OUTER RETINAL TUBULATION MAY RESULT FROM FIBROSED TYPE 2 NEOVASCULARIZATION: Clinical Observations and Model of Pathogenesis.

PURPOSE: To investigate the role of Type 2 macular neovascularization with subsequent subretinal fibrosis in the pathogenesis of outer retinal tubulation (ORT). METHODS: We conducted a retrospective cohort study of patients with stabilized inactive exudative macular degeneration who had been treated with intravitreal injections of antivascular endothelial growth factor agents. Baseline fluorescein and optical coherence tomography images were included. Macular neovascularizations (MNVs) were classified by type and size. Consecutive optical coherence tomography images analyzed for ORT development. RESULTS: One hundred forty-four eyes of 134 patients were included in this study. Sixty eyes presented with pure Type 1 MNV. Eighty-four eyes presented with some Type 2 component of MNV. In total, evidence of ORT is shown in 55 (38%) eyes. In the Type 1 group, 6.7% developed ORT. Outer retinal tubulation developed in 61% of eyes with some Type 2 component of the MNV. Among eyes that developed ORT, 92.7% presented with some Type 2 component. In a multivariate analysis, Type 2 membranes on optical coherence tomography (22.2 [6.1-80.8]; P < 0.001), larger MNV size {>1 DA (5.1 [1.1-24.2]; P = 0.041) and >1.5 DA (9.0 [1.8-44.0]; P = 0.007)}, and presence of subretinal fibrovascular material (3.1 [1.1-8.5]; P = < 0.03) are associated with higher odds of ORT formation. Once the ORT is formed, fibrosis was observed directly underlying the ORT on SD-optical coherence tomography in 70.9% of cases. CONCLUSION: Type 2 membranes at presentation predict ORT formation. Fibrosis often underlies ORT. This suggests that contraction of Type 2 MNV-derived fibrosis may be important in ORT formation.

Optic Nerve Sheath Fenestration for Treatment of Retrolaminar Silicone Oil Migration.

The authors report the case of a 75-year-old man with preexisting glaucoma and recurrent retinal detachment who underwent intraocular silicone oil placement OD resulting in subsequent retrolaminar silicone oil migration to the optic chiasm and vision loss OS. MRI showed silicone oil tracking posteriorly along the right optic nerve to the chiasm. He was placed on high-dose corticosteroids and underwent a successful optic nerve sheath fenestration with improvement of vision in the contralateral eye. Clinicians should be cognizant of the potential for translaminar posterior migration of intraocular silicone oil, as well as the utility of optic nerve sheath fenestration to decompress the anterior visual pathways and restore vision.

CORRELATION OF VISUAL ACUITY WITH FIBROTIC SCAR LOCATION IN TREATED NEOVASCULAR AGE-RELATED MACULAR DEGENERATION EYES.

PURPOSE: To determine whether the optical coherence tomography location of a subfoveal fibrovascular scar is correlated with visual outcome in eyes successfully treated with antivascular endothelial growth factor agents for neovascular age-related macular degeneration. METHODS: Fifty-six eyes from 56 patients with a subfoveal disciform scar after antivascular endothelial growth factor treatment were included. The initial and final visual acuity, fluorescein angiography, and spectral domain optical coherence tomography scar characteristics were retrospectively reviewed. RESULTS: Thirty-five of 56 eyes (62.5%) were classified as having entirely subretinal pigment epithelial (sub-RPE) scars, and 21 eyes (37.5%) had subretinal component scars. Mean initial visual acuity was similar between sub-RPE and subretinal scars (20/100 vs. 20/125, P = 0.517); mean final visual acuity was better in the sub-RPE scar group (20/60 vs. 20/200, P = 0.001). Eyes with sub-RPE scar had better preservation of the external limiting membrane, ellipsoid layer, and retinal thickness (P < 0.001, P = 0.017, P = 0.004, respectively) than subretinal component scar eyes. There was no difference between the groups in scar thickness or scar area (P = 0.707, P = 0.186, respectively). CONCLUSION: Sub-RPE location of subfoveal scarring in eyes treated for neovascular age-related macular degeneration is associated with better preservation of outer retinal structures and better vision, when compared with a subretinal scar.

Caruncular fixation in medial canthal tendon repair: the minimally invasive purse string suture for tendinous laxity and medial ectropion.

PURPOSE: To describe a surgical technique for repair of medial ectropion that simply and reliably addresses tendinous laxity and punctal eversion. METHODS: Prospective, single-blind, consecutive case study of 54 patients (79 eyes) by 3 surgeons. The subject population consisted of 33 males and 21 females, with a mean age of 81 years (SD = 9, range = 64-97). The presenting mechanisms of ectropion were as follows: cicatricial (n = 10), paralytic (n = 1), involutional (n = 62), mechanical (n = 3), and congenital (n = 3). Ectropion and punctal eversion was surgically addressed by use of a purse string suture that incorporated closure of a medial spindle incision and deep fixation to the base of the caruncle. RESULTS: The average postoperative follow-up period was 147 days (SD = 291, range 8-2,352). Sixty-four eyes had a presenting complaint of tearing (81%), with 50 eyes (78%) achieving complete resolution (p = 0.0001). Eyelid malposition was determined to be anatomically corrected in 34 of 35 eyes (97%, p = 0.0001). Four of the 79 operated eyelids had recurrence of ectropion (5%). All other reported complications were minor, resolved without sequalae. CONCLUSION: The technique demonstrated safety, efficacy, and reproducibility, regardless of ectropion mechanism. Incorporation of a purse string suture between the lower eyelid portion of the medial canthal tendon and the caruncle produces a reliable posterior-superior fixation parallel to the vectors of the posterior limb of the medial canthal tendon. This technique is equally effective as a primary correction method or when used in combination with other procedures.

