Concurrent ciliary body detachment in patients presenting with serous choroidal detachment following glaucoma surgery.

PURPOSE: To examine the rate of ciliary body detachment in patients with choroidal detachment following glaucoma surgery and its effect on the clinical course, management, and prognosis. METHODS: A prospective observational case-series study. Patients with choroidal detachment following glaucoma surgery in 2018-2019 were included. All underwent complete ophthalmological examination and ultrasound biomicroscopy for evaluation of the presence and extent of ciliary body detachment. Follow-up examinations including ultrasound biomicroscopy scans were performed at 1 week, 1 month, 3 months, and 6 months. RESULTS: Eight patients (8 eyes) were enrolled, 4 male and 4 female, of mean age 72 years (range 60-83). Five patients underwent trabeculectomy with mitomycin C (0.02%), which was combined with phacoemulsification cataract extraction in one; two underwent Ahmed glaucoma valve implantations, and one underwent ab-interno Xen45 gel stent implantation with mitomycin C (0.02%). The mean intraocular pressure was 26.0 ± 7.65 mmHg preoperatively, dropping to 6.9 ± 2.64 mmHg on first postoperative day one. Mean time from surgery to diagnosis of choroidal detachment was 11.6 ± 5.73 days. Ciliary body detachment was identified by ultrasound biomicroscopy in all patients, ranging between one and four quadrants. All patients were treated with topical steroids and cycloplegics; three (37.5%) received oral steroids. No surgical intervention for the choroidal or ciliary body detachments was indicated. CONCLUSIONS: In this real-world prospective study, concurrent ciliary body detachment was identified in all patients who presented with choroidal detachment following glaucoma surgery. This observation may deepen our understanding of the mechanism underlying the hypotony that is often seen after glaucoma surgery.

Posterior synechia formation after phacovitrectomy - Predicting factors and the role of short-acting mydriatics.

PURPOSE: To evaluate the influence of topical short-acting mydriatics on the formation of posterior synechia after phacovitrectomy surgery of pars plana vitrectomy and phacoemulsification with intraocular lens implantation. METHODS: A prospective randomised controlled trial. Fifty-seven adult (>18 years old) patients (57 eyes) who underwent phacovitrectomy surgery at a single tertiary hospital, were randomly divided into two groups. The control group (29 eyes) received standard postoperative treatment (topical antibiotics and steroids). The study group (28 eyes) received short-acting mydriatics together with standard therapy. Patients were followed until 24 months after surgery. The primary outcome measure was the formation of posterior synechia during the follow-up period. RESULTS: A total of 7 patients developed posterior synechia during the follow-up period (12%), 3 in the study group (11%) and 4 in the control group (14%). There was no statistical difference between the groups. Significant associations for the development of posterior synechia were surgery for retinal detachment, longer surgery duration (>93 min) and the use of tamponade, in particular silicone oil. CONCLUSIONS: The use of topical short-acting mydriatic drops after phacovitrectomy surgery, in addition to standard post-operative treatment, did not reduce the formation of posterior synechia. However, we identified several factors that may influence or act as predictors for the development of posterior synechia: surgery for retinal detachment, using silicone oil tamponade and a longer surgery duration. Our findings may aid in the standardisation of post-phacovitrectomy surgery treatment and define potential at-risk patients who should be monitored more closely.

Prognostic factors for visual acuity improvement after treatment of submacular hemorrhage secondary to exudative age-related macular degeneration.

