatively correlated with choroidal thickness.

Hypopyon uveitis following panretinal photocoagulation in a diabetic patient.

We report the case of a 42-year-old man with uncontrolled diabetes mellitus who presented to us with diminution of vision in both eyes for the past two years. On examination, both eyes showed features of high-risk proliferative diabetic retinopathy and the patient was advised of panretinal photocoagulation (PRP). He underwent the first sitting of PRP in both eyes. On the following day, he developed hypopyon uveitis in the right eye. He was treated with topical steroid and cycloplegic, and complete resolution of hypopyon was achieved over the next three days. This case highlights the importance of adequately controlled diabetes mellitus before PRP. Hypopyon uveitis could be a complication of PRP in patients with uncontrolled diabetes mellitus who respond to frequent topical steroid and cycloplegic.

Vitreo-retinal interface changes on optical coherence tomography in the fellow eyes of patients with macular hole.

AIM: To study the vitreo-retinal interface and macular changes on optical coherence tomography (OCT) in the fellow eyes of patients with macular hole. METHODS: Patients with idiopathic macular hole in one or both eyes presented to our institute between January 2003 and December 2009 were evaluated retrospectively. Demographic details, best-corrected visual acuity and vitreo-retinal interface, and macular changes of the fellow eye on OCT were studied. RESULTS: Seventy patients underwent OCT of both eyes during the study period. The average age group was 61.96 years and 35 (50%) were females. Among the fellow eyes, normal foveal contour was noted in 36 (51.4%) eyes and 34 (48.6%) eyes were observed to have vitreo-retinal interface changes. Of them, 13 (18.6%) eyes had some stage of full thickness macular hole and 21 (30.0%) eyes had interface changes. There was no statistical correlation between involved eye lesions (P=0.64) or visual acuity (P=0.55) as predictors of development of either fellow eye lesions or poor visual acuity. CONCLUSION: There is a significant chance of having vitreo-retinal interface findings in the fellow eyes of patients presenting with macular hole. OCT should be considered in both eyes of patients with macular hole to detect early changes in the fellow eyes, which may require an early intervention.

Fundus autofluorescence patterns in type 2A idiopathic juxtafoveolar retinal telangiectasis.

PURPOSE: To describe fundus autofluorescence (FAF) patterns in patients with type 2A idiopathic juxtafoveolar retinal telangiectasia (IJRT). METHODS: We reviewed FAF images, color photographs, and fluorescein angiography (FA) images of 30 eyes from 16 patients with type 2A IJRT. Eyes with presence of subretinal neovascularization or any other retinal pathology were excluded. All the imaging modalities were obtained with a Heidelberg Retina Angiograph (HRA) confocal laser scanning system. RESULTS: The mean age of the patients was 50.7 years, 68.5% female. At baseline, the median best-corrected visual acuity was 20/50. Loss of normal foveal hypoautofluorescence was noted in 93.3% of eyes. All the eyes showed hypoautofluorescence corresponding to intraretinal crystals and pigment clumps. Increased FAF around the pigments was noted in 93.3% of eyes. Increased FAF corresponding to the angiographic leakage from telangiectatic and nontelangiectatic areas was noted in 86.6% of eyes and 80% of eyes, respectively. CONCLUSIONS: Loss of foveal hypoautofluorescence and increased FAF corresponding to the nontelangiectatic angiographic leakage areas were predominant features. Fundus autofluorescence patterns corresponding to color photography and FA findings may further add to the understanding of morphologic alterations in type 2A nonproliferative IJRT at early stages.

Panuveitis as a manifestation of ocular syphilis leading to HIV diagnosis.

Syphilis is a rare cause of panuveitis. We present the case of a 33-year-old man who presented with diminution of vision of three months duration in his left eye (OS), without any other systemic illness. Ophthalmic examination showed features of pauveitis with dense vitreous exudates, disc pallor and sheathing of vessels on fundoscopy. A diagnosis of probable endogenous endophthalmitis was made and vitreous tap performed. Vitreous biopsy showed no growth of fungus or bacteria. Rapid plasma reagin (RPR) and Treponema pallidum hemagglutination (TPHA) test were positive. Enzyme-Linked Immuno Sorbent Assay (ELISA) and Western Blot test were then performed, which revealed concurrent HIV infection. The patient improved dramatically with intravenous penicillin therapy. HIV positive patients may present with panuveitis secondary to ocular syphilis, as the only presenting feature in HIV positive patient in absence of any other systemic features.