Scleral fixation of the Smaller-Incision New-Generation Implantable Miniature Telescope (SING IMT ™) using GoreTex suture.

PURPOSE: In this case report we describe a surgical technique for scleral fixation of the Smaller-Incision New-Generation Implantable Miniature Telescope (SING-IMT). Using this surgical technique, patient's eye which receive surgery for the SING-IMT, could still have a safe SING IMT implant despite the anatomical conditions of the capsular bag or in cases of intraoperative complications. METHODS: The surgery was performed at Policlinico A. Gemelli, Rome, Italy. The patient's eye underwent a first surgery for artificial intraocular lens (IOL) explant and SING-IMT implant at the same time. We observed SING IMT dislocation into the vitreous chamber 90 days after surgery. We therefore carried out a 23-gauge vitrectomy and after SING IMT recovery from the vitreous chamber, we fixed one of its haptic to the sclera using a 8.0 GoreTex suture. CONCLUSION: Scleral fixation of SING-IMT haptics might be useful in eyes with dislocated or not stable SING IMT. We believe that reporting our experience can help surgeons to fix SING IMT in complicated cases where a capsular bag rupture o disinsertion (like our case) can cause SING IMT decentration or worse its drop into the vitreous chamber. We speculate that GoreTex suture could assure firm fixation of the SING IMT and could reduce the risk of recurrent dislocations.

Enhancing the Functional Performance of Patients with Late-Stage Age-Related Macular Degeneration Implanted with a Miniature Telescope using Rehabilitation Training.

INTRODUCTION: In this work, our aim is to report the functional outcomes of cataract surgery with smaller-incision new-generation miniature telescope (SING IMT) implantation followed by rehabilitation training in patients with central visual loss due to late-stage age-related macular degeneration (AMD). METHODS: This retrospective study included patients who were monocularly implanted with SING IMT and then followed a rehabilitation program based on 6 biweekly sessions focused on visual abilities, reading, writing, visual motor integration and mobility. A total of 11 participants were included in this study. Reading acuity (RA), reading speed (RS), and fixation stability (FS) were assessed biweekly at 6-, 8-, 10-, 12-, 14-, and 16-week follow-up visits after SING IMT implantation and at a final assessment at 24 weeks. Best-corrected distance visual acuity (BCDVA) was also measured at baseline and at the same postoperative timepoints. RESULTS: Mean baseline BCDVA was 12.5 ± 8.6 letter score. Both RA and RS were found to be significantly improved from the first rehabilitation session (6 weeks after surgery) to the last session (24 weeks after surgery). At the end of the rehabilitation program, mean RA was 0.45 ± 0.19 LogMAR and mean RS was 30.9 ± 17.6 words per minute. Moreover, all patients achieved a FS of 15 s or more after the last rehabilitation session. Most patients (55%) achieved an improvement of 15 letters in BCDVA at the end of the study. CONCLUSIONS: This study suggests that rehabilitation training can improve visual functions of patients with late-stage AMD implanted with SING IMT in real-world tasks such as reading skills.

Smaller-Incision new-generation implantable miniature telescope: Three-months follow-up study.

PURPOSE: To evaluate three months follow-up of SING IMT implant in patients affected by late-stage AMD. DESIGN: Prospective cohort study. SUBJECTS: In a total of 80 eyes of 40 patients who underwent the enrollment tests, 11 patients' eyes affected by late-stage AMD matched the inclusion criteria and underwent SING IMT implant from February to June 2022. METHODS: Before surgery, each patient underwent the enrollment examination to verify inclusion and exclusion criteria. MAIN OUTCOME MEASURES: BCVA for distance and for near, IOP, ACD and ECD were evaluated at 1 and 3 months follow up. Also quality of life in doing the activities of daily life was evaluated. RESULTS: BCVA for distance and for near improved from baseline to 3 months follow up (23.91 ± 9.418 ETDRS letters and 59.09 ± 11.58 ETDRS letters respectively (p < 0.001). An endothelial cell loss was shown (p < 0.001), with a rate of cell density reduction around 8.3% (baseline vs 3 months). CONCLUSIONS: SING IMT could be a valid surgical device to improve patients' sight and quality of life which have been deteriorated by late-stage macular degeneration. Further studies with more patients and longer follow up are needed to confirm our results.