PURPOSE: To recognize prognostic factors for better final visual acuity (VA) in patients presenting with submacular hemorrhage (SMH) secondary to exudative age-related macular degeneration. METHODS: This retrospective study included patients who presented to a tertiary ophthalmology department between 2012 and 2019 with SMH and were treated by pars plana vitrectomy (PPV) or injection of tissue plasminogen activator (tPA) with pneumatic displacement. Baseline characteristics included demographic data, VA and optical coherence tomography (OCT) characteristics of the SMH. Patients were divided into groups by improvement of at least 2 lines in BCVA (best corrected visual acuity), and by having a final BCVA better than 20/200. RESULTS: Forty-three eyes of 43 patients were included. Mean age was 86.72 ± 7.18. Prognostic factors for final VA better than 20/200 included better VA at presentation (1.25 vs 1.90 logMAR, p < 0.001), smaller area of SMH in the infra-red image (19.47 mm2 vs 38.45 mm2, p = 0.024), and lower height of SMH as measured by OCT (713.5 µm vs 962.5 µm, p = 0.03). Third of the patients improved in ≥2 lines from presentation, all in the group of the pneumatic and TPA displacement. CONCLUSION: Smaller SMHs with good VA at presentation have a better chance for improvement and result in a better final VA. These patients may benefit the most from pneumatic displacement of the SMH with intravitreal tPA and gas.

Outcomes of Combined Phacovitrectomy Without Corneal Suturing.

BACKGROUND: During combined phacovitrectomy, it is common practice to suture the main corneal incision to prevent intraoperative and postoperative wound leak. However, it may be possible to avoid suturing using a self-sealing corneal incision technique as in standard cataract surgery. OBJECTIVES: To evaluate the clinical outcome, safety, and complications of combined phacovitrectomy without preventive suturing. METHODS: This retrospective case series study included consecutive patients who underwent combined phacovitrectomy between January 2018 and June 2019 for mixed indications. Surgeries were performed at a tertiary university hospital. All surgeries were performed by the same two retinal surgeons. Cataract surgery was performed first, followed by insertion of trocars and vitrectomy. Corneal sutures were not planned but were used at the discretion of the surgeon. RESULTS: The cohort included 106 eyes of 102 patients. Suturing of the main corneal incision was deemed necessary in five cases (5%) because of a main incision leak or anterior chamber shallowing during trocar insertion. No other complications related to the absence of prophylactic corneal sutures were encountered during surgery or follow-up. CONCLUSIONS: Preventive corneal suturing may not be necessary in combined phacovitrectomy surgery and can be used in the few cases in which it is indicated during surgery.

Optical coherence tomography angiography patterns of type 1 macular neovascularization in age-related macular degeneration patients.

PURPOSE: To compare morphologic characteristics of type 1 macular neovascularization (MNV) flow pattern in treatment-naïve and previously treated patients with age-related macular degeneration (AMD) as assessed by optical coherence tomography angiography (OCTA). STUDY DESIGN: Cross-sectional study. MATERIALS AND METHODS: Macular OCT angiography images were acquired using RTVue XR Avanti with AngioVue. Distinct morphologic biomarkers and quantifiable features of the neovascular membranes were studied on en-face projection images comparing treatment-naïve and previously treated patients. RESULTS: The study included 68 eyes of 58 patients. Among them, 24 eyes were treatment-naïve, and the remaining eyes had received a mean of 19.6 injections. Immature lesions were more associated with treatment-naïve eyes and hyper-mature lesions were associated with previously treated eyes (p = 0.005). Tangle pattern was associated with treatment-naïve eyes (p = 0.013), whereas mature core vessels and sea fan pattern were associated more with previously treated eyes (p = 0.001 and p = 0.044, respectively). Vascular density of the neovascular membrane was higher in the treatment-naïve group (p = 0.036) and the average MNV area was similar between the 2 groups (p = 0.683). CONCLUSIONS: Based on OCTA, morphologic biomarkers of type 1 MNV might be an indication of previous treatment. The MNV pattern can improve our understanding of its maturation under anti-VEGF treatment and might be valuable to better guide therapeutic decisions and provide more personalized care to patients with AMD.

Visual acuity outcome in patients with subretinal hemorrhage - office procedure vs. surgical treatment.

