Occlusive Retinal Vasculitis After a Single Injection of Pegcetacoplan.

Purpose: To describe a patient with retinal vasculitis after a single intravitreal injection (IVI) of pegcetacoplan. Methods: A case and its findings were analyzed. Results: An 80-year-old woman was treated with pegcetacoplan for subfoveal geographic atrophy. Ten days later, the patient noted "purple iridescent waves" but did not immediately report it. On day 18, she presented with pain and decreased visual acuity from 20/80 (pinhole) preinjection to 20/150 postinjection. No signs of inflammation were observed, and she was treated for high intraocular pressure (30 mm Hg). On day 23, iritis was noted. The fluorescein angiogram showed severe occlusive vasculitis involving all quadrants and the macula. The vasculitis/neuroretinitis laboratory panels were negative, and no contributing systemic features were identified other than well-controlled diabetes. Conclusions: In this patient, occlusive retinal vasculitis occurred shortly after a single IVI of pegcetacoplan.

New Approaches to Overcoming Antimicrobial Resistance in Endophthalmitis.

Endophthalmitis is a rare but vision-threatening infection characterized by marked inflammation of intraocular fluids and tissues, uncommonly seen following surgery and intravitreal injection. Antimicrobials are used worldwide in the prophylaxis and treatment of bacterial and fungal infections of the eye and are standard treatment in the preoperative and postoperative care of surgical patients. However, antimicrobials are reported to be overprescribed in many parts of the world, which contributes to antimicrobial resistance (AMR). AMR complicates the prophylaxis and treatment of endophthalmitis. This article examines the prevalence and mechanisms of AMR in ocular microorganisms, emphasizing the importance of understanding AMR patterns for tailored treatments. It also explores prophylaxis and management strategies for endophthalmitis, with a discussion on the use of intracameral antibiotic administration. The use of prophylactic intracameral antibiotics during cataract surgery is common in many parts of the world but is still controversial in some locations, especially in the US. Finally, it highlights the role of stewardship in ophthalmology and its benefits in the treatment of endophthalmitis.

Genetics and Age-Related Macular Degeneration: A Practical Review for Clinicians.

Age-related macular degeneration (AMD) is a multifactorial genetic disease, with at least 52 identifiable associated gene variants at 34 loci, including variants in complement factor H (CFH) and age-related maculopathy susceptibility 2/high-temperature requirement A serine peptidase-1 (ARMS2/HTRA1). Genetic factors account for up to 70% of disease variability. However, population-based genetic risk scores are generally more helpful for clinical trial design and stratification of risk groups than for individual patient counseling. There is some evidence of pharmacogenetic influences on various treatment modalities used in AMD patients, including Age-Related Eye Disease Study (AREDS) supplements, photodynamic therapy (PDT), and anti-vascular endothelial growth factor (anti-VEGF) agents. However, there is currently no convincing evidence that genetic information plays a role in routine clinical care.

Recovery course of persistent posterior subretinal fluid after successful repair of rhegmatogenous retinal detachment.

PURPOSE: To investigate best corrected visual acuity (BCVA), subretinal fluid (SRF) absorption time or ellipsoid zone (EZ) restoration time and various variables in patients with persistent SRF after successful primary repair of rhegmatogenous retinal detachment (RRD). METHODS: This retrospective multicenter study allowed independent analysis of the healing pattern by two observers based on composite of serial cross-sectional macular optical coherence tomography (OCT) scans. Univariate and multivariate analyses were implemented. RESULTS: One hundred and three cases had persistent SRF after pars plana vitrectomy, scleral buckling, or pneumatic retinopexy. By univariate analysis, SRF resolution time correlated positively with the number of retinal breaks (p < 0.001) and with increased myopia (p = 0.011). Using multivariate analysis, final BCVA (log MAR) correlated positively with age, duration of RRD, initial BCVA (OR = 3.28; [95%CI = 1.44-7.47]; p = 0.015), and SRF resolution time (OR = 0.46 [95%CI 0.21-1.05]; p = 0.049). EZ restoration time was longer with increasing number of retinal tears (OR = 0.67; [95%CI 0.29-1.52]; p = 0.030), worse final BCVA, and presence of macula-off RRD (OR = 0.26; [95%CI 0.08-0.88]; p = 0.056). SRF resolution time correlated marginally with prone position. CONCLUSIONS: Residual posterior SRF is more common in eyes with multiple breaks or in myopic eyes. Final BCVA is better in younger subjects and in eyes with shorter duration of RRD. Persistent SRF is a self-limited disorder with a mean resolution of 11.2 months with good visual prognosis improving from a mean baseline logMAR of 1.08 to 0.25 at one year.