Ocular Morpho-Functional Evaluation in ATTRv Pre-Symptomatic Carriers: A Case Series.

The present study aimed to investigate ocular findings in hereditary transthyretin amyloidosis (ATTRv) pre-symptomatic carriers. Fourteen ATTRv pre-symptomatic carriers, who are patients with positive genetic testing but without signs or symptoms of the disease, were retrospectively evaluated. Retinal morphology was assessed using optical coherence tomography (OCT) and OCT-angiography. Retinal function was evaluated using cone b-wave and photopic negative response (PhNR). Pupillometry and in vivo corneal confocal microscopy (IVCM) were performed. ATTRv pre-symptomatic carriers presented a significantly reduced central macular thickness (CMT) (p = 0.01) and outer nuclear layer (ONL) thickness (p = 0.01) in comparison to normal controls. No differences were found when analyzing sub-foveal choroidal thickness, retinal nerve fiber layer and ganglion cell complex. In comparison to healthy controls, pre-symptomatic carriers presented an attenuated superficial retinal vascular network and a significantly augmented PhNR amplitude (p = 0.01). However, PhNR implicit times, B-wave amplitude and B-wave peak time did not show significant differences in comparison to controls. No differences were found for pupillometric values. All the examined eyes presented alterations in the IVCM. Preclinical ocular structural and functional abnormalities can be found in ATTRv pre-symptomatic carriers. Thus, an extensive ophthalmological evaluation should be included at the baseline visit and during follow-up. Considering the availability of new drugs potentially able to prevent or delay disease progression, the identification of new disease biomarkers appears to be particularly promising.

The role of hypochlorous acid in the management of eye infections: a case series.

Experiences from clinical practice suggest that hypochlorous acid (HOCl) used as adjuvant treatment can shorten the time to clinical resolution of blepharitis, particularly in relation to the ophthalmic complications that often occur with a blepharitis diagnosis. In addition, in clinical practice, HOCl adjuvant treatment also resulted in a viable option for the management of ophthalmic disorders other than blepharitis. This case series presents and discusses real-life experiences with using an HOCl ophthalmic spray to manage eye infections, further characterizing the use of HOCl for ophthalmic applications.

A New Intraocular Telescopic Device for Age-Related Macular Degeneration.

Age-related macular degeneration is the third leading cause of blindness worldwide after cataracts and glaucoma. We described our recent surgical experience in managing the smaller-incision, new-generation, implantable, miniature telescope that has been designed to enlarge retinal images of the central visual field implanted monocularly in the capsular bag after lens extraction.

Reading with central vision loss: binocular summation and inhibition.

PURPOSE: There are conflicting reports as to whether there is a binocular advantage or disadvantage when reading with central vision loss. This study examined binocular reading summation in patients with macular degeneration. METHODS: Seventy-one patients with bilateral central vision loss [mean age: 63 (S.D. = 21) years] participated. Reading performances during binocular and monocular viewing with the better eye (i.e., the eye with the best monocular visual acuity) were evaluated using different versions of the Italian MNREAD reading chart (www.precision-vision.com). Fixation stability and preferred retinal loci (PRLs) were recorded monocularly for each eye. The overall sample was split into inhibition, equality, and summation groups based on the binocular ratio (i.e., binocular/monocular) of the maximum reading speed. RESULTS: 41% of patients experienced binocular inhibition, 42% summation, and 17% equality. Binocular reading speed of the inhibition group was approximately 30 words per minute slower than those of the equality and summation groups, although the inhibition group had the best visual acuity. These patients generally had monocular PRLs in non-corresponding locations temporal or nasal to the scotoma, had the largest interocular acuity difference and lacked residual stereopsis. The three groups did not differ in fixational control, contrast sensitivity or critical print size. CONCLUSIONS: Equal proportions of patients with central vision loss show binocular reading summation and inhibition. Patients with binocular reading inhibition have poorer reading performance and different clinical characteristics than those with binocular reading summation and equality.