PURPOSE: To evaluate the effects of intravitreal injection of tissue plasminogen activator (tPA) and gas vs. pars plana vitrectomy (PPV) surgery as first-line treatment for subretinal hemorrhage. METHODS: Retrospective study of 107 adults treated for subretinal hemorrhage at a tertiary hospital during 2008-2019; 51 received injection of tPA and gas and 56 underwent PPV. RESULTS: No between-group differences were found in age and sex, medical history, use of anticoagulants or antiplatelets, history of ocular surgeries, and previous use of intravitreal anti-VEGF. Overall follow-up time was longer in the PPV group (median 4.9 vs 3.28 years, p = 0.005). The hemorrhage was displaced in a similar percentage of patients in the tPA-and-gas group (n = 40, 78.4%) and the PPV group (n = 45, 80.4%) (p = 0.816). Approximately 80% of patients in the tPA-and-gas group were able to forgo PPV surgery. Visual acuity (in LogMAR) was similar in the two groups prior to the diagnosis of subretinal hemorrhage but better in the tPA-and-gas group at the end of follow-up (p < 0.001). CONCLUSION: Injection of gas and tPA can be done immediately following diagnosis of subretinal hemorrhage as an office procedure. Visual acuity outcome is good, with a high rate of blood displacement. About 20% of patients might require additional PPV as secondary intervention.

Postoperative complications of combined phacoemulsification and pars plana vitrectomy in diabetic retinopathy patients.

Purpose: To compare intra- and postoperative complications in combined phacoemulsification and pars plana vitrectomy surgeries performed in patients with non-proliferative diabetic retinopathy (NPDR) vs. proliferative diabetic retinopathy (PDR). Methods: Retrospective, case series of patients with diabetic retinopathy who underwent combined phacovitrectomy surgery between 2008 and 2017. We compared intraoperative complications including posterior capsular rupture and retinal tear, and postoperative complications including corneal edema, macular edema (ME), epiretinal membrane (ERM), neovascular glaucoma and persistent inflammation. Results: A total of 104 eyes of 104 patients were included in this study. Twenty-four eyes (23.1%) were categorized as NPDR and 80 eyes (76.9%) as PDR. The most common indications for surgery in the NPDR group were ERM (67%) and rhegmatogenous retinal detachment (12.5%), while in the PDR group, indications were vitreous hemorrhage (56%) and tractional retinal detachment (19%). The most common intraoperative complication was retinal tear (8% in NPDR and 19% in PDR, p = 0.195) and postoperative complication was ME (29% in NPDR and 26% in PDR, p = 0.778). There were no statistically significant differences in intra- and postoperative complication rates between the NPDR and PDR groups, even after adjusting for confounders; patient age at surgery and indication for surgery. Conclusion: After combined phacovitrectomy in NPDR and PDR patients, new-onset ME was found in about a quarter of eyes in both groups. Intraoperative anti-VEGF or steroid administration, and intense postoperative anti-inflammatory medication and follow-up should be regarded after phacovitrectomy regardless of the DR level.

Continuous Curvilinear Capsulorhexis - A Practical Review.

BACKGROUND: Continuous curvilinear capsulorhexis (CCC) has become the gold standard technique for anterior capsulotomy, a cardinal development in modern cataract surgery. CCC enables safer and relatively convenient access to the crystalline lens, however it is more challenging to master than older methods. Understanding the physics underlying this procedure is key to achieving the desired results and avoiding complications. PURPOSE: To review and present the established information about CCC, and to create a practical guide to this important step in cataract surgery. METHODS: A literature review was conducted using PubMed, Embase, Cochrane and Scopus databases, with emphasis on up-to-date information. The first part of this review describes the evolution of CCC and discusses the different approaches, the various instruments available, tips and pearls and the general setup for best results. The second half covers more recent innovations and common complications, and strategies to prevent or manage them. This paper provides a practical review of all aspects of CCC.

Computational Modeling of Ophthalmic Procedures: Computational Modeling of Ophthalmic Procedures.

