Outcomes of Primary Vitrectomy for Rhegmatogenous Retinal Detachment With No Postoperative Positioning.

Purpose: To evaluate the anatomic and visual outcomes of primary vitrectomy for rhegmatogenous retinal detachment (RRD) repair using no amount of postoperative prone positioning to clarify the role of face-down posturing for RRD reattachment. Methods: This retrospective consecutive interventional case series comprised patients who had primary vitrectomy for RRD repair. The surgical outcomes, single-surgery anatomic success rate, and postoperative best-corrected visual acuity (BCVA) were assessed. The primary objective was to evaluate the anatomic and visual outcomes of vitrectomy RRD reattachment using no postoperative prone positioning. Results: This study comprised 116 eyes of 116 patients. Single-surgery anatomic success was achieved in 112 (96.5%) of 116 eyes. The single-surgery anatomic success rate was 100% in phakic patients (n = 56) and 93% in pseudophakic patients (n = 60), with both groups having an improvement in the mean BCVA. Conclusions: Primary vitrectomy with no postoperative prone positioning is a successful surgical intervention for RRD repair. The anatomic closure rate in this study is one of the highest reported in the literature and involved a large number of macula-off RRDs, with minimal complications and a significant improvement in BCVA, primarily using 14% perfluoropropane for gas tamponade.

Diagnostic implications of Gardner Syndrome, case report of a familial adenomatous polyposis (FAP) variant, for eye care professionals.

INTRODUCTION: Gardner Syndrome (GS) is a variant of Familial Adenomatous Polyposis (FAP). FAP is characterized by several precancerous adenomatous intestinal polyps while GS has additional distinct extraintestinal features such as congenital hypertrophy of retinal epithelium (CHRPE), which we describe here. PRESENTATION OF CASE: 42-year-old male with GS presenting with flashes and floaters observed to have CHRPE-like lesions characteristic of GS. DISCUSSION: Subtle CHRPE findings differentiate pathological, described in the present case, from non-pathological etiologies and may guide further management. CONCLUSION: Here we present the signs and symptoms that raise suspicion for GS associated with CHRPE and how to approach management late in the disease presentation.

Relationship Between Macular Thickness and Visual Acuity in the Treatment of Diabetic Macular Edema With Anti-VEGF Therapy: Systematic Review.

Purpose: To examine the relationship between central macular thickness (CMT) measured by optical coherence tomography (OCT) and visual acuity (VA) in patients with center-involving diabetic macular edema (DME) receiving antivascular endothelial growth factor (anti-VEGF) treatment. Methods: Peer-reviewed articles from 2016 to 2020 reporting intravitreal injections of bevacizumab, ranibizumab, or aflibercept that provided data on pretreatment (baseline) and final retinal thickness (CMT) and visual acuity (VA) were identified. The relationship between relative changes was assessed via a linear random-effects regression model controlling for treatment group. Results: No significant association between the logarithm of the minimum angle of resolution (logMAR) VA and CMT was found in 41 eligible studies evaluating 2667 eyes. The observed effect estimate was a 0.12 increase (95% CI, -0.124 to 2.47) in logMAR VA per 100 µm reduction in CMT after treatment change. There were no significant differences in logMAR VA between the anti-VEGF treatment groups. Conclusions: There was no statistically significant relationship between the change in logMAR VA and change in CMT as well as no significant effect of the type of anti-VEGF treatment on the change in logMAR VA. Although OCT analysis, including measurements of CMT, will continue to be an integral part of the management of DME, further exploration is needed on additional anatomic factors that might contribute to visual outcomes.

Long-Acting Fluocinolone Acetonide Intravitreal Implant for Recurrent Bilateral Non-Infectious Posterior Uveitis.

