EVALUATING ULTRA-WIDEFIELD IMAGING UTILITY IN THE DETECTION OF TREATMENT-REQUIRING PERIPHERAL RETINAL TEARS AND HOLES.

PURPOSE: To determine the utility of ultra-widefield (UWF) imaging in detecting pathologic peripheral retinal tears and holes. METHODS: This was a retrospective, observational study. One-hundred ninety-eight eyes of 198 patients diagnosed with acute posterior vitreous detachment were included. Eyes were divided into two groups: 89 eyes with peripheral retinal holes and tears treated with laser retinopexy (treatment group) and 109 control eyes. Patients underwent UWF imaging and indirect ophthalmoscopy with scleral depression. UWF images from both groups were reviewed by two blinded graders and then compared with funduscopic examination and medical records. RESULTS: UWF imaging identified 60 of the 89 eyes (sensitivity of 67.4%) found to have treatment-requiring peripheral retinal lesions and 107 of the 109 control eyes (specificity of 98.2%).The distribution of misses based on octant location did reach statistical significance ( P = 0.004). Lesions anterior to the equator were more likely to be missed (21/41 eyes, 51.2%) compared with those located posterior to the equator (4/20 eyes, 25.0%) and at the equator (4/28, 14.3%), P = 0.002. The combined discordance rate between graders in the entire cohort was 12.1% (24/198 eyes) yielding an interrater agreement of 87.9%. CONCLUSION: UWF imaging showed a moderate sensitivity and high specificity in detecting treatment-requiring retinal tears and holes, with high interrater agreement. Given there is only a moderate sensitivity in identifying treatment-requiring retinal tears and holes, UWF imaging can assist with clinical examination, but a 360-degree scleral depressed examination should remain the gold standard.

TECHNIQUE FOR REMOVAL OF A GANCICLOVIR IMPLANT DISLOCATED IN THE VITREOUS CAVITY.

PURPOSE: To report a technique to remove a dislocated ganciclovir implant in the vitreous cavity. METHODS: Retrospective case series. Two patients with dislocated ganciclovir implants in the vitreous cavity. RESULTS: A 6-mm pars plana incision was made; the soft tip was used to elevate the implant behind the intraocular lens and then 0.12-mm forceps were used to externalize the implant. The implant was successfully removed in both patients. CONCLUSION: Removal of a dislocated ganciclovir implant with its encasing strut can be effectively retrieved using a bimanual approach.

Primary and secondary focal choroidal excavation morphologic phenotypes, associated ocular disorders and prognostic implications.

AIMS: To characterise and classify the morphological, clinical and tomographic characteristics of focal choroidal excavation (FCE) lesions to determine their prognostic implications. METHODS: 36 eyes with FCE (32 patients) underwent multimodal imaging, including spectral domain optical coherence tomography and fundus autofluorescence. FCE lesions were classified into three subtypes: (1) type 1: myopic (central choroidal thickness: <100 µm), (2) type 2: suspected congenital (central choroidal thickness: 100-200 µm, without associated chorioretinal pathology) and (3) type 3: secondary or acquired (central choroidal thickness: >200 µm, with associated chorioretinal pathology). RESULTS: 80.6% of eyes were followed longitudinally (26.8±18.8 months). There were 9 type 1 FCEs (myopic), 8 type 2 FCEs (U-shaped, congenital) and 19 type 3 FCEs (V-shaped, secondary). Type 2 FCEs trended towards larger maximum widths (p=0.0563). Type 3 FCEs were associated with central serous chorioretinopathy or pachyvessels (47.4%), but were also seen in pattern dystrophy, geographic atrophy, inactive choroiditis, torpedo maculopathy and adult-onset vitelliform dystrophy. Choroidal neovascular membranes (CNVMs) were more prevalent in type 3 FCE (41.2% compared with 11.1% for type 1 FCE, p=0.251, and 0% for type 2 FCE, p=0.043). CONCLUSIONS: The FCE types, stratified by central choroidal thickness, demonstrated distinct morphological characteristics and associated findings. The classification scheme held prognostic implications as type 3 FCE with V shapes were associated with other chorioretinal conditions and were more likely to develop CNVM.

Didanosine-Associated Retinal Toxicity in a Patient With a Mutation in the CRB1 Gene.

