Long-Term Follow-Up of Outer Retinal Layers in Patients with Epiretinal Membranes.

PURPOSE: This study aimed to investigate the long-term effect of observed epiretinal membranes on the outer retinal layers and visual acuity. METHODS: It is a retrospective observational study. Subjects with an epiretinal membrane and consecutive optical coherence tomography scans were followed for changes in visual acuity, central macular thickness, ellipsoid zone loss, and outer foveal thickness (OFT). RESULTS: The study consisted of 24 eyes of 22 patients, with a mean follow-up of 5 ± 1.6 years. The mean visual acuity was slightly worse at the last follow-up (0.22 ± 0.36 LogMAR [20/33] vs. 0.27 ± 0.36 LogMAR [20/36], p = 0.05). Ellipsoid zone loss was found in 37.5% of eyes. Vision loss was associated with initial size of ellipsoid disruption (p = 0.048) and age (p = 0.027). A decrease in OFT was associated with an initially larger zone of ellipsoid disruption (p = 0.006) and an initially thicker OFT (p = 0.011). An epiretinal membrane associated with vitreomacular adhesion within 1,000 µm of the foveal center at baseline was associated with ellipsoid zone loss (p = 0.012) but not with a change in visual acuity. CONCLUSIONS: Ellipsoid zone changes were common in this study and tended to enlarge over time. Epiretinal membranes associated with vitreomacular adhesion within 1,000 µm of the foveal center may be a risk factor for ellipsoid zone loss.

Lighting conditions and perceived visual function in ophthalmic conditions.

PURPOSE: To determine the influence of different lighting conditions on perceived visual function in patients of different age, gender, race, and in various ophthalmic diseases. METHODS: A prospective study. A survey given to patients seen in general ophthalmic and retina clinics. Patients were asked four questions: Is your vision better, worse, or the same in (1) bright light vs dim light, (2) indoors or outdoors, (3) beginning or end of the day, and (4) sunny or cloudy day? Parameters tested were age, race, gender, visual acuity, and a variety of ophthalmic conditions. Multivariable models for each question were fit using multinomial regression. Association was considered significant if p < 0.05. RESULTS: A total of 722 patients were enrolled in the study. Patients with lower vision (LogMAR ≥ 0.3) were more likely to indicate they either had better vision indoors or outdoors compared with better vision patients (LogMAR < 0.1). Patients with pseudophakia were also more likely to indicate they had better vision on a cloudy day (OR = 1.9). White patients had double the odds of selecting bright light compared with others. Males were less likely than females to indicate better vision indoors (OR = 0.62). There were no significant associations with age-related macular degeneration (AMD) in the multivariable model. CONCLUSIONS: Most patients did not note any difference in lighting conditions, and although there is explanatory rational for some of the findings in this study, those questions concerning lighting conditions or time of day are not useful for screening of disease. Gender and ethnicity were found to have associations with lighting preferences which needs to be further studied.

Foveal vasculature changes and nonperfusion in patients with diabetes types I and II with no evidence of diabetic retinopathy.

PURPOSE: To analyze the foveal avascular zone (FAZ) in patients with diabetes and no retinopathy vs. controls using OCT angiography (OCT-A). METHODS: Prospective, observational clinical study. Type I and II diabetics with no retinopathy and healthy control patients underwent OCT-A. The FAZ size and capillary density were calculated using Image J and Adobe Photoshop CS8. Statistical analysis was performed using one-way ANOVA with Tukey's multiple comparison test and the Pearson correlation test. RESULTS: Fifty-two eyes of 28 diabetic patients and 28 eyes of 16 healthy controls were enrolled. Type I diabetes patients had a longer disease duration than type II (30.3 ± 10.3 vs. 12.3 ± 9.7 years). The mean superficial capillary plexus (SCP) of the FAZ area was 0.27 ± 0.1, 0.36 ± 0.14, and 0.27 ± 0.12 mm2, for the type I, type II, and controls (p = 0.0058) and was significantly larger in type II diabetics (p < 0.05). The mean DCP (deep capillary plexus) FAZ was significantly larger in type II diabetics vs. controls (0.67 ± 0.2 and 0.52 ± 0.16 mm2 respectively) (p < 0.05). Both type I and type II SCP capillary density were significantly lower than the controls (p < 0.05, p < 0.005), and DCP capillary density was significantly lower in type II vs. controls (p < 0.005). CONCLUSIONS: Type I patients showed fewer changes in the FAZ than the type II group, although their duration of diabetes was longer. Larger studies are needed to better analyze the differences between type I and type II diabetics.