Purpose: Our case emphasizes the utility of long-acting intravitreal fluocinolone implants (YUTIQ) for managing recalcitrant forms of non-infectious posterior uveitis, NIPU. Patient: We present a case of bilateral NIPU refractory to topical corticosteroids and intravitreal triamcinolone and dexamethasone. Results: Management with bilateral YUTIQ improved local ocular inflammatory control with improved vision and anatomical outcomes. Conclusion: NIPU can develop into recurrent forms resistant to short-acting therapeutics. Long-acting efficacy with YUTIQ emphasizes the need to recognize such refractory NIPU cases.

Combined Retinoschisis and Rhegmatogenous Retinal Detachment With a Very Large Outer Retinal Hole.

This case report describes a diagnosis of retinoschisis and retinal detachment in a patient in their 40s who presented with acute onset of flashes and floaters.

Vitrectomy with Silicone Oil Tamponade and Single-Dose Intravitreal Methotrexate for Recurrent Retinal Detachment with Proliferative Vitreoretinopathy.

Our case emphasizes the approach of a single-dose of intraoperative methotrexate (MTX) - applied directly into silicone oil - to arrest the anomalous progression of proliferative vitreoretinopathy (PVR). A 78-year-old male presented with severe vision loss secondary to a pseudophakic macula-off rhegmatogenous retinal detachment oculus sinister (OS). He was initially treated with primary pars plana vitrectomy and intraocular gas; however, the patient developed recurrent macula-off retinal detachment complicated by proliferative vitreoretinopathy OS. Subsequent management involved vitrectomy with membrane removal, silicone oil tamponade, and adjuvant intravitreal MTX. The patient had an uneventful postoperative recovery with a dramatic vision improvement after silicone oil removal OS. Here, we highlight the use of silicone oil tamponade with single-dose adjuvant MTX for the management of complex retinal detachment associated with proliferative vitreoretinopathy.

Retrolenticular Vitreous Opacities as a Diagnostic Indicator of Systemic Amyloidosis.

Purpose: Systemic amyloidosis is a group of rare, life-threatening disorders characterized by the deposition of amyloid plaques in numerous tissues. Vitreous involvement can occur in amyloidosis and here we describe critical diagnostic findings. Methods: Case report of vitreous amyloidosis diagnosis confounded by non-specific presentation. Results: Despite false-negative vitreous biopsies, in the setting of previous vitreoretinal surgery, the case reveals vitreous opacities, decreased visual acuity, and retinal neovascularization as critical signs in ocular amyloidosis. Conclusions: Here we present the signs and symptoms that raise suspicion for vitreous amyloidosis and how to approach diagnosis early in the disease presentation.

Trocar-Based Surgical Approach to Suprachoroidal Hemorrhage Drainage.

Purpose: Suprachoroidal hemorrhage is an uncommon but serious ocular condition that typically occurs in the setting of intraocular surgery and trauma. We present an external trans-conjunctival vitreoretinal trocar-cannula-based drainage of suprachoroidal hemorrhage as a viable surgical approach. Methods: Case report. Results: Trans-conjunctival trocar-cannula-based drainage of suprachoroidal hemorrhage is a safe and efficacious surgical approach to drainage of large choroidal hemorrhages. Conclusions: Although discrepancies persist regarding the optimal surgical approach to suprachoroidal hemorrhage management; herein, we describe the successful execution of an external trans-conjunctival vitreoretinal trocar-cannula-based drainage of suprachoroidal hemorrhage.

Chronic Unilateral Uveitis with Macular Edema Secondary to Dabrafenib for Pilocytic Astrocytoma.

This report describes a unique case of chronic unilateral anterior uveitis associated with macular edema while on oral dabrafenib treatment for chronic recurrent pilocytic astrocytoma. After gradual taper of prednisolone acetate OS, the patient developed recurrent mild low-grade anterior uveitis and macular edema OS that required low dose of prednisolone acetate OS to prevent recurrences while on oral dabrafenib. When oral dabrafenib was temporarily discontinued for 3 months due to her ocular inflammation, she had no flares of her uveitis; however, her tumor increased significantly in size. The collaborative decision was made to continue her oral dabrafenib while on topical anti-inflammatory therapy for her uveitis. Clinicians should be aware of this potential unilateral sequela of uveitis secondary to dabrafenib. Further investigation should be conducted to identify factors that may place certain patients at higher risk for this complication.