Purpose: This article describes a case of didanosine (DDI)-associated retinal toxicity in a patient with a heterozygous pathogenic variant in the CRB1 gene. Methods: Case report. Results: A middle-aged patient with HIV controlled on HAART therapy, and a remote 10-year year history of treatment with DDI and tenofivir, presented with external ophthalmoplegia and well-circumscribed, midperipheral patterns of bilateral pigmentary retinopathy and chorioretinal atrophy in both eyes. Genetic testing revealed a heterozygous pathogenic variant in the CRB1 gene that encodes a protein (Crumbs homolog 1) involved in regulation of cell polarity and junctions and is localized adjacent to mitochondria in the ellipsoid and myoid area. Conclusions: This case highlights a potential role for genetic susceptibility to retinal toxicity in DDI-associated retinal toxicity. Large, prospective pharmacogenomics studies may be informative to further elucidate the role of genetic risk factors in drug-induced retinal toxicity.

Optical Coherence Tomography Angiography: Clinical Utility and Future Directions.

Purpose: This work aims to review the principles of optical coherence tomography angiography (OCTA), to survey its clinical utility, and to highlight the strengths of this technology as well as barriers to adoption. Methods: A literature review with editorial discussion of the current applications for OCTA is presented. Results: There have been recent advances in multiple domains in OCTA imaging, including devices, algorithms, and new observations pertaining to a range of pathologies. New devices have improved the scanning speed, signal-to-noise ratio, and spatial resolution and offer an increased field of view. New algorithms have been proposed to optimize image processing and reduce artifacts. Numerous studies employing OCTA have been published describing changes to the microvasculature in diabetic retinopathy, age-related macular degeneration, central serous chorioretinopathy, retinal vein occlusion, and uveitis. Conclusions: OCTA provides noninvasive, high-resolution volumetric scans of the retinal and choroidal vasculature. OCTA can provide valuable data to augment traditional dye-based angiography in a range of chorioretinal diseases.

Epimacular Inverted Retinal Flap Simulating an Epiretinal Membrane.

A 66-year-old man was referred for management of a visually significant epiretinal membrane (ERM) with persistent cystoid macular edema after surgery for recurrent retinal detachment with proliferative vitreoretinopathy. The membrane was noted to be particularly thick and vascularized on preoperative optical coherence tomography. During the subsequent vitrectomy, the "membrane" was found to be an inverted retinal flap and successfully removed. The inverted retinal flap was thought to have been related to retinal slippage during prior surgery. This is the first report of an epimacular inverted flap simulating an ERM and highlights the importance of careful review of preoperative imaging. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:293-295.].

ROLE OF OPTICAL COHERENCE TOMOGRAPHY FOR PREDICTING POSTOPERATIVE VISUAL OUTCOMES AFTER REPAIR OF MACULA-OFF RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To identify any prognostic associations between preoperative optical coherence tomography findings and postoperative visual outcomes in patients with macula-off rhegmatogenous retinal detachment. METHODS: A retrospective, single-center study of patients diagnosed with macula-off rhegmatogenous retinal detachment whom underwent surgical reattachment from 2012 to 2017. Optical coherence tomography images were analyzed by two retina surgeons. Outcome measures included "good" final vision (best-corrected visual acuity of 20/40 or better), "poor" final vision (best-corrected visual acuity of 20/200 or worse), and change in vision (worsened, improved, and improved ≥15 letters) at most recent follow-up. P values were calculated using t tests, analysis of variance, Wilcoxon rank-sum, or Kruskall-Wallis test. RESULTS: A total of 49 eyes were included. There was a significant difference in the mean preoperative central retinal thickness between patients who had good final vision and patients who did not (96 µm vs. 161 µm, P = 0.048). In addition, a worse preoperative best-corrected visual acuity and greater subretinal fluid height were associated with vision improvement (P < 0.001). Those with persistent ellipsoid zone disruption postoperatively were less likely to have good final vision (odds ratio = 0.217, 95% confidence interval: 0.057-0.828). CONCLUSION: A lower mean preoperative central retinal thickness is associated with good visual prognosis. Eyes with ellipsoid zone disruption postoperatively were less likely to have good final vision. Future studies should include a larger cohort of patients and more optical coherence tomography variables to address the inconsistencies in the current literature.

Current intravitreal therapy and ocular hypertension: A review.