TISSUE PLASMINOGEN ACTIVATOR FOR SUBFOVEAL HEMORRHAGE DUE TO AGE-RELATED MACULAR DEGENERATION: Comparison of 3 Treatment Modalities.

PURPOSE: To analyze and compare the effects of three common treatment modalities for a thick subfoveal hemorrhage due to exudative age-related macular degeneration on final visual acuity and the size of the final subretinal scar. DESIGN: Retrospective case series. SETTING: Single-site, tertiary referral center. PATIENTS: Thirty-nine patients with exudative age-related macular degeneration and acute SMH greater than 250 µm. INTERVENTION: Patients received vitrectomy with a subretinal tissue plasminogen activator (tPA) injection, pneumatic displacement (PD) with intravitreal tPA, or PD without tPA within 2 weeks of presentation. MAIN OUTCOME MEASURE: Functional outcome was determined by Snellen visual acuity. Anatomical outcome was determined as the final disciform scar size. RESULTS: Treatment groups did not differ in age, sex, initial visual acuity, the initial area of the thick subfoveal hemorrhage, follow-up duration, lens status, duration of exudative age-related macular degeneration, previous intravitreal bevacizumab injections, or time from last given injection to the acute thick subfoveal hemorrhage. Final visual acuity improved significantly in both the vitrectomy and subretinal tPA injection group (P < 0.001), and the intravitreal tPA injection group (P = 0.002) but not with PD alone. Patients treated with subretinal tPA achieved 40% ± 54% reduction in final scar area, in contrast to 27% ± 35% decrease in patients treated with intravitreal tPA (P = 0.001). CONCLUSION: Treatment with tPA improves the functional and anatomical outcomes in patients with thick subfoveal hemorrhage due to subfoveal choroidal neovascular membrane secondary to exudative age-related macular degeneration and was superior to PD without tPA. Vitrectomy with subretinal tPA injection reduced the final disciform scar compared with PD with or without intravitreal tPA.

Unilateral, Sectoral Retinal Metastasis of Small-Cell Lung Cancer Mimicking Viral Retinitis.

PURPOSE: To report a case of unilateral, sectoral retinal metastasis of small-cell lung cancer (SCLC) that mimicked cytomegalovirus (CMV) retinitis. METHOD: Case report. RESULTS: A 48-year-old woman presented with a four-week history of a visual field loss in her right eye. She had a past medical history of extensive-stage SCLC with brain metastasis, stable on maintenance atezolizumab for two years. On initial presentation, she was diagnosed with CMV retinitis. No improvement was observed with 4 weeks of oral valganciclovir. Upon referral for a second opinion, her fundus exam appeared compatible with CMV retinitis, and anterior chamber tap for polymerase chain reaction for viral etiologies was performed followed by intravitreal and intravenous ganciclovir without improvement. She was referred for a third opinion, where diagnostic vitrectomy with vitreous and retinal biopsies were consistent with SCLC metastatic to the retina. The patient underwent enucleation of the right eye for definitive pathologic analysis and subsequently was started on additional systemic chemotherapy. CONCLUSION: Retinal metastases are exceedingly rare, particularly retinal metastasis of SCLC. Retinal metastasis should be considered in patients initially diagnosed with viral retinitis who fail to improve despite antiviral therapy, particularly if they have a known history of malignancy. Furthermore, retinal metastasis of SCLC potentially could be misdiagnosed histopathologically as retinoblastoma if the patient's history is unknown and appropriate immunohistochemical stains are not performed.

Primary retinal detachment repair: comparison of 1-year outcomes of four surgical techniques.

