The Removal of Hydrogel Explants: An Analysis of 467 Consecutive Cases.

PURPOSE: To describe the complications associated with hydrogel explants and to describe the indications, surgical technique, and risks involved in the removal of a hydrogel explant. DESIGN: Single-center, retrospective interventional case series. PARTICIPANTS: Patients who underwent surgical removal of a symptomatic, swollen hydrogel explant. METHODS: We reviewed the medical records of 457 consecutive patients (467 eyes in total) who underwent surgical removal of a symptomatic, swollen episcleral MIRAgel (MIRA Inc., Waltham, MA) explant at the Radboud University Medical Center from 1998 to 2011. We reviewed the initial symptoms, clinical findings, surgical aspects, and intraoperative and postoperative complications. MAIN OUTCOME MEASURES: Presenting symptoms, retinal redetachment rate, and intraoperative scleral perforation. RESULTS: The median interval between initial placement of the hydrogel explant and removal of the explant was 159 months. More than 34% of the episcleral hydrogel explants developed symptomatic swelling and required surgical removal. Intraoperative scleral perforation or retinal redetachment related to the removal of the explant occurred in 11% of patients. CONCLUSIONS: The percentage of explants that ultimately develop symptomatic swelling is considerably higher than reported previously. A swollen hydrogel explant can be removed many years after the primary detachment surgery, and 11% of cases develop intraoperative scleral perforation or retinal redetachment.

EXTENT AND LOCATION OF INTRARETINAL AND SUBRETINAL FLUID AS PROGNOSTIC FACTORS FOR THE OUTCOME OF PATIENTS WITH OPTIC DISK PIT MACULOPATHY.

PURPOSE: To determine if baseline fundoscopic and optical coherence tomography (OCT) features influence the clinical course of optic disk pit maculopathy. METHODS: A multicenter retrospective case note review was undertaken, using standardized OCT and clinical data collection. Visual success was defined as at least a two-line visual acuity improvement, anatomical success as full resolution of OCT foveal fluid with restoration of the normal foveal contour, and partial anatomical success as incomplete resolution of the OCT foveal fluid. Outcomes were compared with a synthesis of the literature, using similar eligibility criteria. RESULTS: Of 36 patients (36 eyes), 2 spontaneously improved and 34 underwent surgery. Visual success was achieved in 64% of surgical cases, anatomical success in 36%, and partial anatomical success in 47%. Cases with multilayer intraretinal and subretinal fluid were less likely to have visual success (P = 0.003). Cases where the fluid did not extend to the macular arcade vessels also had better visual and anatomical outcomes (P = 0.004 and 0.005, respectively). CONCLUSION: Fundoscopic and OCT features can help predict surgical outcome in optic disk pit maculopathy.

[Acute onset of floaters, even without flashes, is an urgent ophthalmic warning sign]. / Plotse toename van mouches volantes is een alarmsymptoom, ook zónder lichtflitsen.

Acute onset of floaters is most likely caused by a posterior vitreous detachment (PVD). A PVD can lead to a retinal tear and subsequently to a retinal detachment with permanent vision loss if left untreated. A patient who presents to a primary care physician with acute onset of floaters, in the absence flashes or visual field loss, is often referred to an ophthalmologist without urgency. In the current Dutch general practitioners standard, acute onset or increase of floaters, without flashes or visual loss, is not included as a reason for urgent referral to an ophthalmologist. Patients who present with acute onset of floaters without flashes have a 14-23% risk of having a retinal tear. Risk factors for developing a retinal tear are high myopia, trauma, cataract surgery, or a retinal tear or retinal detachment in the past medical or family history. Patients with acute onset of floaters should be triaged for urgent ophthalmologic assessment.

Acute Endophthalmitis after Cataract Surgery: Clinical Characteristics and the Role of Intracameral Antibiotic Prophylaxis.

PURPOSE: To evaluate the clinical characteristics and investigate the role of surgical antibiotic prophylaxis (SAP) in acute endophthalmitis cases after cataract surgery. DESIGN: Retrospective, consecutive case series. PARTICIPANTS: A total of 126 patients referred to a tertiary center from 2007 to 2015 for acute endophthalmitis after unilateral cataract surgery. METHODS: All patients who underwent a vitreous biopsy were included. Clinical and microbiology data were reviewed, and associations with visual outcome were analyzed using multivariate logistic regression. Data regarding SAP via intracameral injection were also retrieved. MAIN OUTCOME MEASURES: Bacterial culture results and visual acuity outcome. RESULTS: Bacterial growth was observed in 92 of 126 cases (73%). Among these positive cultures, 49 (53.3%), 29 (31.5%), and 13 (14.1%) were coagulase-negative staphylococci, other gram-positive, and gram-negative bacteria, respectively. Among the 77 gram-positive strains tested, 76 (98.7%) were vancomycin-sensitive; among the 12 gram-negative strains tested, all 12 (100%) were ceftazidime-sensitive. Best achieved visual acuity outcome was ≥20/40 Snellen in 77 of 114 cases (67.5%). On multivariate analysis, we found an association between visual outcome of worse than 20/40 Snellen and a positive culture of more virulent bacteria (gram-negative and other gram-positive groups) and presentation with light perception or worse, with an odds ratio of 3.3 and 3.0, respectively. A subgroup of 25 cases (19.8%) developed endophthalmitis despite receiving a SAP by cefuroxime at the end of cataract surgery. CONCLUSIONS: Two-thirds of the patients in this endophthalmitis cohort experienced a visual outcome of ≥20/40 Snellen. Efficacy of primary treatment with vancomycin combined with ceftazidime is supported by this study. A subgroup treated prophylactically with cefuroxime demonstrated that SAP alone does not prevent endophthalmitis. This highlights the importance of surgical factors in the prevention of postoperative endophthalmitis.