To determine the effect of commonly used intravitreal agents on immediate and long-term IOP elevations and their association, if any, with glaucoma. Literature searches in PubMed and the Cochrane databased in January 2020 yielded 407 individual articles. Of these, 87 were selected for review based on our inclusion criteria. Based on the evidence provided, 20 were assigned level I, 27 level II, and 22 level III. Eight articles were rejected because of poor quality, insufficient clarity, or irrelevance based on standardized protocols set out by the American Academy of Ophthalmology. The studies that reported on short-term IOP elevation (i.e., between 0 and 60 min) showed that an immediate increase in IOP is seen in all patients who receive anti-VEGF agents or triamcinolone acetonide when measured between 0 and 30 min of intravitreal injection and that the IOP elevation decreases over time. The data on long-term IOP elevation were mixed; Pretreatment with glaucoma medications, anterior chamber tap, vitreous reflux, longer intervals between injections, and longer axial lengths were associated with lower IOP elevations after injection of anti-VEGF agents, while the position of the implant vis-à-vis, the anterior chamber was important for steroid therapy. Data were mixed on the relationship between IOP increase and the type of intravitreal injection, number of intravitreal injections, preexisting glaucoma, and globe decompression before injection. There were no data on the onset or progression of glaucoma in the studies reviewed in this assessment. However, some studies demonstrated RNFL thinning in patients receiving chronic anti-VEGF therapy. Most, if not all, intravitreal agents cause ocular hypertension, both in the short term and long term. The functional consequences of these observations are not very clear.

Choroidal Neovascularization and Macular Hemorrhage: Real-World Experience During the New York City COVID-19 Lockdown.

Purpose: This work reviews ocular, systemic, and demographic factors contributing to presentation of choroidal neovascular membrane (CNVM)-associated macular hemorrhage after the New York City coronavirus disease 2019 (COVID-19) lockdown. Methods: A retrospective, consecutive case series was conducted of all established patients presenting with macular hemorrhage between March 22, 2020, and August 10, 2020. Results: Fourteen patients (mean age 82.2 years) were evaluated. Ten patients had active CNVMs, 1 had an inactive lesion that was last injected 2 years prior, and 3 had new conversions from nonexudative age-related macular degeneration. In the actively treated CNVM group there was a delay in expected follow-up from 50.4 days to 125 days. Eight patients with previously active CNVM (73%) had a history of prior macular hemorrhage. Eight patients (57%) were on some form of antiplatelet or anticoagulation therapy. Twelve patients (86%) had COVID-19-specific risk factors besides age, and all but 1 patient (93%) delayed care without discussion with a physician. Ten patients (71%) had more than 1 week of symptoms prior to presentation. Twelve patients (86%) had signs of CNVM on prior optical coherence tomography. Conclusions: Adequate documentation of potential risks for hemorrhage (particularly prior hemorrhage or presence of subclinical type 1 CNVM), as well as COVID-19-specific risk factors, would aid triage of clinic appointments in future lockdowns. High-risk patients would likely benefit from direct physician communication discussing their individual risk profiles to alleviate anxiety over clinic visits and communicate their risk of severe vision loss.

Feasibility and Clinical Utility of Ultra-Widefield-Navigated Swept-Source Optical Coherence Tomography Imaging.

Purpose: This work aims to evaluate the clinical utility and feasibility of a novel scanning laser ophthalmoscope-based navigated ultra-widefield swept-source optical coherence tomography (UWF SS-OCT) imaging system. Methods: A retrospective, single-center, consecutive case series evaluated patients between September 2019 and October 2020 with UWF SS-OCT (modified Optos P200TxE, Optos PLC) as part of routine retinal care. The logistics of image acquisition, interpretability of images captured, nature of the peripheral abnormality, and clinical utility in management decisions were recorded. Results: Eighty-two eyes from 72 patients were included. Patients were aged 59.4 ± 17.1 years (range, 8-87 years). During imaging, 4.4 series of images were obtained in 4.1 minutes, with 86.4% of the image series deemed to be diagnostic of the peripheral pathology on blinded image review. The most common pathologic findings were chorioretinal scars (18 eyes). In 31 (38%) eyes, these images were meaningful in supporting clinical decision-making with definitive findings. Diagnoses imaged included retinal detachment combined with retinoschisis, retinal hole with overlying vitreous traction and subretinal fluid, vitreous inflammation overlying a peripheral scar, Coats disease, and peripheral retinal traction in sickle cell retinopathy. Conclusions: Navigated UWF SS-OCT imaging was clinically practical and provided high-quality characterization of peripheral retinal lesions for all eyes. Images directly contributed to management plans, including laser, injection or surgical treatment, for a clinically meaningful set of patients (38%). Future studies are needed to further assess the value of this imaging modality and its role in diagnosing, monitoring, and treating peripheral lesions.