Update on current pharmacologic therapies for diabetic retinopathy.

INTRODUCTION: Diabetic retinopathy is a major cause of visual loss worldwide. The most important clinical findings include diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). AREAS COVERED: PubMed was used for our literature review. Articles from 1995 to 2023 were included. Pharmacologic treatment of diabetic retinopathy generally involves the use of intravitreal anti-vascular endothelial growth factor (VEGF) therapy for DME and PDR. Corticosteroids remain important second-line therapies for patients with DME. Most emerging therapies focus on newly identified inflammatory mediators and biochemical signaling pathways involved in disease pathogenesis. EXPERT OPINION: Emerging anti-VEGF modalities, integrin antagonists, and anti-inflammatory agents have the potential to improve outcomes with reduced treatment burdens.

INTRAOCULAR INFLAMMATION INCIDENCE AFTER INTRAVITREAL BROLUCIZUMAB INJECTION FOR EXUDATIVE AGE-RELATED MACULAR DEGENERATION.

PURPOSE: We evaluated the clinical outcomes of intraocular inflammation (IOI) of eyes with neovascular age-related macular degeneration (AMD) injected with brolucizumab in our tertiary referral center. METHODS: A retrospective case series for which clinical records of all eyes that received intravitreal brolucizumab at Bascom Palmer Eye Institute between December 1, 2019, and April 1, 2021, were reviewed. RESULTS: There were 345 eyes of 278 patients who received 801 brolucizumab injections. IOI was detected in 16 eyes of 13 patients (4.6%). In those patients, baseline Logarithm of Minimu Angle of Resolution (logMAR) best-corrected visual acuity was 0.32 0.2 (20/42), while it was 0.58 0.3 (20/76) at IOI presentation. The mean number of injections among eyes experiencing IOI was 2.4, and the interval between the last brolucizumab injection and IOI presentation was 20 days. There was no known case of retinal vasculitis. Management of IOI included topical steroids in seven eyes (54%), topical and systemic steroids in five eyes (38%), and observation in one eye (8%). Best-corrected visual acuity returned to baseline and inflammation resolved in all eyes by the last follow-up examination. CONCLUSION: Intraocular inflammation after brolucizumab injection for neovascular AMD was not uncommon. Inflammation resolved in all eyes by the last follow-up visit.

Infectious Endophthalmitis vs Noninfectious "Pseudohypopyon" After Intravitreal Triamcinolone Acetonide.

Introduction: To describe a patient who presented with visual loss and an apparent hypopyon but none of the other symptoms or signs most common with infectious endophthalmitis. Methods: A case and its findings were analyzed. Results: A 73-year-old woman was treated with intravitreal triamcinolone acetonide (IVTA) for cystoid macular edema. The eye had 12 previous injections without complication. After the 13th injection, the patient noted painless visual loss. An examination showed a visual acuity (VA) of finger counting and an apparent hypopyon, which shifted after a head-tilt test, suggesting a noninfectious "pseudohypopyon." Two days later, the VA worsened to hand motions and the hypopyon had increased in size. The eye was treated with a vitreous tap and injection with vancomycin and ceftazidime. The inflammation resolved, VA improved to 20/40, and cultures showed no growth. Conclusions: Distinguishing infectious endophthalmitis from noninfectious inflammation remains challenging. There is no definitive technique by which to distinguish between the 2 conditions; thus, clinicians must use their best judgment and follow the patient closely.

Extracapsular cataract extraction in Europe prior to Jacques Daviel.