PURPOSE: To compare functional and anatomical outcomes of modern methods of repair of primary retinal detachment. MATERIALS AND METHODS: Retrospective interventional comparative case series. A total of 1,226 patients with primary retinal detachment were included in the study. All patients completed 1-year follow-up and were divided into 4 groups: 322 patients underwent scleral buckling surgery, 442 patients underwent pars plana vitrectomy surgery, 316 patients underwent a combination of scleral buckling and vitrectomy surgery, and 56 patients underwent pneumatic retinopexy surgery for the primary repair of retinal detachment. Reattachment success rates, pre- and postoperative visual acuity, complications, and change in refractive error were reviewed. RESULTS: Initial success rate for retinal reattachment was 86% for scleral buckling only, 90% for vitrectomy only, 94% for the combination of scleral buckling and vitrectomy, and 63% for pneumatic retinopexy surgery. Although patients undergoing pneumatic retinopexy had a lower initial success rate, there was no statistically significant difference in initial reattachment rates between the other three groups. There was no statistically significant difference in final visual acuity between the four groups. Complication rates varied among the techniques used. CONCLUSION: Postoperative visual acuity at 1 year did not differ among the various techniques used to repair primary rhegmatogenous retinal detachments. However, scleral buckling, vitrectomy, or a combination of both resulted in an initially better anatomical success rate and fewer operative procedures than pneumatic retinopexy.

Bilateral neuroretinits and exudative retinal detachment with multifocal subretinal deposits secondary to Bartonella henselae infection.

PURPOSE: to describe a case of bilateral neuroretinitis with bullous retinal detachment and multiple subretinal lesions, in a 10-year-old immunocompetent girl. OBSERVATIONS: A broad workup for infectious, inflammatory and masquerade etiologies was done for the patient, resulting in positive IgM and IgG for Bartonella henselae. The patient demonstrated improvement in the visual acuity, and rapid resolution of the retinal detachment and subretinal lesions in both eyes in response to systemic rifampin, doxycycline and corticosteroids. CONCLUSIONS AND IMPORTANCE: Bartonella henselae neuroretinitis may present as an acute form of bullous retinal detachment with multiple subretinal lesions and markedly reduced vision. Significant visual improvement may occur with prompt treatment with a combination of systemic antibiotics and corticosteroids.

Vitamin Analysis Comparison Study.

PURPOSE: We compared and analyzed the concentrations of vitamin C, vitamin E, zinc, and copper in both national and regional brands of dietary supplements recommended for patients who are at risk for macular degeneration. DESIGN: Prospective cross-sectional study. METHODS: National brand name and generic multivitamin formulations for age-related macular degeneration were obtained. Comparative analysis of the vitamin C and vitamin E content was performed by gas chromatography-mass spectrometry and the zinc and copper content was analyzed by atomic absorption spectroscopy in an institutional chemistry laboratory. RESULTS: All national brand name vitamins, both tablet and gel capsule formulations, and generic brands in tablet form were relatively accurate in their product labeling. For most of the samples tested, the measured quantities of vitamin C, vitamin E, zinc, and copper were slightly higher than labeled but not to an amount that would cause any systemic toxicity if taken at the recommended dosages. CONCLUSIONS: Physicians may recommend national brand name vitamins and generic brands in tablet form to their patients with some confidence; however, the content may have some inaccuracies regarding labeling.

Outcomes After the Use of Silicone Oil in Complex Retinal Detachment Repair.

Purpose: This study compares visual acuity (VA), anatomic outcomes, and complications in eyes that underwent complex retinal detachment (RD) repair in which silicone oil (SO) was retained vs removed. Methods: A retrospective chart review of patients undergoing vitrectomy with SO tamponade. The eyes were divided into 2 groups based upon SO removal or retention. Main outcome measures were corrected VA, anatomic outcomes, and the presence of SO-related complications. Results: Fifty-seven eyes with removed SO and 53 eyes with retained SO were identified. In both groups, the mean best-corrected VA (BCVA) at the final visit was significantly better than at baseline. In the retained-SO group, vision improved from 1.79 ± 0.6 to 1.2 ± 0.7 logarithm of the minimum angle of resolution (logMAR) (Snellen, 20/1200 to 20/350) at the final visit (P < .001). In the removed-SO group, mean BCVA improved from 1.84 ± 0.5 at baseline to 1.55 ± 0.6 logMAR units (Snellen, 20/1400 to 20/700) at the visit preceding SO removal (P < .002) and to 1.43 ± 0.6 logMAR units (Snellen, 20/500) at the final visit (P < .001). Complication rates were similar in both groups, apart from RD, which occurred more frequently in the removed-SO group (P = .03). Conclusions: There was similarity in VA and complications among patients with removed or retained SO. Removal of SO may benefit eyes with SO-related complications, but SO retention may decrease the chance of RD and may be indicated in selected cases.