PURPOSE: To explore how finite-element calculations can continue to contribute to diverse problems in ophthalmology and vision science, we describe our recent work on modeling the force on the peripheral retina in intravitreal injections and how that force increases with shorter, smaller gauge needles. We also present a calculation that determines the location and stress on a retinal pigment epithelial detachment during an intravitreal injection, the possibility that stress induced by the injection can lead to a tear of the retinal pigment epithelium. BACKGROUND: Advanced computational models can provide a critical insight into the underlying physics in many surgical procedures, which may not be intuitive. METHODS: The simulations were implemented using COMSOL Multiphysics. We compared the monkey retinal adhesive force of 18 Pa with the results of this study to quantify the maximum retinal stress that occurs during intravitreal injections. CONCLUSIONS: Currently used 30-gauge needles produce stress on the retina during intravitreal injections that is only slightly below the limit that can create retinal tears. As retina specialists attempt to use smaller needles, the risk of complications may increase. In addition, we find that during an intravitreal injection, the stress on the retina in a pigment epithelial detachment occurs at the edge of the detachment (found clinically), and the stress is sufficient to tear the retina. These findings may guide physicians in future clinical research. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

PATIENTS WEARING FACE MASKS DURING INTRAVITREAL INJECTIONS MAY BE AT A HIGHER RISK OF ENDOPHTHALMITIS.

PURPOSE: To investigate the safety of face masks worn by patients during intravitreal injections. METHODS: A prospective, qualitative, interventional study performed in a tertiary university hospital. Healthy volunteers were asked to wear three different professional surgical face masks while air leaks around the eyes were monitored. Three types of masks were investigated as follows: 1) surgical face mask with four tying strips, 2) surgical face mask with elastic ear loops and 3) 2200 N95 tuberculosis particulate face mask. For each session the periocular area was inspected for air leak during normal respiration, speech, and deep respiration. Detection of air leak was performed using the following two professional thermal cameras: FLIR A310-thermal camera and EyeCGas 2.0-super sensitive infrared camera used for detection of minute fugitive emissions of industrial gases. RESULTS: Ten healthy volunteers were enrolled in this study. The experiment was repeated 45 times for each camera; 3 times for each of 3 mask types, on 5 volunteers, for a total of 90 trials. Air jets were detected originating from the superior edges of the masks radiating toward the eyes in 81% (73/90) of cases in total; 71% (32/45) with the FLIR camera and 91% (41/45) with the OPGAL camera. Air leaks were detected with all investigated mask types. CONCLUSION: Patients wearing face masks during intravitreal injections may be at a higher risk of endophthalmitis. Until further data are available, we recommend verifying proper face mask fitting and either taping the upper edges of the face masks with a medical adhesive tape or using an adhesive surgical drape around the injected eye.

Disseminated Nocardiosis with retinal abscess in a patient treated for bullous pemphigoid.

PURPOSE: To report a case of disseminated Nocardiosis with retinal and intracranial lesions. OBSERVATIONS: A 49-year-old woman immunosuppressed because of treatment given for bullous pemphigoid presented with altered mental status and multiple intracranial lesions on imaging. The patient was found to have multiple retinal lesions in both eyes, including a subretinal abscess in the right eye. The patient underwent brain biopsy, confirming Nocardia farcinica histopathologically and in culture. CONCLUSIONS AND IMPORTANCE: Ocular Nocardiosis is a rare disease with varying prognosis that requires prompt diagnosis to ensure appropriate medical therapy.

Local S100A8 Levels Correlate With Recurrence of Experimental Autoimmune Uveitis and Promote Pathogenic T Cell Activity.

