MULTIMODAL IMAGING OF AN INTRARETINAL TUBERCULAR GRANULOMATOUS NEURORETINITIS.

PURPOSE: To report a rare case of an intraretinal tuberculoma and associated neuroretinitis. METHODS: The patient was evaluated with various imaging modalities including fundus photography, fluorescein angiography, magnetic resonance imaging, and optical coherence tomography; her extensive laboratory workup returned positive for tuberculosis. RESULTS: After initially presenting with no light perception, 13 weeks of antitubercular therapy allowed for visual acuity recovery to 20/30. CONCLUSION: We demonstrate the spectral domain optical coherence tomography characteristics of an intraretinal tuberculoma.

ADULT WITH CHICKENPOX COMPLICATED BY SYSTEMIC VASCULITIS AND BILATERAL RETINAL VASCULITIS WITH RETINAL VASCULAR OCCLUSIONS.

PURPOSE: To describe an adult with chickenpox resulting in systemic vasculitis and bilateral retinal vascular occlusions. METHODS: Single case report. RESULTS: A 58-year-old man with chickenpox complicated by disseminated varicella-zoster systemic and retinal vasculitis resulting in a combined arterial and venous occlusion in one eye with multiple branch retinal vein occlusions in the other eye. There was no evidence of retinitis. The patient systemically improved after treatment with acyclovir and steroids; however, his vision remained poor. CONCLUSION: Chickenpox can be associated with systemic vasculopathy and may rarely result in multiple systemic and ocular infarcts, including severe retinal vascular occlusions.

SCLEROTOMY LEAKAGE IN TRANSCONJUNCTIVAL SMALL-GAUGE PARS PLANA VITRECTOMY: Effect of Removing the Cannula Over the Light Pipe.

PURPOSE: To determine the effect of cannula removal over the light pipe on the incidence of sclerotomy leakage and to evaluate other factors that may influence the incidence of sclerotomy leaks and hypotony on conclusion of small-gauge transconjunctival pars plana vitrectomy. METHODS: Retrospective, interventional clinical study of consecutive patients who underwent small-gauge transconjunctival pars plana vitrectomy at a single academic center. Eyes were divided into a group in which cannulae were removed over the light pipe (Group L) and a group in which cannulae were simply pulled out (Group N). The primary comparison was the comparison in requirement for suturing of sclerotomies between Groups L and N. RESULTS: Forty-eight eyes of 48 patients were included in the study (Group L: 21 eyes; Group N: 27 eyes). In Group L, 14/42 (33%) superior sclerotomies required suturing compared with 7/54 (13%) sclerotomies in Group N (P = 0.024). Superior sclerotomy leaks were also more common in Group L (28/42, 67%) compared with Group N (23/54, 43%, P = 0.024). Similarly, more eyes had hypotony after cannula removal in Group L (11/21; 52%) compared with Group N (5/27; 19%, P = 0.03). There were no differences in any of these measures when comparing fluid-filled to air- or gas-filled eyes. CONCLUSION: Removing the cannula over the light pipe results in a greater frequency of leaking, including leaking that results in hypotony or that requires suturing. The technique of cannula removal affects the risk of leakage and the risk of requiring suturing of a sclerotomy.

Adjunct Intravitreous Triamcinolone Acetonide in the Treatment of Diabetic Macular Edema with Anti-VEGF Agents.

Aims. To compare visual and anatomic outcomes of adjunct intravitreous (IVT) triamcinolone acetonide to antivascular endothelial growth factor (VEGF) injections to IVT anti-VEGF injections alone for center-involving diabetic macular edema (DME) in treatment-naïve eyes. Methods. Retrospective study of treatment-naïve eyes with center-involving DME. The primary outcome was the change in best corrected visual acuity (BCVA) in eyes receiving only IVT anti-VEGF (group 1) and eyes receiving IVT anti-VEGF and adjunct IVT-TA (group 2). Results. Included were 192 eyes. The mean change in BCVA was +3.5 letters in group 1 compared to -3.5 letters in group 2 (p = 0.048). Final macular thickness improved by -94 µm in group 1 versus -68 µm in group 2 (p = 0.26). In group 1, 5/150 eyes compared to 9/42 eyes in group 2 (3.3% versus 21%, p = 0.0005) had a IOP >10 mmHg increase. Six of 126 phakic eyes in group 1 versus 12/33 phakic eyes in group 2 underwent cataract surgery (4.7% versus 36.3%, p = 0.00009). Conclusions. IVT-TA results in no additional benefit in eyes treated with anti-VEGF agents for DME.