Central retinal vessel blood flow after surgical treatment for central retinal vein occlusion.

PURPOSE: The purpose of this study was to determine the effect of radial optic neurotomy and retinal endovascular surgery on retinal blood flow velocity in patients with central retinal vein occlusion. METHODS: A prospective interventional case series. RESULTS: Six patients with a central retinal vein occlusion of <12 months' duration were included. Three patients were treated with radial optic neurotomy and three with retinal endovascular surgery. Five patients had decreased central venous blood flow velocity compared with the fellow eye, and one patient had similar central venous blood flow in both eyes at baseline. All study eyes had decreased central venous blood flow velocity compared with the fellow eye at 24 weeks after treatment. Two patients had a further decrease in central venous blood flow during the study. Three patients had no minimal change in central venous blood flow, and 1 patient showed a minimal increase from 3 cm/s at baseline to 4 cm/s 24 weeks after surgery. CONCLUSION: Radial optic neurotomy and retinal endovascular surgery do not alter central retinal blood flow velocity. The place of these therapies in the treatment for central retinal vein occlusion should be questioned.

Optic nerve compression as a late complication of a hydrogel explant with silicone encircling band.

PURPOSE: To present a complication of compressive optic neuropathy caused by a swollen hydrogel explant and posteriorly displaced silicone encircling band. OBSERVATIONS: A 72-year-old female patient presented with progressive visual loss and a tilted optic disc. Her medical history included a retinal detachment in 1993 that was treated with a hydrogel explant under a solid silicone encircling band. Visual acuity had decreased from 6/10 to 6/20 and perimetry showed a scotoma in the temporal superior quadrant. On Magnetic Resonance Imaging (MRI), compression of the optic nerve by a displaced silicone encircling band inferior nasally in combination with a swollen episcleral hydrogel explant was observed. Surgical removal of the hydrogel explant and silicone encircling band was uneventful and resulted in improvement of visual acuity and visual field loss. CONCLUSIONS AND IMPORTANCE: This is the first report on compressive optic neuropathy caused by swelling of a hydrogel explant resulting in a dislocated silicone encircling band. The loss of visual function resolved upon removal of the explant and encircling band.

Antibodies against the CUB1-2 domains of ADAMTS13 in a patient with benign monoclonal gammopathy: no causal relationship.

We present a patient with a history of benign monoclonal gammopathy, who developed thrombotic thrombocytopenic purpura (TTP), initially presenting as bilateral serous retinal detachment. Plasma of the patient contained high titers of anti ADAMTS13 antibodies that were directed towards the disintegrin/TSR1/cysteine-rich/spacer and CUB1-2 domains. ADAMTS13 activity was undetectable. Total IgG purified from plasma of the patient partially inhibited ADAMTS13 activity. In contrast, the isolated M-protein did neither bind to, nor inhibit activity of ADAMTS13. We conclude that in this patient the monoclonal gammopathy and TTP co-existed as distinct pathological entities.

[A man with progressive diplopia]. / Een man met progressieve diplopie.

A 71-year-old man presented with progressive diplopia due to swelling of a Miragel explant. Removal of the explant resulted in relief of symptoms.

Acute endophthalmitis after cataract surgery: 250 consecutive cases treated at a tertiary referral center in the Netherlands.

PURPOSE: To evaluate the clinical characteristics, bacterial culture, and visual outcome of patients with acute endophthalmitis after cataract surgery. DESIGN: Retrospective consecutive interventional case series. METHODS: Clinical notes from patients treated for acute endophthalmitis after cataract surgery in a single center from 1996 to 2006 were reviewed. Patients with less than 1 month of follow-up and missing bacterial cultures were excluded. Vitreous biopsy or primary vitrectomy followed by intravitreal injection of vancomycin and ceftazidime (+/- prednisolone) was performed. Main outcome measures were bacterial culture and final visual acuity. RESULTS: Bacterial cultures (total 250 cases) showed bacterial growth in 166 cases (66.4%). From these 166 cultures, 89 (53.6%) revealed gram-positive coagulase-negative, 63 (38.0%) other gram-positive, 10 (6.0%) gram-negative, and 4 (2.4%) polymicrobial cultures. Vitreous biopsy with intravitreal antibiotics injection was performed in 225 (90.0%) of cases. Primary vitrectomy with intravitreal antibiotics was performed in 25 eyes (10.0%). Final visual acuity >/=0.5 was achieved in 129 (51.6%) of all cases, 54 (60.7%) of the 89 gram-positive coagulase-negative cultures, 20 (31.7%) of the 63 other gram-positive cultures, 5 (50.0%) of the 10 gram-negative cultures, and 9 (45.0%) of the 20 Staphylococcus aureus cultures. There was no additional effect for treatment by primary vitrectomy or intravitreal prednisolone. CONCLUSIONS: Treatment outcome after endophthalmitis is highly dependent on the causative organism. Treatment outcomes for gram-negative bacteria and S. aureus may be better than previously reported. Prompt treatment of endophthalmitis remains essential and the role of complete primary vitrectomy remains subject to debate.