The first successful planned extracapsular cataract extraction was reported by Jacques Daviel in 1752. The history of European cataract surgery in the first half of the 18th century, immediately preceding Daviel's report, contains interesting information that explains the foundations of this accomplishment. Daviel himself credited the prior work of Francois Pourfour du Petit. Other important advances were reported by Michel Brisseau, Antoine Maitre-Jan, Jean Méry and others. A critical insight during this time period was the realization that the cataract was, in fact, the opacified crystalline lens, rather than a membrane or opacity located anterior to the lens.

AN 82-YEAR-OLD WOMAN WITH RETINAL VASCULAR SHEATHING AND VITREOUS HEMORRHAGE.

PURPOSE: This report describes a case of hereditary transthyretin amyloidosis in an 82-year-old woman who presented with bilateral retinal arteriolar vascular sheathing and vitreous hemorrhage in one eye. METHODS: The patient underwent a full history, physical examination, genetic workup, and cardiac imaging to establish the diagnosis. Fundus photographs, optical coherence tomography, fluorescein angiography, and indocyanine green angiography were performed throughout the patient's treatment course. RESULTS: Fundus examination demonstrated segmental sheathing of the retinal arterioles, telangiectasias, and intraretinal hemorrhages in both eyes without neovascularization. Fluorescein angiography revealed delayed filling of the nasal retinal arterioles in the right eye with severe temporal nonperfusion and areas hyperfluorescent segmental sheathing in both eyes. Ocular coherence tomography demonstrated retinal vessels with hyperreflective thickened walls. Cardiac amyloid nuclear scan was consistent with transthyretin-mediated amyloidosis amyloid heart disease, and genetic testing confirmed a heterozygous pathogenic transthyretin mutation: c.290 C>A (p.Ser97Tyr) also known as Ser77Tyr. CONCLUSION: Amyloidosis should be considered in the differential of vasculitis and vitreous hemorrhage with or without significant vitreous opacities. Ophthalmologists aware of this diagnosis should complete a full review of systems with specific focus on cardiac history and symptoms of peripheral neuropathy when amyloidosis is in the differential.

Glaucoma Drainage Device Erosions in Patients Receiving Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Retinopathy.

Purpose: To determine if intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections are associated with an increased risk of glaucoma drainage device (GDD) erosions. Patients and Methods: A retrospective chart review was conducted including patients with diabetic retinopathy and had a GDD implanted at a large academic institution. The rate of GDD erosions was compared between eyes that did or did not receive intravitreal anti-VEGF injections. A subanalysis was also performed the relationship between diabetic macular edema (DME) and intravitreal steroid injections and GDD erosions. Results: A total of 677 eyes from 608 patients was included. A total of 447 eyes received at least one anti-VEGF injection; 230 eyes never received such therapy. Twenty eyes (4.5%) receiving anti-VEGF had at least one erosion event, compared to 7 eyes (3.0%) of patients not receiving anti-VEGF therapy (OR 1.49, p=0.37). Diabetic macular edema was associated with a significantly increased rate of erosion in eyes not receiving anti-VEGF (71.4% versus 31.4%, p=0.034), but not in eyes receiving anti-VEGF (30.0% versus 40.7%, p=0.34). Receiving more than one specific anti-VEGF agent, an increased frequency or total number of anti-VEGF injections, or receiving intravitreal steroids were not associated with an increased risk of erosion (p>0.05). Conclusion: In patients with diabetic retinopathy, the use of anti-VEGF does not result in an increased rate of GDD erosions or recurrent erosions. Further research is needed over a longer follow-up period to determine if longer or more frequent anti-VEGF treatment is a risk factor for recurrent erosions.

Optical Coherence Tomography Angiography Findings in Sclerochoroidal Calcification.

Optical coherence tomography angiography (OCT-A) is a modern non invasive imaging technique that may aid in the evaluation of retinal diseases through the assessment of chorioretinal vasculature. The literature regarding OCT-A in sclerochoroidal calcification is scarce. We present the case of a 57-year-old female who was referred to the clinic due to an atypical choroidal lesion in the right eye. OCT-A showed an apparent decrease in the vascular flow of the choroidal/choriocapillaris layers and an apparent increase in the vascular flow of the deep retinal layers. A mass effect may be seen in OCT-A en face imaging that may create artifactual vascular flow pattern. This case reports the first OCT-A findings of sclerochoroidal calcification.