Favorable Outcomes of Filamentous Fungal Endophthalmitis Following Aggressive Management.

PURPOSE: To evaluate the visual outcomes following aggressive management of filamentous fungal endophthalmitis with prompt surgical intervention and oral and intravitreal voriconazole. METHODS: Retrospective chart review study of consecutive patients with culture- or biopsy-proven filamentous fungal endophthalmitis treated at an academic referral center. Clinical characteristics, treatment regimens, and visual outcomes were analyzed. RESULTS: Included were 5 patients, 1 with endogenous endophthalmitis due to systemic fusariosis and 4 due to exogenous endophthalmitis (1 with Fusarium, 2 with Scedosporium apiospermum, and 1 with Glomerella spp.). On presentation, 1 patient had best-corrected visual acuity (BCVA) of 20/20. The remaining 4 patients had count-fingers to hand motion (HM) vision. All patients underwent immediate surgical intervention for infection control. All patients received oral or intravenous voriconazole and aggressive intravitreal voriconazole every 2-3 days initially. Intravitreal amphotericin was added if there was poor response to voriconazole alone. Three patients achieved a final BCVA of 20/20, 1 patient achieved BCVA of 20/50, and 1 remained HMs only. CONCLUSION: Aggressive treatment of filamentous fungal endophthalmitis with early surgical intervention, systemic antifungal therapy, and frequent intravitreal injections of voriconazole can result in excellent visual outcomes in some patients.

Evaluation of Automated Teleretinal Screening Program for Diabetic Retinopathy.

IMPORTANCE: Diabetic retinopathy is a leading cause of blindness, but its detrimental effects are preventable with early detection and treatment. Screening for diabetic retinopathy has the potential to increase the number of cases treated early, especially in populations with limited access to care. OBJECTIVE: To determine the efficacy of an automated algorithm in interpreting screening ophthalmoscopic photographs from patients with diabetes compared with a reading center interpretation. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort analysis of 15,015 patients with type 1 or 2 diabetes in the Harris Health System in Harris County, Texas, who had undergone a retinal screening examination and nonmydriatic fundus photography via the Intelligent Retinal Imaging System (IRIS) from June 2013 to April 2014 were included. The IRIS-based interpretations were compared with manual interpretation. The IRIS algorithm population statistics were calculated. MAIN OUTCOMES AND MEASURES: Sensitivity and false-negative rate of the IRIS computer-based algorithm compared with reading center interpretation of the same images. RESULTS: A total of 15 015 consecutive patients (aged 18-98 years); mean 54.3 years with known type 1 or 2 diabetes underwent nonmydriatic fundus photography for a diabetic retinopathy screening examination. The sensitivity of the IRIS algorithm in detecting sight-threatening diabetic eye disease compared with the reading center interpretation was 66.4% (95% CI, 62.8%-69.9%) with a false-negative rate of 2%. The specificity was 72.8% (95% CI, 72.0%-73.5%). In a population where 15.8% of people with diabetes have sight-threatening diabetic eye disease, the IRIS algorithm positive predictive value was 10.8% (95% CI, 9.6%-11.9%) and the negative predictive value was 97.8% (95% CI, 96.8%-98.6%). CONCLUSIONS AND RELEVANCE: In this large urban setting, the IRIS computer algorithm-based screening program had a high sensitivity and a low false-negative rate, suggesting that it may be an effective alternative to conventional reading center image interpretation. The IRIS algorithm shows promise as a screening program, but algorithm refinement is needed to achieve better performance. Further studies of patient safety, cost-effectiveness, and widespread applications of this type of algorithm should be pursued to better understand the role of teleretinal imaging and automated analysis in the global health care system.

PARS PLANA VITRECTOMY FOR SYMPTOMATIC EPIRETINAL MEMBRANES IN EYES WITH 20/50 OR BETTER PREOPERATIVE VISUAL ACUITY.

