Triple Trouble with Triple Solutions: A Unique Case Report of a Severe Exudative Retinal Detachment Accompanied by Retinal Traction and Two Retinal Holes in Coats Disease.

Introduction: Coats disease is a rare vasculature pathology that usually presents as retinal telangiectasia with possible progression to exudative retinal detachment (RD). Intravitreal anti-VEGF injections, cryotherapy, laser photocoagulation, and surgery are commonly used to control the disease and prevent its progression. Although iatrogenic tractional RDs secondary to anti-VEGF injections have been reported in patients with Coats disease, RDs in Coats disease are exudative, secondary to retinal exudation and vascular abnormalities. In this article, we present the first reported case of a severe exudative RD accompanied by retinal traction and two retinal holes in a patient with Coats disease. Case Presentation: A 32-year-old male initially presented with Coats disease stage 2A, which then progressed to 3A1 within a month of close follow-ups, finally leading to exudative RD. Following cryotherapy and bevacizumab injections, the exudative RD progressed, with the emergence of retinal traction and two retinal holes. This complex case was successfully treated with a scleral buckle vitrectomy accompanied by radial elements to support the RD, pars plana vitrectomy, silicon oil tamponade, and post-surgical bevacizumab injections. Six months following the surgical intervention, the patient's vision is restored at 20/30, and retinal imaging shows a totally flattened retina. Conclusion: We present the first reported case of a severe exudative RD accompanied by retinal traction and two retinal holes in a patient with Coats disease. The combination of surgical treatment and bevacizumab injections is thought to have collectively contributed to our patient's favorable outcome.

Macular hole repair: the effect of size and nonsupine posture on postoperative outcomes.

Background: Postoperative face-down positioning (FDP) for up to 2 weeks is believed to be necessary for successful closure of macular holes. FDP, however, can be disabling and uncomfortable and is a major burden for elderly patients. The aim of this study was to investigate how nonsupine posturing and macular hole size affect anatomical and functional success of macular hole closure. Methods: The medical records of patients with idiopathic macular holes who were treated surgically between 2016 and 2019 were reviewed retrospectively. Exclusion criteria included vitreomacular traction, previous retinal detachment, or chronic macular hole. Results: A total of 115 eyes of 115 patients were included. Average age was 69.2 ± 8.2 years; 63 patients (55%) were female. Anatomical success was achieved in 108 patients (94%) with a single operation. In small holes (<400 µm), closure was seen in 98% of cases (95% CI, 94%-100%); in large holes (≥400 µm), 90% of cases (95% CI, 76%-94%). Visual acuity remained stable or improved in 108 patients (92%). Average preoperative best-corrected visual acuity was 1.02 ± 0.45, with an overall improvement of 5 lines postoperatively. Small holes and large holes improved, with an average of 3 versus 7 lines gained, respectively. Conclusions: In this study cohort, favorable anatomical and functional outcomes were achieved without postoperative FDP. These outcomes are comparable to the traditional FDP approach.

Internal limiting membrane flap with viscoelastic device for lamellar hole surgery with no postoperative positioning.

PURPOSE: To propose a novel technique of an internal limiting membrane (ILM) flap using ophthalmic viscoelastic device (OVD) with no requirement for postoperative head posture for the treatment of lamellar macular hole (LMH) repair. METHODS: A retrospective analysis of 16 consecutive eyes of LMH patients who underwent vitrectomy with ILM flap with OVD. Best-corrected visual acuity (BCVA), central macular thickness (CMT), simultaneous cataract extraction, and ellipsoid zone disruption preoperatively and at the final follow-up were compared. RESULTS: The mean age was 73.19 ± 7.26 years, and ten patients (62%) were females. The mean follow-up was 5.06±1.43 months (range 3-6). For all patients, BCVA was significantly improved at the final visit, from 0.65±0.36 logMAR units to 0.42±0.29 (p < 0.001). None of the patients had visual loss. Six patients had epiretinal membrane (ERM) foveoschisis, and the rest had LMH with epiretinal proliferation. Both subgroups presented a significant improvement in their BCVA with a trend for better improvement in the latter (p=0.09). Ellipsoid zone disruption was seen in 7 patients including one patient with a macular scar. There was no significant effect of ellipsoid zone disruption on the final BCVA (p=0.33). Twelve eyes (75%) underwent simultaneous cataract extraction. Mean BCVA at the final postoperative visit improved regardless of whether the eyes underwent simultaneous cataract surgery (p=0.39). CMT was also significantly improved at the final visit, from 200.06±46.8 µm preoperatively to 305.00±85.5 µm (p<0.001). No full-thickness macular holes were developed postoperatively. No intraoperative or postoperative complications were observed. CONCLUSIONS: Treatment of LMH with ILM flap with OVD showed promising anatomical and functional results with no postoperative head position requirements.