Sutureless intrascleral fixation of intraocular lens through self-sealing sclerotomy wounds using haptic externalization and reinternalization technique.

In eyes with absent or insufficient capsule support, three-piece posterior chamber intraocular lens (PC IOL) may be fixed to the sclera. Previous techniques involve the use of sutures, flaps, glue, needles, trocars, or intrascleral tunnels to fixate the distal tips of the haptics intrasclerally. Herein we describe a modified technique for the sutureless scleral fixation of a standard 3-piece PC IOL using self-sealing sclerotomies created with a crescent blade and a 20-gauge microvitreoretinal blade, and then reinserting the haptics to leave the tips inside the vitreous cavity. We believe the relative simplicity of this technique makes it widely applicable for the placement of an IOL with insufficient capsule support.

MACULAR TELANGIECTASIA TYPE 2 IN AN OTHERWISE HEALTHY TEENAGE BOY WITH CONSANGUINEOUS PARENTS.

PURPOSE: To report a case of macular telangiectasia Type 2 in a teenage boy with consanguineous parents. METHOD: Clinical case report and literature review. RESULTS: A healthy 14-year-old boy presented with mildly reduced vision in both eyes. Visual acuity was 20/30 in the right eye and 20/25 in the left eye. Fundus examination revealed intraretinal crystals in both eyes and an intraretinal pigment plaque temporal to the fovea in the left eye. Neither eye showed evidence of choroidal neovascular membrane or peripheral telangiectasia. Fluorescein angiography revealed temporal juxtafoveal leakage in both eyes. Spectral-domain optical coherence tomography showed ellipsoid layer and external limiting membrane disruption in the right eye and an inner retinal pigment plaque with shadowing in the left eye. The patient was of South Asian descent, and his parents were first cousins. His younger brother and parents were unaffected with a normal fundus examination. CONCLUSION: This is the youngest reported case of a healthy individual with MacTel Type 2, which usually manifests in the fifth or sixth decade. This is also the only reported case of MacTel Type 2 with consanguineous parents. This proband offers a unique opportunity to study possible monogenic etiologies of the condition.

The effects of cataract surgery on patients with wet macular degeneration.

PURPOSE: To explore whether cataract surgery contributes to the progression of wet age-related macular degeneration (wet AMD). DESIGN: Retrospective cohort study. METHODS: Retrospective review was performed of consecutive patients with wet AMD who underwent cataract surgery at the midpoint of a 1-year study window. A control arm included wet AMD eyes treated with anti-vascular endothelial growth factor (VEGF) injections that did not undergo cataract surgery for a 1-year period. Best-corrected visual acuity (BCVA), number of anti-VEGF injections, and optical coherence tomography (OCT) features were compared between the 2 arms. RESULTS: Forty eyes in the surgical group and 42 in the nonsurgical group were included. BCVA was equivalent in the first half of the study, and became significantly better in the surgical group vs the nonsurgical group (0.23 ± 0.65 vs 0.11 ± 0.59 logMAR improvement, P = .049). There was no change in the number of injections given 6 months before vs after the midpoint in the surgical group (P = .921). The mean OCT central retinal thickness became greater in postsurgical eyes compared to nonsurgical eyes (265.4 ± 98.4 µm vs 216.4 ± 58.3 µm, P = .011). Surgical eyes were more likely to develop new or worse cystoid changes after the study midpoint (13 surgical eyes [54.2%] vs 9 nonsurgical eyes [28.1%], P = .048). CONCLUSIONS: Cataract surgery leads to vision improvement and does not appear to contribute to worsening of wet AMD. However, anatomic changes based on OCT analysis suggest a subclinical susceptibility to postoperative cystoid macular edema or exacerbation of choroidal neovascularization.

The effect of antivascular endothelial growth factor therapy on the development of neovascular glaucoma after central retinal vein occlusion: a retrospective analysis.

Purpose. Ischemic central retinal vein occlusion (CRVO) eyes are at high risk of developing neovascular glaucoma (NVG). Our purpose is to investigate the effect of anti-VEGF therapy for macular edema after CRVO on the development of neovascular glaucoma (NVG) in ischemic CRVO eyes. Methods. This is a retrospective case series of 44 eyes from 44 patients with CRVO treated with anti-VEGF therapy for macular edema. The primary outcome was the development of NVG. Results. Of the 44 eyes, 14 eyes had ischemic CRVO, and 30 eyes had nonischemic CRVO. Nonischemic eyes received a mean of 8.4 anti-VEGF doses, over mean follow-up of 24 months. One nonischemic eye (3.3%) developed NVD but not NVG. The 14 ischemic eyes received a mean of 5.6 anti-VEGF doses, with mean follow-up of 23 months. Of these 14 ischemic eyes, two eyes (14%) developed iris neovascularization and 3 eyes (21%) developed posterior neovascularization. Three of these 5 eyes with neovascularization progressed to NVG, at 19.7 months after symptom onset, on average. Conclusion. Anti-VEGF therapy for macular edema may delay, but does not prevent, the development of ocular NV in ischemic CRVO. Significant risk of NVG still exists for ischemic CRVO eyes.