Antioxidants for the Treatment of Retinal Disease: Summary of Recent Evidence.

Retinal tissue is prone to oxidant burden and oxidative stress secondary to the generation of reactive oxygen species from high metabolic demand. The formation of reactive oxygen species occurs primarily from the mitochondrial respiratory chain as well as several enzymatic and oxidation reactions that occur in the neurosensory retina and retinal pigment epithelium. This oxidative stress has been implicated in the pathogenesis of several retinal diseases and the role of antioxidants as a therapeutic treatment shows promise in slowing the progression of certain diseases. The aim of this narrative review is to describe the mechanisms of retinal oxidative stress and summarize the current available evidence for antioxidants as a treatment for vitreoretinal disorders.

Idiopathic retinal arterial occlusive vasculitis in the setting of multiple arterial occlusions.

PURPOSE: We present a patient with vaso-occlusive retinal vasculitis to summarize this uncommon entity and review the clinical features and management challenges applicable to patients with retinal vasculitis. OBSERVATIONS: A 76-year-old male presented with sudden-onset severe central vision loss. On examination, vitreous hemorrhage, neovascularization of the optic nerve, peripheral segmental periphlebitis, vessel sclerosis, vascular sheathing, and retinal hemorrhages were observed, and a diagnosis of active vaso-occlusive retinal vasculitis was made. The patient then underwent a complete infectious, inflammatory, and neoplastic workup which returned negative. The patient was treated with locally with a sub-Tenon's injection of 40 mg triamcinolone on presentation and later with oral prednisone. At three-month follow-up, vision improved to 20/300 with regressing neovascularization and clearing of vitreous hemorrhage in the right eye (OD). CONCLUSIONS: Considering novel associations of occlusive retinal vasculitis, it is important to recognize that idiopathic occlusive retinal vasculitis, although uncommon, can occur and represents a prototypical disease form. It is imperative that these patients have a complete infectious, inflammatory, and neoplastic workup owing to the possible overlap of masquerade clinical signs and symptoms.

Vision Recovery Velocity, Momentum and Acceleration: Advanced Vitreoretinal Analytics as Measure of Treatment Efficacy for Neovascular Age-Related Macular Degeneration.

PURPOSE: Currently, varying treatment paradigms and different clinical trial constructs preclude cross-trial comparison between different available vascular endothelial growth factor (VEGF) inhibitors. This study aimed to review the evidence and compare the efficacy of anti-VEGF therapies for neovascular age-related macular degeneration (nAMD), and to develop metrics as a means of facilitating standardized comparison between different anti-VEGF agents within the Advanced VitreoRetinal Analytics (AVRA) model. METHODS: The study analyzed key outcomes in clinical trials of bevacizumab, ranibizumab, aflibercept, and brolucizumab, including best corrected visual acuity (BCVA), number of injections, and duration of follow-up (minimum follow-up of 48 weeks). RESULTS: The AVRA model includes 1) vision recovery velocity (VRV; letters per unit time), which provides a metric of letters gained or lost over time (or the speed of improvement); 2) injection momentum (InjMom; number of injections multiplied by letters per unit time; units of injections•(letters/time)), which is defined as the number of injections multiplied by VRV and describes the quantity of treatment needed to achieve a vision outcome; and 3) vision recovery acceleration (VRA; letters per unit time squared; units of letters/time2), which denotes final VRV minus initial VRV, per unit time, and describes the rate of change in letters gained or lost over time. CONCLUSION: AVRA stipulates that the ideal VEGF inhibitor to treat nAMD would have a higher positive VRV (more letters gained per unit time), low InjMom (lower treatment burden requiring fewer interventions for a given visual acuity outcome), and VRA approximating zero (indicating stable vision over time). AVRA allows comparisons across different trials to determine the optimal anti-VEGF agent for the treatment of nAMD.