Multimodal imaging evaluation of combined hamartoma of the retina and retinal pigment epithelium.

PURPOSE: Combined hamartoma of the retina and retinal pigment epithelium is a rare benign tumor characterized by a variable combination of glial, vascular, and pigmented components. The purpose of our study was to analyze the features of combined hamartoma of the retina and retinal pigment epithelium on optical coherence tomography angiography. METHODS: Small case series of two cases of combined hamartoma of the retina and retinal pigment epithelium with macular and optic nerve involvement, evaluated with multimodal imaging including optical coherence tomography, fluorescein angiography, and optical coherence tomography angiography. RESULTS: On optical coherence tomography, combined hamartoma of the retina and retinal pigment epithelium is characterized by disruption of the inner neurosensory retina and a variable degree of involvement of the external retina. Optical coherence tomography angiography showed diffuse alterations of the retinal vessels of the superficial and deeper layers, extended to the peripapillary area. Vessel abnormalities included increased tortuosity and caliber of vessels, vascular traction, and vessel stretching within the lesion. CONCLUSION: Optical coherence tomography angiography allows in-depth multilayer analysis of tumor vascular network, highlighting the fine abnormalities of retinal vasculature characteristic of combined hamartoma of the retina and retinal pigment epithelium.

Perceptual learning in patients with Stargardt disease.

OBJECTIVE: To evaluate the efficacy of Perceptual Learning in improving the peripheral reading performance of patients with Stargardt disease (STGD). DESIGN: Prospective observational randomized study. PARTICIPANTS: Fourteen consecutive patients (7 females, 7 males; median age of 50.4 ± 12.8 years) with STGD were analyzed and divided into two groups: Group A received "Win-flash" as Perceptual Learning training and Group B was used as control. METHODS: Subjects underwent an ophthalmic evaluation at baseline, after perceptual learning training and at 6 months of follow-up. Outcomes measured included reading speed, contrast sensitivity and fixation stability. RESULTS: Reading speed improved of 51,7% after training in group A. Visual acuity, contrast sensitivity and fixation stability enhanced in group A after training from 0.89 (±0.09) LogMAR to 0.75 (±0.2) LogMAR (t(6)= 3.6, p= 0.001), from 0.8 (±0.3) LogC (0.6 - 0.9) to 1.3 (±0.3) LogC (t(13)=3.17, p= 0.003) and from 59.3 % (± 24.3) to 71.5 % (± 20.4) (t(13)=1.8 p= 0.04), respectively. No changes were found in group B. At 6-monts of follow-up, visual acuity and contrast sensitivity decreased in group A. CONCLUSIONS: STGD patients receiving "Win-flash training", as PL technique, showed an improvement of reading performance on a real-world task. Early follow-up for perceptual learning re-intervention should be considered.

ARCUATE NERVE FIBER LAYER CHANGES AFTER INTERNAL LIMITING MEMBRANE PEELING IN IDIOPATHIC EPIRETINAL MEMBRANE.