Modified dagger-tip Sheets glide to facilitate 2-point fixation across the anterior chamber in aniridic aphakic eyes.

Presented is a modified technique for removing a failed endothelial allograft in an aniridic aphakic eye that reduces the risk of posterior dislocation. This technique involves the creation of an artificial iris plane using a Sheets glide by trimming it into the shape of a dagger so that it can be pulled through the anterior chamber and fixated by both its passage through a paracentesis incision and the main incision. The Sheets glide then acts as a physical barrier, or scaffold, to allow safe removal of the failed endothelial allograft and subsequent repeat endothelial keratoplasty while avoiding posterior dislocation of the tissue into the vitreous cavity.

Drug-induced maculopathy.

PURPOSE OF REVIEW: The purpose of this article is to provide an overview of drug-induced maculopathies including their clinical presentations, diagnostic findings, and treatment options. With the increasing pace of development and arrival of drugs to the market, this review aims to inform retina specialists of relevant side effects that may be encountered in a clinical practice setting. RECENT FINDINGS: The major themes visited in this article focus on relevant findings of drugs that cause pigmentary and crystalline maculopathy, photoreceptor dysfunction, cystoid macular edema, central serous choroidopathy, uveitis, and vascular damage. SUMMARY: The current review reports updated findings and discusses the pathophysiologic mechanisms, presentations, and treatments of drug-induced maculopathies.

Outcomes of primary rhegmatogenous retinal detachment repair with extensive scleral-depressed vitreous removal and dynamic examination.

There are multiple surgical approaches to the repair of rhegmatogenous retinal detachment (RRD). Here, we evaluated the outcomes of small-gauge pars plana vitrectomy (PPV), alone or in combination with scleral buckle (SB-PPV), for RRD repair using a standardized technique by 3 vitreoretinal surgeons: "extensive" removal of the vitreous with scleral depression and dynamic examination of the peripheral retina. One hundred eighty seven eyes of 180 consecutive patients treated for primary RRD by three vitreoretinal surgeons at a tertiary academic medical center from September 2015 to March 2018 were analyzed. Most RRDs occurred in males (134 [71.3%] eyes), affected the left eye (102 [54.3%]), and were phakic (119 [63.3%]). PPV alone was performed in 159 eyes (84.6%), with a combined SB-PPV used in the remaining 29 eyes (15.4%); focal endolaser was used in all (100%) cases. The single surgery anatomic success rate was 186 eyes (99.5%) at 3 months, and 187 (100%) at last follow up. Overall best-corrected visual acuity (BCVA) had significantly improved at 3 months ([Snellen 20/47] P<0.00005) and last follow up ([Snellen 20/31] P<0.00005), as compared to day of presentation ([Snellen 20/234]). Our findings suggest that "extensive" removal of the vitreous and dynamic peripheral examination with scleral depression may lead to high single surgery success in primary uncomplicated RRD repair.

The Expanded Clinical Spectrum of Coxsackie Retinopathy.

The authors present two cases of coxsackie retinopathy that presented with the classic findings of acute outer retinal disruption that evolved to an outer retinal scar. In these two cases, the classic lesions displayed an extramacular distribution. The authors provide detailed multimodal imaging in both cases highlighting the nature of the lesions. It is important to consider coxsackie virus infection in the differential diagnosis of extramacular lesions with outer retinal disruption. The term "unilateral acute idiopathic maculopathy" should be replaced with "coxsackie retinopathy" to better align with the expanded clinical spectrum and the known etiology of this disorder. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:529-532.].

Retinal Microvasculature Changes After Repair of Macula-off Retinal Detachment Assessed with Optical Coherence Tomography Angiography.

OBJECTIVE: To characterize the microvascular retinal changes after repair of macula-off rhegmatogenous retinal detachment (RRD) using optical coherence tomography angiography (OCT-A). PATIENTS AND METHODS: A retrospective review of patients who underwent repair of macula-off RRD. Fellow unaffected eyes were used as controls. Post-operative OCT-A allowed comparison of vessel density (VD) and foveal avascular zone (FAZ) area in the superficial and deep retinal capillary plexus (DCP) as well as VD in the choriocapillaris layer. RESULTS: Seventeen eyes of 17 RRD patients were included in the final analysis. There was a reduction in VD of the deep retinal capillary plexus in affected eyes compared to fellow eyes (p = 0.046). RRD eyes with reduced VD in DCP compared with their fellow control eyes had worse visual acuity after repair compared to those without (p = 0.032). No significant microvasculature changes were detected in the FAZ area and VD in the superficial capillary plexus and choriocapillaris compared to fellow eyes. CONCLUSION: In macula-off RRD eyes, significant microvascular changes were detected in the DCP using OCT-A even after successful anatomical repair. Decreased VD in the DCP compared to the fellow healthy eyes was correlated with worse visual acuity.