Iatrogenic Subretinal Triamcinolone During Primary Surgical Repair of a Retinal Detachment With a Giant Retinal Tear.

Purpose: We describe the outcome of a 23-year-old man undergoing vitreoretinal surgery for a macula-off rhegmatogenous retinal detachment secondary to a giant retinal tear. Methods: Patient underwent combined 25- gauge 3-port pars plana vitrectomy with scleral buckle, perfluorocarbon liquid, and perfluoropropane gas tamponade. During surgery, triamcinolone inadvertently entered the subretinal space and was retained. Results: The subretinal triamcinolone deposits spontaneously absorbed over a 2-month period. No adverse sequelae were associated with this complication. Conclusion: This may support avoiding aggressive mechanical removal of iatrogenic subretinal triamcinolone in the context of retinal detachment repair.

Recurrent Spontaneous Macular Hole Formation and Resolution in a Patient With Previous Vitrectomy.

Purpose: We report a case of recurrent macular hole (MH) formation and spontaneous closure in the absence of any vitreoretinal interface abnormality. Methods: A 49-year-old man presented for his annual ocular examination with no specific ocular complaints. He had a history of retinal detachment in the left eye, which was treated years prior with vitrectomy and scleral buckle. During a routine follow-up, the patient was discovered to have a full-thickness MH. Optical coherence tomography revealed the formation of an MH with spontaneous closure after 3 months without intervention. One month later, the MH recurred but once again closed spontaneously over 4 months. Results: The patient remained asymptomatic during the entire follow-up without any symptoms, vision changes, or therapeutic intervention. Conclusions: To our knowledge, this is the first known case report of recurrent spontaneous opening and closure of an MH in the absence of any vitreoretinal interface abnormality, as revealed by macular optical coherence tomography imaging.

Lipemia Retinalis in a Patient with Familial Hypertriglyceridemia.

A 45-year-old female with a history of hypertension presented with complaints of intermittent vision loss and blurred vision. Clinical examination revealed diffuse retinal whitening in the peripapillary area with multiple visible emboli in the first- and second-order arteries. The patient's retinal findings were keeping within features of lipemia retinalis, and serum lipids were ordered which returned a triglyceride level of 1504 mg/dL. The patient was referred to primary care for vascular risk factor management and potential genetic testing. Ocular signs of hypertriglyceridemia manifest as lipemia retinalis, characterized by white vascular lesions and retinal lipid infiltration. The high comorbidity of hypertriglyceridemia and hypertension may warrant close monitoring hypertensive complications such as hypertensive retinopathy.

Management and Visual Outcomes of Acute Bacterial Endophthalmitis Following Intravitreal Injection of Contaminated Bevacizumab in a Single Day.

BACKGROUND AND OBJECTIVE: Bevacizumab requires compounding for off-label intravitreal injection, thus creating a risk of possible contamination during preparation. PATIENTS AND METHODS: This retrospective, consecutive case series from a single site included patients who developed culture-proven acute endophthalmitis after intravitreal injection with contaminated bevacizumab. All patients suspected of endophthalmitis had vitreous biopsy and microbial cultures prior to initiation of treatment and were managed with immediate tap and injection of antibiotics followed early by pars plana vitrectomy. Main outcome measures included best-corrected visual acuity (BCVA) at 3-month follow-up after treatment. RESULTS: Twenty-four patients developed acute bacterial endophthalmitis following intravitreal injection of contaminated bevacizumab single-dose syringes in a single day. Twenty-three cases (95.8%) grew Streptococcus species and one (4.2%) grew Enterococcus species. Six cases (25.0%) had optic nerve atrophy, three (12.5%) developed retinal detachment, one (4.2%) had vitreous hemorrhage, and one (4.2%) had band keratopathy. At 3-month follow-up, compared to BCVA at the time of initial presentation, 11 patients (45.8%) had improved vision, eight (33.3%) had unchanged BCVA, and five (20.8%) had worse BCVA. However, when compared to BCVA prior to endophthalmitis (baseline), 22 cases (91.7%) had significantly worse BCVA at 3-month follow-up. CONCLUSIONS: Contamination of off-label bevacizumab poses devastating risk of endophthalmitis following intravitreal injection. Vigilance is needed to ensure all possible safeguards are in place to prevent contamination. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:346-352.].