Management of macular holes: a comparison of 1-year outcomes of 3 surgical techniques.

PURPOSE: To evaluate the contribution of internal limiting membrane (ILM) peeling with and without indocyanine green (ICG) to hole closure and functional results in patients with idiopathic macular hole. METHODS: Two hundred sixty-four patients with macular hole underwent pars plana vitrectomy. Of the 264, 240 patients completed 1-year follow-up and were divided into three groups: no ILM peeling (84 patients), ILM peeling without ICG (66 patients), and ICG-assisted ILM peeling (90 patients). RESULTS: Macular holes were closed in 87% of the "no peeling" group, in 75% of the ILM peeling without ICG group, and in 92.3% of the ICG-assisted ILM peeling group. Visual acuity improved 2 Snellen lines in all groups (71%, 68%, and 78%, respectively) after successful surgery. In all 3 groups, 20% gained 4 Snellen lines and 14% reached 20/20 vision. There was no statistically significant difference in outcomes among the three groups. Cataract progression was noted more frequently in the ILM peeling groups. No cases of ICG toxicity were recognized. CONCLUSION: ICG-assisted peeling of the ILM increased macular hole closure rate but was not statistically superior to vitrectomy without membrane peeling. The patients who had ILM peeling without ICG had the least favorable results both anatomically and functionally. The visual gain that was recorded for the majority of the patients after successful macular hole surgery was two Snellen lines.

Disseminated Nocardiosis with retinal abscess in a patient treated for bullous pemphigoid.

PURPOSE: To report a case of disseminated Nocardiosis with retinal and intracranial lesions. OBSERVATIONS: A 49-year-old woman immunosuppressed because of treatment given for bullous pemphigoid presented with altered mental status and multiple intracranial lesions on imaging. The patient was found to have multiple retinal lesions in both eyes, including a subretinal abscess in the right eye. The patient underwent brain biopsy, confirming Nocardia farcinica histopathologically and in culture. CONCLUSIONS AND IMPORTANCE: Ocular Nocardiosis is a rare disease with varying prognosis that requires prompt diagnosis to ensure appropriate medical therapy.

Outcome of eyes developing retinal detachment during the Early Treatment for Retinopathy of Prematurity Study (ETROP).

OBJECTIVE: To report the structural and visual outcomes of eyes in which retinal detachment developed from retinopathy of prematurity (ROP) in the Early Treatment of Retinopathy of Prematurity (ETROP) Study. Method Infants in the ETROP Study with bilateral high-risk prethreshold ROP had 1 eye randomized to early treatment, with the fellow eye managed conventionally. In infants with asymmetric disease, the eye with high-risk prethreshold ROP was randomized to early treatment or conventional management. When a retinal detachment was detected, observation or vitreoretinal surgery (ie, scleral buckling and/or vitrectomy) was provided at the discretion of the individual investigator. At 9 months corrected age, retinal examinations were performed and visual acuities were assessed by masked testers using grating acuity. RESULTS: The ETROP Study enrolled 401 patients with high-risk prethreshold ROP. Retinal detachments occurred in 89 eyes of 63 patients. Follow-up was available for 78 eyes of 56 patients. The detachments were bilateral in 21 patients (38%) and were classified as stage 4A in 30 eyes, stage 4B in 14 eyes, and stage 5 in 16 eyes. Detachments were not classified in 18 eyes. Twelve eyes of 11 patients were observed and 66 eyes of 52 patients underwent vitreoretinal surgery. Attachment of the macula at 9 months persisted or was achieved in 17 (30%) of 56 eyes after vitrectomy with or without scleral buckle, in 6 (60%) of 10 eyes after scleral buckle only, and in 2 (17%) of 12 eyes followed up without surgery. Favorable visual acuity (> or =1.85 cycles/degree) was found in 13 (17%) of the 78 eyes. All 6 eyes that maintained normal visual acuity (> or =3.70 cycles/degree) had a stage 4A detachment (1 of 6 managed by observation, 3 of 6 by scleral buckle, and 2 of 18 by vitrectomy). Eleven eyes with stage 5 detachment underwent vitreoretinal surgery, resulting in 6 with no light perception, 3 with light perception only, and 2 with detection of only the low vision card. CONCLUSIONS: In the ETROP Study, the outcome of retinal detachment owing to ROP was generally poor. Vitreoretinal surgery for retinal detachment was associated with macular attachment in 16 of 48 eyes. Normal acuity was maintained after surgical repair of stage 4A retinal detachment in 5 (21%) of 24 eyes. Vitreoretinal surgery for stage 5 disease was associated with some structural successes but poor functional outcomes.