LGBTQ+ Identity and Ophthalmologist Burnout.

PURPOSE: To evaluate lesbian, gay, bisexual, transgender, questioning, and other sexual/gender minority (LGBTQ+) orientation as a burnout risk factor among an international ophthalmologist cohort. METHODS: An anonymous, cross-sectional electronic survey was distributed via an Internet platform to characterize the relationship among demographic factors, including LGBTQ+ orientation, and burnout as measured by the Copenhagen Burnout Inventory (CBI). Univariable data analysis (linear) by sexual orientation was performed and variables with an association with a P value of <0.15 in univariable analysis were included in the multiple linear regression modeling. RESULTS: A total of 403 ophthalmologists participated in the survey. The majority self-identified as "White" (69.2%), were from North America (72.0% United States, 18.6% Canada) and were evenly distributed between age of 30 and 65 years. Overall, 13.2% of participants identified as LGBTQ+ and 98.2% as cisgender. Approximately 12% had witnessed or experienced LGBTQ+-related workplace discrimination or harassment. The personal and work-related burnout scores and confidence limits of persons identified as LGBTQ+ were higher and nonoverlapping compared with those reported as non-LGBTQ+. Multivariable analysis identified significant risk factors for higher personal and work-related burnout scores: LGBTQ+ (11.8 and 11.1, P = .0005 and .0023), female gender (5.36 and 4.83, P = .0153 and .0434), older age (19.1 and 19.2, P = .0173 and .0273). and caretaker stress (6.42 and 5.97, P = .0085 and .0239). CONCLUSIONS: LGBTQ+ orientation is a burnout risk factor among ophthalmologists, and LGBTQ+ workplace discrimination may be a contributing factor. Support from ophthalmology organizations to address LGBTQ+-, gender-, and age-related workplace discrimination may decrease burnout. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Combined Subthreshold Laser with Push-Pull Fluid Exchange for Treatment of Refractory Macular Hole.

We report on a 55-year-old patient presenting with a 400 µm macular hole which failed to resolve with vitrectomy and internal limited membrane peeling. In accordance with patient wishes to avoid further surgery, subthreshold laser was applied to the macular hole followed by gas exchange with euvolemic C3F8. Successful hole closure was subsequently observed with vision improved by four Snellen lines. Subthreshold laser has several advantages over conventional laser techniques, including reduced collateral thermal damage to the adjacent cells. This case has demonstrated a new use for subthreshold laser, which combined with push-pull technique may be an effective treatment option for persistent MH.

Multiple XEN Gel Stents for Refractory Pediatric Glaucoma.

Although trabeculotomy and goniotomy are currently the mainstay of surgical management for congenital glaucoma, XEN Gel Stent (Allergan) implantation and other microinvasive glaucoma surgery technologies may offer the advantage of having a lower risk of postoperative complications than conventional techniques. A 10-year-old boy presented with aphakic glaucoma in his left eye secondary to previous cataract surgery. Intraocular pressure (IOP) in the left eye at initial presentation was 31 mm Hg with maximal tolerated medical therapy. Surgical history included tube shunt, shunt revision, and subsequent shunt removal. Shunt surgery and revision had been unsuccessful at achieving target IOP. The patient underwent two treatments of micro-pulse transscleral laser therapy that failed to achieve target IOP. At this time, an open conjunctiva ab externo superior XEN Gel Stent (Allergan) was implanted. Within 1 month of surgery, conjunctival dehiscence and contraction occurred. Following this, ab interno inferonasal air-ophthalmic viscosurgical device XEN Gel Stent implantation was performed. In the 6 months following the second XEN Gel Stent, IOP in the left eye was stable at 6 to 8 mm Hg. This report describes the effective use of a XEN Gel Stent implant in the management of congenital glaucoma, while also highlighting a complication. Further studies are required to determine the comparative outcomes of this technique with conventional surgical management. [J Pediatr Ophthalmol Strabismus. 2022;59(1):e11-e14.].

INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE WITHOUT POSTOPERATIVE FACE-DOWN POSITIONING FOR MACULAR HOLE REPAIR.

PURPOSE: To describe the outcomes of the inverted internal limiting membrane flap technique without postoperative face-down positioning for macular hole (MH) closure. METHODS: This retrospective longitudinal study identified patients who had undergone surgical repair for large (>400 µm), idiopathic MHs and did not maintain face-down positioning postoperatively. Outcome measures included anatomical success, defined as confirmation of hole closure by the optical coherence tomography scan and functional success and defined as improved best-corrected visual acuity from baseline at the last follow-up. RESULTS: Of the 63 eyes enrolled in the study, 94% patients (59 of 63) achieved anatomical success and 91% patients (57 of 63) achieved functional success. Fifteen (15) of these patients presented with a MH >600 µm. This subgroup achieved an anatomical success rate of 93% and a functional success rate of 87%. Statistically significant improvement in best-corrected visual acuity was demonstrated for all subgroups of MH size (P < 0.001). CONCLUSION: We report a high success rate of large, idiopathic MH closure with the inverted internal limiting membrane flap technique without postoperative face-down positioning. The results described in this study are favorable. However, larger studies with prospective design are warranted to explore this further.

[TREATMENT OPTIONS FOR DIABETIC MACULAR EDEMA].

INTRODUCTION: Diabetic retinopathy (DR) is the leading cause of vision loss in people under 65 years of age. Diabetic macular edema (DME) is the most common cause of moderate visual impairment in individuals with DR. Until recently, focal or grid laser photocoagulation has been the standard of care for DME. Laser photocoagulation has been shown to stabilize vision and prevent moderate vision loss. Recent studies on the effect of anti-vascular endothelial growth factor (VEGF) substances in DME, showed resolution of the edema and visual acuity gain. Thus, anti-VEGF therapy has become the first line of treatment for DME. Intravitreal steroids, also play a role in the management of DME, particularly in refractory cases, due to their antiinflammatory effect. This review focuses on the emerging treatment options in the management of DME.

Epidemiological data of 290 pemphigus vulgaris patients: a 29-year retrospective study.

Pemphigus vulgaris (PV), an autoimmune blistering disease involving the skin and mucosa, is traditionally considered to be prevalent among Jews, particularly those of Ashkenazi origin. Israel, where the Ashkenazi and non-Ashkenazi Jewish population live alongside a large Arab minority, is a particularly interesting place for epidemiological studies of PV. To characterise the epidemiological and clinical parameters of PV patients from a single tertiary medical centre in Israel. Data was retrieved retrospectively from the medical records of newly diagnosed PV patients referred to the Sheba Medical Center between 1980 and 2009. A total of 290 PV patients were diagnosed during the study period. The mean age at diagnosis was 49.7 years (range: 10-92 years) and a female predominance was identified (1.54:1; p<0.001). Among the Jewish patients, the ratio of Ashkenazi to non-Ashkenazi was 1.23:1, which was not statistically significant in comparison to the ratio of the general Jewish population in Israel (p = 0.289). We describe the comorbidities found among the patients. Disease severity at diagnosis was not found to be related to the epidemiological parameters examined. Studies from different countries reveal variations in the clinical and epidemiological characteristics of the disease. The epidemiology of PV in Israel, a Middle-Eastern country with a Western lifestyle and a diverse ethnic population, shows some characteristics that represent an "admixture" between European and Middle-Eastern or Asian countries. The associated comorbidities of PV emphasize the need for dermatologists to keep a high index of suspicion and actively evaluate patients to determine their presence.