PURPOSE: To evaluate pars plana vitrectomy with membrane peel for symptomatic epiretinal membranes in eyes with preoperative best-corrected visual acuity of 20/50 or better. METHODS: Patients with symptomatic epiretinal membrane and 20/50 or better vision who underwent pars plana vitrectomy with membrane peel by a single surgeon at our institution between January 2007 and January 2014 were identified. The principal outcomes measured were best-corrected visual acuity and central subfield macular thickness at 1, 6, and 12 months of follow-up. Subjective improvement in patient symptoms and complications were also documented. RESULTS: Thirty-three eyes of 33 consecutive patients were included in this retrospective case series. Mean preoperative best-corrected visual acuity was 20/40 and improved to 20/28 (P = 0.00008) at Month 12. Mean central subfield macular thickness improved from 437 µm preoperatively to 391 µm by Month 1 (P = 0.00006) and 388 µm at 12 months (P = 0.00142). Seventy-three percent (24 of 33) of patients (95% confidence interval: 55.6-85.1%) reported improvement of visual symptoms during the follow-up period. Of the 13 patients who were phakic preoperatively, 6 patients (46.1%, 95% confidence interval: 23.2-70.9%) underwent phacoemulsification surgery within 1 year of vitrectomy. CONCLUSION: Patients experienced a gradual gain in acuity and improvement of symptoms after pars plana vitrectomy with membrane peel. Cataract progression necessitating cataract surgery is common in phakic patients.

Long-term risk of glaucoma after encircling scleral buckle.

PURPOSE: To determine the long-term risk of developing glaucoma after an encircling scleral buckle procedure. METHODS: Retrospective case series of patients with at least 10 years of follow-up who underwent successful, unilateral retinal detachment repair by encircling scleral buckle. The main outcome measure was the proportion of eyes that developed perimetric glaucoma of buckled compared with fellow eyes. RESULTS: Sixty-eight patients with an average postoperative follow-up of 21 years were included. Perimetric glaucoma developed in 13% (9 patients), and an additional 22% (15 patients) had preperimetric glaucoma or were glaucoma suspects. Perimetric glaucoma was present in 2.9% of patients in the buckled eye only, 8.8% in the fellow eye only (P = 0.27), and 1.3% in both eyes. There was no increased prevalence of ocular antihypertensive use in buckled (5.9%) compared with fellow eyes (11.8%, P = 0.36). CONCLUSION: Our study showed no evidence of increased risk for developing glaucoma after repair of retinal detachment in eyes that underwent an encircling scleral buckling technique compared with fellow eyes with follow-up of at least 10 years.

Autoimmune-Related Retinopathy and Optic Neuropathy Accompanied by Anti-GAD Antibodies.

Autoimmune-related retinopathy and optic neuropathy is characterized by visual loss in the presence of antibodies against retina or optic nerve antigens in the absence of neoplasia. We report a case with progressive central visual loss accompanied by latent autoimmune diabetes in an adult. Visual fields, multimodal imaging and electrophysiological testing showed characteristic changes without evidence of neoplasia on positron emission tomography. Immunologic testing revealed abnormal reactivity against a 20 kDa optic nerve antigen and 40 kDa and 62 kDa retina antigens along with antibodies against anti-glutamic acid decarboxylase, a constellation which we believe to be unique.

Current treatment of toxoplasma retinochoroiditis: an evidence-based review.

Objective. To perform an evidence-based review of treatments for Toxoplasma retinochoroiditis (TRC). Methods. A systematic literature search was performed using the PubMed database and the key phrase "ocular toxoplasmosis treatment" and the filter for "controlled clinical trial" and "randomized clinical trial" as well as OVID medline (1946 to May week 2 2014) using the keyword ''ocular toxoplasmosis". The included studies were used to evaluate the various treatment modalities of TRC. Results. The electronic search yielded a total of 974 publications of which 44 reported on the treatment of ocular toxoplasmosis. There were 9 randomized controlled studies and an additional 3 comparative studies on the treatment of acute TRC with systemic or intravitreous antibiotics or on reducing the recurrences of TRC. Endpoints of studies included visual acuity improvement, inflammatory response, lesion size changes, recurrences of lesions, and adverse effects of medications. Conclusions. There was conflicting evidence as to the effectiveness of systemic antibiotics for TRC. There is no evidence to support that one antibiotic regimen is superior to another so choice needs to be informed by the safety profile. Intravitreous clindamycin with dexamethasone seems to be as effective as systemic treatments. There is currently level I evidence that intermittent trimethoprim-sulfamethoxazole prevents recurrence of the disease.