Choroidal neovascularization after intraocular foreign body injury.

PURPOSE: To report the use of bevacizumab to treat intraocular foreign body-induced choroidal neovascularization. METHODS: An intraocular foreign body was diagnosed clinically and confirmed via optical coherence tomography and head computed tomography. Fluorescein angiography was used to confirm the diagnosis of choroidal neovascular membrane on follow-up examination. The patient was treated with vitrectomy and intravitreal bevacizumab with follow-up at progressive intervals to determine the treatment response. RESULTS: The visual acuity was measured at 20/20 1 year after vitrectomy, with no recurrence of choroidal neovascularization. CONCLUSION: Intravitreal bevacizumab should be considered a useful alternative or adjunct to photocoagulation for the treatment of choroidal neovascularization due to intraocular foreign body.

Management of retained lens fragments after cataract surgery with and without pars plana vitrectomy.

PURPOSE: To compare the clinical course of patients with retained lens particles after phacoemulsification who had early or late pars plana vitrectomy (PPV) and removal of retained lens fragments or who were managed medically. SETTINGS: Private practice and University of Louisville, School of Medicine, Louisville, Kentucky, USA. METHODS: This retrospective review comprised patients who had cataract fragments dislocated into the vitreous during attempted cataract extraction and intraocular lens implantation over an 8-year period. Patients were divided into 3 groups. The early surgery group was treated with PPV and removal of lens fragments within 1 week of cataract surgery. The late surgery group had PPV more than 2 weeks after cataract surgery. The medical therapy group was managed with topical and systemic medications alone. The visual acuity, degree of corneal edema, inflammation, and intraocular pressure (IOP) were measured. Postoperative follow-up was at 7, 14, and 30 days and 1 year. RESULTS: The study evaluated 42 patients (12 early surgery, 15 late surgery, and 15 medical therapy). Demographic characteristics, visual acuity, and mean IOP values at presentation were similar between the 3 groups. Visual acuity was not statistically significantly different between groups at 30 days and 1 year. There was no statistically significant difference in IOP between groups throughout the study period. CONCLUSIONS: Retained lens fragments were managed conservatively with good visual results. Vitrectomy was effective in patients with retained lens fragments not responding to topical and oral medication. Results indicate that surgery can be successfully delayed in certain patients.

Effect of blood on susceptibility to Staphylococcal endophthalmitis.

PURPOSE: The authors examined the effect of blood on susceptibility to experimental endophthalmitis. METHODS: Forty rabbits received an injection of 5-25 colony-forming units of Staphylococcus epidermidis into the vitreous of the right eye. Twenty of these same eyes received a subsequent intravitreal injection of 0.2 mL blood while the remaining 20 received an intravitreal injection of 0.2 mL of a salt solution. All eyes were examined daily for signs of endophthalmitis. Vitreous cultures were obtained on day 2 from 30 of the 40 rabbits. Twenty rabbits were assigned for culture and euthanasia at day 5 and those remaining were cultured and killed at day 7. RESULTS: In rabbits with blood and bacteria, 10 of 15 (67%) were culture positive at 2 days, compared to 2 of 15 (13%) that received salt solution and bacteria (P < 0.01). At days 5 and 7 there was no statistically significant difference in culture results. However, inflammatory scores were significantly higher at days 3-7 in rabbits with blood compared to those with salt solution (P