Ultra-Widefield Autofluorescence Imaging of Retinal Detachment Compared to Retinoschisis.

BACKGROUND AND OBJECTIVE: Localized retinal detachment can appear similar to peripheral retinoschisis (RS) based on clinical exam alone. This study utilized ultra-widefield autofluorescence (UAF) to characterize retinal changes in patients with rhegmatogenous retinal detachment (RRD) compared to RS and to help differentiate these two entities in the era of multimodal imaging. PATIENTS AND METHODS: A retrospective review of 282 eyes undergoing diagnostic UAF. Eyes were excluded if the quality of the color photograph or UAF prevented reliable evaluation, or if they contained significant peripheral retinal pathology such as diabetic retinopathy or retinal vein occlusions. Eyes were determined to have RRD or RS based on dilated fundus examination, ultrasound, and optical coherence tomography imaging consistent with the diagnosis. RESULTS: Fifty-three eyes were included; 38 had retinal detachment, and 25 had RS. Eyes were determined to be bullous or not from the color photographs. Based on all UAFs reviewed, images were determined to have granular, normal, hypo-, hyper-, or mixed autofluorescence patterns. The posterior border of the RRD and RS was evaluated separately and determined to have hyper-, hypo-, granular, mixed, or normal autofluorescence. Thirty-three eyes with RRD (86.8%) appeared bullous compared to 12 eyes with RS (48%; P = .002). UAF was considered granular in zero (0%) of RRD eyes and one (4%) RS eye, normal in one RRD eye (2.63%) and 17 (68%) RS eyes, hypoautofluorescent in 27 (71.1%) RRD eyes and four (16%) RS eyes, hyperautofluorescent in one (2.63%) RRD eye and one (4%) RS eye, and mixed in nine (4%) RRD eyes and two (8%) RS eyes (P < .001). When evaluating the posterior leading edge on UAF, 84.2% (n = 32) of patients with RRD had a hyperautofluorescent leading edge compared to 25% (n = 6) of patients with RS (P < .001). UAF was homogenous in 65.8% (n = 25) of cases of RRD versus in 92% (n = 23) of cases of RS (P = .037). CONCLUSIONS: To the authors' knowledge, this is the first study to utilize UAF imaging to differentiate RRD and RS. Findings suggest there are differences between RRD and RS with regards to UAF, UAF of the posterior border, and homogeneity of the area affected. UAF should be considered in the era of multimodal imaging, particularly when clinical exam alone is inadequate to differentiate these two entities. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:550-556.].

Comorbid hepatitis C does not modulate prevalence or severity of diabetic retinopathy.

PURPOSE: There are limited and conflicting data regarding the impact of comorbid hepatitis C virus (HCV) infection on diabetic retinopathy (DR). This study sought to compare the prevalence and severity of DR among patients with diabetes mellitus (DM) with and without HCV. PATIENTS AND METHODS: This was a retrospective, case-control study of patients with DM comparing 120 patients with comorbid HCV and 120 age-matched controls. DR prevalence and several measures of severity were compared between groups. Subgroup analyses were performed among HCV patients with cirrhosis, comorbid HIV, or history of treatment with interferon. Statistical analysis for between-group comparisons utilized both univariate and multivariate analyses. RESULTS: Cases and controls exhibited similar baseline characteristics: average hemoglobin A1c, DM duration, and age (p>0.05). Among cases and controls, there was no difference in DR prevalence (35.8% versus 42.5%, respectively, p=0.29) or severity (p>0.05). Within the HCV subgroup, DR severity was reduced in patients with HIV or cirrhosis. However, multivariate analysis identified reduced DM duration in these subgroups as the primary contributor to lesser DR severity, rather than HIV or cirrhosis. CONCLUSION: In this study, comorbid HCV did not modulate the prevalence or severity of DR among patients with DM. These findings may inform clinical monitoring among HCV-positive diabetics undergoing ophthalmic evaluation.