PURPOSE: To analyze the relationship between swelling of the arcuate nerve fiber layer (SANFL) and long-term decrease of retinal nerve fiber layer thickness after internal limiting membrane peeling for idiopathic epiretinal membrane, and to investigate if SANFL is related to a mechanical surgical damage. METHODS: Prospective, interventional consecutive case series of 46 eyes that underwent combined epiretinal membrane/internal limiting membrane peeling for idiopathic epiretinal membrane. Infrared, blue autofluorescence, color fundus imaging and measurement of retinal nerve fiber layer thickness in six peripapillary sectors by spectral-domain optical coherence tomography were performed preoperatively and at 2 weeks, 1, 3, 6, and 12 months after surgery. The presence of SANFL was checked postoperatively on infrared and blue autofluorescence fundus imaging, and the extent of each SANFL was measured on infrared fundus images. RESULTS: Areas of SANFL were identified in 39 eyes (84.8%) at 2-week follow-up. Retinal nerve fiber layer thickness significantly decreased in the temporal sectors at 1, 6, and 12 months (P < 0.0001). The linear extent of SANFL was significantly correlated with the percentage of reduction in retinal nerve fiber layer thickness in the temporal (R = 0.45; P < 0.0001) and infero-temporal (R = 0.23; P = 0.0008) sectors at 12 months of follow-up. Correspondence between sites of surgical grasping and the points of origin of SANFL was demonstrated on blue autofluorescence fundus images superimposed on intraoperative surgical frames. CONCLUSION: Early postoperative SANFL is correlated with late focal retinal nerve fiber layer thinning in the temporal sectors. Intraoperative surgical grasping seems to be a leading factor for the onset of SANFL.

Morpho-functional analysis of Stargardt Disease for reading.

OBJECTIVE: To analyze Stargardt disease (STGD) by morpho-functional examination and investigate the relationship between morpho-functional measures and reading performance. DESIGN: Observational case series study. PARTICIPANTS: Fifteen patients with STGD. METHODS: Twenty-six eyes of 15 patients underwent complete ophthalmic evaluation. Spectral domain optical coherence tomography, fundus autofluorescence (FAF), best corrected visual acuity (BCVA), and microperimetric examinations were performed. FAF and optical coherence tomography (OCT) overlap on microperimetric images was obtained in order to evaluate both tomographic and FAF features passing through the eccentric fixation area. Both morphologic features and functional data were correlated with magnification of prescribed device and reading rate. RESULTS: Univariable analysis showed a significant correlation between magnification power and greatest linear dimension of both OCT and FAF (r = 0.69 and r = 0.67; p < 0.05). Magnification power was related to best corrected visual acuity (r = 0.56; p < 0.05). Retinal sensitivity map (r = 0.57; p < 0.05) was considered an indicator of reading rate. Magnification levels showed a positive correlation with eccentric preferred retinal location (p = 0.03) and the degree of FAF alteration (normal, dishomogeneous, ipoautofluorescence; p < 0.0001). CONCLUSIONS: As a result of the overlapping of OCT/FAF imaging on microperimetric exam, residual activity of outer retinal layers passing through the eccentric fixation area seems to be related with required magnification and reading rate. Identification of morpho-functional parameters is helpful for designing a customized rehabilitative program.

25-Gauge Pars Plana Vitrectomy for Retained Lens Fragments in Complicated Cataract Surgery.

PURPOSE: To verify the efficacy of 25-gauge pars plana vitrectomy (PPV) for the management of posteriorly dislocated lens material after complicated cataract extraction and to determine in what patients this approach offers the optimal benefit in terms of efficacy and safety, considering the amount of retained nuclear material and the duration of surgery. METHODS: Forty eyes of 40 patients with retained lens fragments undergoing early (within 1 week) or late (within >1 week) 25-gauge PPV were retrospectively reviewed. The amount of dislocated nuclear material was graded by the surgeon intraoperatively, and the patients were divided into two groups according to the nuclear grading: group A (≤50% dropped nucleus) and group B (>50% dropped nucleus). The presence of brunescent nuclear pieces was considered. The outcomes measured included best-corrected visual acuity (BCVA) and postoperative complications such as retinal detachment, cystoid macular edema (CME) and postoperative ocular hypertension or hypotonia. RESULTS: The patients had a mean age of 78 years. The mean preoperative logarithm of the minimum angle of resolution (logMAR) BCVA was 0.57 ± 0.24 (20/80). A significant positive correlation was found between nuclear material grade and PPV duration (R2 = 0.81, p < 0.0001). None of the patients had dislocation of brunescent nuclear pieces. On postoperative day 1, the mean postoperative intraocular pressure was 16.75 ± 2.7 mm Hg, with no case of ocular hypotonia. At 6 months of follow-up, the mean logMAR BCVA improved to 0.23 ± 0.3 (20/32). Retinal detachment developed in 4 patients (10%), occurring only in patients of group B (p < 0.002). Four patients with late PPV developed postoperative CME, with no case of CME among patients with early vitrectomy (p = 0.014). CONCLUSION: Removal of dislocated lens fragments after complicated cataract surgery can be effectively managed with 25-gauge PPV, although it appears to be most efficient for cases with a limited amount of dislocated lens material. In consideration of the higher rate of retinal detachment observed in cases of prolonged PPV time, the expected duration of surgery should be taken into account when choosing the best surgical approach. Visual outcomes are not affected by the timing of PPV, whereas early vitrectomy seems to prevent the onset of inflammatory macular edema.