Recovery course of foveal microstructure in the nonsurgical resolution of full-thickness macular hole.

PURPOSE: To analyze the recovery course of foveal microstructures in eyes with nonsurgical healing of full-thickness macular hole (FTMH). METHODS: By serial OCT scans, the temporal healing sequences were analyzed in ocular trauma, vitreomacular traction (VMT), cystoid macular edema (CME), and the remaining group. We evaluated correlations between the final best-corrected spectacle visual acuity and reconstruction time of external limiting membrane (ELM), and inner segment/outer segment (IS/OS). RESULTS: The healing (mean±standard deviation in months) most involved fusion at the level of the outer nuclear layer (ONL) (6.3±10.5) followed by restoration of ELM (9.1±13.8), and lastly, by IS/OS regeneration (13.1±19.5). In severe blunt ocular trauma, healing was fast and involved subretinal zipper glue-like reapposition with resulting outer retinal atrophy. Best spectacle-corrected visual acuity correlated with normalization of the clivus (p=0.012), faster ELM (p=0.006), and IS/OS reconstitution (p=0.024). Recurrence of FTMH occurred when the healing was halted (3 eyes) or was aberrant by lamellar hole epiretinal proliferation (LHEP) (3 eyes) or by the persistence of VMT (1 eye). CONCLUSION: Recovery sequences proceeded from the ONL to the deeper layers with BCVA correlating absolutely and temporally with the restoration of outer retinal layer integrity.

Acute macular neuroretinopathy in dengue virus serotype 1.

PURPOSE: To report a case of acute macular neuroretinopathy (AMN) associated with dengue virus serotype 1 infection. OBSERVATION: An 18-year-old Puerto Rican female was evaluated due to painless paracentral scotomas in each eye that developed after being hospitalized for dengue fever a week before. Clinical examination and multimodal imaging revealed bilateral hypopigmented macular lesions, hyperreflectivity at the outer nuclear and photoreceptor layer, and reduced flow signal in the deep capillary plexus. Additionally, hypoautofluorescent parafoveal lesions were found in the left eye. AMN was diagnosed. Two-month follow-up after the initial evaluation showed resolution of symptoms but persistence of some findings on optical coherence tomography. CONCLUSIONS AND IMPORTANCE: Patients with dengue virus serotype 1 may develop paracentral scotomas with classic AMN findings and obtain complete symptomatic recovery without treatment.

Clinical spectrum of blunted foveal contour.

Foveal hypoplasia is the absence of a foveal depression and the presence of the ganglion cell layer in the foveola. A spectrum of clinical characteristics, including normal or variably decreased visual acuity, has been described in patients with blunted foveal contours. Multiple systemic and ophthalmologic conditions including albinism, aniridia, nanophthalmos, prematurity, and fovea plana have been associated with this anomaly. This article illustrates select clinical conditions characterized by a blunted foveal contour. Given the heterogeneity of findings, a thorough medical history and detailed physical and ocular examinations are usually sufficient for the clinician to make the correct diagnosis.

Clinical characteristics of full thickness macular holes that closed without surgery.

PURPOSE: To ascertain the anatomic factors that help achieve non-surgical sealing in full thickness macular hole (FTMH). METHODS: Retrospective collaborative study of FTMH that closed without surgical intervention. RESULTS: A total of 78 patients (mean age 57.9 years) included 18 patients with blunt ocular trauma, 18 patients that received topical or intravitreal therapies and 42 patients with idiopathic FTMH. Mean±SD of the initial corrected visual acuity (VA) in logMAR improved from 0.65±0.54 to 0.34±0.45 (p<0.001) at a mean follow-up of 33.8±37.1 months. FTMH reopened in seven eyes (9.0%) after a mean of 8.6 months. Vitreomacular traction was noted in 12 eyes (15.8%), perifoveal posterior vitreous detachment in 42 (53.8%), foveal epiretinal membrane in 10 (12.8%), cystoid macular oedema (CME) in 49 (62.8%) and subretinal fluid (SRF) in 20 (25.6%). By multivariate analysis, initial VA correlated to the height (p<0.001) and narrowest diameter of the hole (p<0.001) while final VA correlated to the basal diameter (p<0.001). Time for closure of FTMH (median 2.8 months) correlated to the narrowest diameter (p<0.001) and the presence of SRF (p=0.001). Mean time for closure (in months) was 1.6 for eyes with trauma, 4.3 for eyes without trauma but with therapy for CME, 4.4 for eyes without trauma and without therapy in less than 200 µm in size and 24.7 for more than 200 µm. CONCLUSION: Our data suggest an observation period in new onset FTMH for non-surgical closure, in the setting of trauma, treatment of CME and size <200 µm.