An Atypical Presentation of Acute Macular Neuroretinopathy after Non-Ocular Trauma.

PURPOSE: Acute macular neuroretinopathy (AMN) is a rare clinical entity with an uncertain etiology. We report an atypical case presenting with retinal hemorrhages (RH) and cotton-wool spots (CWS) following non-ocular trauma. OBSERVATIONS: A 49-year-old male presented with an acute onset of a paracentral scotoma in his left eye, immediately following a motor vehicle accident 1 day prior. Fundus findings revealed a unilateral nasal petalloid perifoveal lesion with the tip pointing toward the fovea associated with CWS and RH. Optical coherence tomography demonstrated disruption of the ellipsoid zone. Symptoms and exam findings improved at 2-week follow-up without any intervention, consistent with the natural history of the disease process. CONCLUSION: We report a rare case of AMN following non-ocular trauma with the unique fundus findings of CWS and RH. This presentation supports the role of ischemia in the retinal deep capillary plexus, of which trauma contributed to the pathophysiological process. SUMMARY: AMN is a rare condition whose pathophysiological process remains speculative. We report an atypical case of AMN, which supports the role of trauma in the pathophysiology of deep retinal capillary plexus compromise.

Delayed Vision Recovery after Carotid Vascular Surgery for Branch Retinal Artery Occlusion.

Branch retinal artery occlusion (BRAO) is typically associated with irreversible vision and peripheral visual field loss. We report a case of a 62-year-old woman with a BRAO related to several cardiovascular risk factors. Our patient encountered gradual but significant vision recovery months following carotid artery endarterectomy for carotid stenosis.

PREDICTIVE FACTORS FOR PROLIFERATIVE VITREORETINOPATHY FORMATION AFTER UNCOMPLICATED PRIMARY RETINAL DETACHMENT REPAIR.

PURPOSE: To determine predictive factors of proliferative vitreoretinopathy (PVR) formation after uncomplicated primary retinal detachment repair. METHODS: Retrospective, single-center, case-control study of 74 consecutive patients with (37 eyes) and without (37 eyes) PVR formation after undergoing uncomplicated primary surgery for retinal detachment repair. Logistic regression was used to assess factors associated with PVR formation. RESULTS: Retinal detachment involving the macula was 4.2 times (adjusted odds ratio; 95% confidence interval, 1.4-12.9; P = 0.0119) more likely to have PVR formation compared with those without. Patients who were current or former smokers were 3.6 times (adjusted odds ratio; 95% confidence interval, 1.1-11.7; P = 0.0352) more likely to have PVR formation compared with nonsmokers. Compared with 25-gauge (g) vitrectomy, larger gauge vitrectomy (20 g or 23 g) was 3.6 times (adjusted odds ratio; 95% confidence interval, 1.2-11.3; P = 0.0276) more likely to have PVR formation. Duration of retinal detachment symptoms, high myopia, lens status, lattice degeneration, location of retinal break, number of retinal breaks, and surgical technique (e.g., scleral buckle with or without vitrectomy versus vitrectomy alone) were not found to be predictive of PVR formation. CONCLUSION: Cigarette smoking and macular involvement are significant risk factors predictive of PVR formation after uncomplicated primary retinal detachment repair.