Idiopathic macular hole: post-operative morpho-functional assessment and prognostic factors for recovery of visual acuity.

INTRODUCTION: Idiopathic macular hole (MH) is a full-thickness retinal damage typical of the advanced age with a high social impact because, as it affects the macula, it produces severe loss of vision. AIM: This study aims to evaluate the therapeutic efficacy of surgery and to determine prognostic factors, considering how hypovision weighs on individual quality of life and on public health. METHODS: All patients affected by MH were evaluated with an ophthalmic visit, measurement of visual acuity and Optical Coherence Tomography (OCT) documentation before surgical intervention. Surgical treatment followed and, subsequently, all the patients were examined with the same documentation at 7 days, 1 month, 3 months, 6 months and 12 months. RESULTS: Surgical therapy, with the modern techniques available, demonstrated the efficacy of anatomical recovery and retinal function. Furthermore, the quantitative characteristics of the MH in the OCT scanning revealed an important prognostic function.

Assessment of retinal function before and after idiopathic macular hole surgery.

PURPOSE: To evaluate preoperative and postoperative retinal function in patients who underwent macular surgery for idiopathic macular hole. DESIGN: Prospective, comparative, interventional case series. METHODS: Thirty eyes of 30 patients with idiopathic macular hole were included in the study. Patients underwent pars plana vitrectomy and peeling of the internal limiting membrane (ILM). ILM visualization was improved in 15 patients by using triamcinolone acetonide and in the remaining 15 patients by using infracyanine green dye. Spectral-domain optical coherence tomography examination was performed to document macular hole closure. Retinal function was assessed preoperatively and postoperatively over a period of 12 months by best-corrected visual acuity (BCVA) measurement (ETDRS chart), MP-1 microperimetry, and focal electroretinogram recording (fERG). Focal electroretinograms were recorded in response to a sinusoidally modulated (41 Hz), uniform field presented to the macular (18 degrees) and foveal (2.25 degrees) region. RESULTS: Macular hole closure was achieved in all patients in both groups. At 12 months, visual acuity improved in both groups (P < .001), and there were no statistically significant differences between groups. Mean macular sensitivity within the central 2 and 8 degrees increased in both groups, and there were no statistically significant differences between groups at any follow-up. In the triamcinolone acetonide group, 12 months after surgery the amplitude of the fERG's first harmonic (1F) increased both in the macular region (P < .001) and in the foveal region (P < .05). In the infracyanine green group, at 12 months the amplitude of the first harmonic (1F) decreased in both areas. The decrease was significant in the macular region (P < .05) and not significant in the foveal region (P = .095). CONCLUSION: Vitrectomy and ILM peeling assisted with either triamcinolone acetonide or infracyanine green staining improves visual acuity and mean macular sensitivity at 12 months in patients affected by idiopathic macular hole. However, triamcinolone acetonide staining is associated with an increase of fERG's first harmonic amplitude in the foveal and macular region, whereas in the case of infracyanine green staining it seems to decrease after surgery. The reduction of the amplitude of fERG's first harmonic suggests that infracyanine green may have a late toxic effect on photoreceptor cells.