The 100 most cited papers on retinal detachment: a bibliographic perspective.

The 100 most cited papers on retinal detachment (RD) were analysed using a bibliographic study. The bibliographic databases of the ISI Web of Knowledge were searched, limited to research articles published between 1965 and 2020 in peer-reviewed journals. The papers were ranked in order of number of citations since publication. Ninety of the 100 most cited papers on RD were published in 12 ophthalmology journals, with 74 of them published in American Journal of Ophthalmology (n=31), Ophthalmology (n=23), Archives of Ophthalmology (n=10) and Investigative Ophthalmology and Visual Science (n=10); the remaining 10 papers were published in 8 journals from other fields of medical research. All papers in the top 100 were published in English. The 100 most cited papers on RD originated from 12 different countries, with the majority (72 papers) originating from the USA. The 100 identified papers represent a mix of clinical trials and animal/laboratory studies. This bibliographic study provides a unique perspective and insight into some of the most influential contributions in RD understanding and management over the last 55 years.

Transient vision loss associated with paracentral acute middle maculopathy detected on multi-modal imaging.

PURPOSE: To report two patients with transient decreased vision and associated paracentral acute middle maculopathy (PAMM) lesions identified with multi-modal imaging, including what we believe to be the first documented patient of PAMM associated with iron deficiency anemia. OBSERVATIONS: Case 1 is a 56-year-old man who experienced transient blurred vision one week following cardiac ablation for atrial fibrillation. Symptoms resolved by the time of presentation and visual acuity was 20/20 in each eye. Ocular examination was unremarkable aside from subtle discoloration within the papillomacular bundle in the right eye. Spectral domain optical coherence tomography (SD-OCT) revealed thickening of the middle retinal layers with a corresponding area of hyporeflectivity on the en face infrared image. This area of hyporeflectivity was confirmed on "structural" SD-OCT angiography, although no flow voids were identified. Fluorescein angiography was normal. Case 2 is a 25-year-old man with no past medical history who noted decreased central vision in his right eye upon awakening. Visual acuity was light perception in the right eye and 20/20 in the left eye. Posterior segment examination in the right eye showed tortuous retinal vessels and subtle pallor involving the superior part of the macula. SD-OCT showed thickening of the middle retinal layers of the superior macula with a corresponding area of hyporeflectivity on the en face infrared image. Systemic work-up was completed and identified severe iron deficiency anemia as the most likely inciting factor. In both cases, visual acuity was 20/20 in each eye at follow-up. CONCLUSIONS: Small arterial occlusions of the retina remain difficult to diagnose and may represent a sequela of systemic disease. Multi-modal imaging is helpful in equivocal cases with subtle clinical findings. IMPORTANCE: The present case report illustrates the utility of multi-modal imaging in diagnosing transient ischemic events of the retina, and reports what we believe to be the first association of PAMM with iron deficiency anemia.

The 100 most-cited papers on age-related macular degeneration: a bibliographic perspective.

The 100 most-cited papers on age-related macular degeneration (AMD) were analysed using a bibliographic study. The bibliographic databases of the Institute for Scientific Information Web of Knowledge were searched, limited to research articles published between 1965 and 2020 in peer-reviewed journals. The papers were ranked in order of number of citations since publication. Five of the top 10 (and 3 of the top 4) papers reported randomised clinical trial results for either anti-vascular endothelial growth factor agents or nutritional supplements. Four of the top 10 papers reported genotype-phenotype associations between AMD and variants in Complement Factor H. This bibliographic study provides perspective and insight into many of the most influential contributions in the understanding and management of AMD and its evolution over time.