SD-OCT imaging of idiopathic macular holes with spontaneous closure.

Spectral-domain optical coherence tomography serial changes in three cases of spontaneous closure of idiopathic macular hole at stages II, III, and IV are described. Initial and serial spectral-domain optical coherence tomography images document the progressive closure. Macular holes apparently resolved spontaneously through two different mechanisms: posterior hyaloid detachment in case 1 and a contraction of epiretinal macular membrane in cases 2 and 3. The spontaneous closure of idiopathic full-thickness macular holes may occur in any stage of idiopathic macular hole; the small size of the hole is a common feature in all cases of spontaneous closure reported.

Macular functional changes evaluated with MP-1 microperimetry after intravitreal bevacizumab for subfoveal myopic choroidal neovascularization: one-year results.

PURPOSE: The purpose of this study was to evaluate 1-year functional and structural effects of intravitreal bevacizumab for subfoveal choroidal neovascularization secondary to pathologic myopia (myopic choroidal neovascularization). METHODS: Fifteen eyes with myopic choroidal neovascularization participated in this prospective interventional, noncomparative case series. All patients were treated with one intravitreal injection of 1.25 mg bevacizumab. Retreatments were performed in case of persistent or recurrent leakage on fluorescein angiography and/or intraretinal fluid on optical coherence tomography. Evaluation of best-corrected visual acuity using Early Treatment of Diabetic Retinopathy Study criteria, MP-1 microperimetry, optical coherence tomography, and fluorescein angiography were performed before treatment and 1 month, 3 months, 6 months, and 1 year after treatment. RESULTS: After a follow-up of 12 months, best-corrected visual acuity improved on average of 0.23 logarithm of the minimum angle of resolution. Mean macular sensitivity within the central 8 degrees increased on average of 2.62 dB at 12-month postinjection. The mean number of measurement points within the central absolute scotoma reduced significantly from 12.47 before treatment to 6.27 at 1-year follow-up. An improvement of fixation stability from baseline was observed in 9 patients (60%). No treatment adverse events were evidenced. CONCLUSION: Improvement of macular sensitivity and fixation stability 1 year after intravitreal bevacizumab for myopic choroidal neovascularization suggest a stable and progressive macular function recovery. The mean treatment session was 1.53, with 53.3% of patients needing only a single intravitreal bevacizumab injection, supporting a potential long-lasting efficacy of intravitreal bevacizumab treatment.

Photodynamic therapy for vasoproliferative retinal tumors.

PURPOSE: To report our experience with photodynamic therapy (PDT) with verteporfin for patients with vasoproliferative retinal tumors (VPRTs). METHODS: Three patients with VPRTs who presented with macular exudative changes were treated with one session of PDT with 6 mg/m body surface area of verteporfin and a light dose of 100 J/cm at 689 nm delivered in 166 seconds. Biomicroscopy, fluorescein angiography, indocyanine green angiography, optical coherence tomography, and ultrasonography were performed before treatment and 1 month, 3 months, 6 months, and 1 year after treatment; visual acuity was measured using Early Treatment Diabetic Retinopathy Study criteria. RESULTS: At the 1-year follow-up, all tumors responded with a reduction in size (mean height: pretreatment, 2.96 mm; posttreatment, 1.32 mm), and optical coherence tomography showed complete resolution of macular exudates. For all patients, fluorescein angiography evidenced reduction of leakage from the lesion, and indocyanine green angiography verified nonperfusion of the vascular channels. An improvement in visual acuity (average, 4.7 Early Treatment Diabetic Retinopathy Study letters) was observed. No retreatment was needed. CONCLUSION: PDT may represent an effective and safe modality of treatment for VPRTs because of its selectivity. Our study supports the application of a light dose of 100 J/cm, although further studies with larger numbers of cases and longer follow-ups are required.