Purpose: To investigate the role of damage-associated molecular patterns (DAMPs) in recurrent experimental autoimmune uveitis (EAU). Methods: Recurrent EAU was induced in Lewis rats by interphotoreceptor retinoid-binding protein (IRBP) R16-peptide specific T cells (tEAU). Aqueous humor and serum samples were kinetically collected and DAMPs examined by quantitative proteomics, Western blot analysis, and ELISA. tEAU rats were treated with S100 inhibitor paquinimod followed by disease evaluation. The functions of T effector cells and T regulatory cells (Tregs) were compared between treated and nontreated groups. The expression of costimulatory molecules on antigen-presenting cells was examined by flow cytometry. Results: S100A8, but not high mobility group box 1 (HMGB1), in the eye was found to be correlated with intraocular inflammatory episodes. Administration of paquinimod significantly protected tEAU rats from recurrence. Treated tEAU rats had fewer R16-specific Th1 and Th17 cells, but increased numbers of Tregs. R16-specific T cells from treated tEAU rats into naïve recipients prevented induction of tEAU by R16-specific T cells from nontreated tEAU rats. Moreover, APCs from treated tEAU rats expressed higher levels of a negative costimulatory molecule, CD200R, and lower levels of CD80, CD86, and MHC class II molecules compared to APCs from nontreated tEAU rats. An opposite pattern of expression of these molecules was observed on APCs incubated in vitro with recombinant S100A8. Conclusions: Our data demonstrate a link between local expression of DAMPs and autoimmune responses, and suggest that complete S100A8/A9 blockade may be a new therapeutic target in recurrent autoimmune uveitis.

Osseous Metaplasia (Cataracta Ossea) of Lens Remnants in Chronic Uveitis-A Clinicopathologic Report.

PURPOSE: To describe clinically and pathologically the rare occurrence of calcification and osseous metaplasia in lens remnants in both eyes of a patient with pseudophakic chronic uveitis. METHODS: We performed 25-gauge pars plana vitrectomy, removal of dislocated intraocular lens (IOL), and secondary IOL fixation in the left eye. A similar procedure was performed in the right eye with 27-gauge pars plana vitrectomy. RESULTS: The postoperative visual acuities were 20/30 OD and 20/125 OS. Hematoxylin and eosin staining demonstrated an abundance of calcified tissue and rare osteoclasts in lacunae, compatible with osseous metaplasia (cataracta ossea). CONCLUSION: To our knowledge this is the first clinicopathologic report demonstrating cellular metaplasia that resulted in osseous transformation of the cortical lens remnants into bone in both eyes of a psuedophakic patient with chronic granulomatous pan uveitis of unknown etiology. The surgical technique described in the supplemental videos demonstrates an effective way of managing this complication.

Delivery of steroids into the eye for the treatment of macular edema.

INTRODUCTION: Steroids have been in extensive use in ophthalmology since their discovery in 1948. Steroids are effective for the treatment of macular edema and may be delivered into the eye either topically, systemically, subconjunctivally, sub-Tenon, intravitreally and through injectable sustained release devices. Various steroid formulations and devices are commercially available. Each carries advantages and disadvantages, which requires the ophthalmologist to exercise careful medical judgment upon treatment selection. AREAS COVERED: This article focuses in steroid delivery into the eye for the treatment of macular edema, and reviews the current and future treatment options, summarizing their clinical efficacy and possible adverse effects. EXPERT OPINION: Steroids have an important role in the treatment of macular edema, regardless of its cause. Steroids are efficacious, low-cost, and much clinical experience has been accumulated regarding their use over the years. Prolonged systemic steroid use may be associated with severe systemic and local side effects, directly proportional to dosage and time. Intravitreal delivery of steroids has gained popularity as the medication is administered close to the target tissue, significantly reducing the possibility of systemic adverse effects. The biggest problem associated with intravitreal steroids still remains unacceptably high risk of glaucoma and cataract formation. Various controlled-release intravitreal delivery devices are currently commercially available, and more are in the pipeline. While they still carry the risk of local side effects, they are efficacious and can control macular edema for months and years after a single administration.

Regression of severe corneal neovascularization after a triple procedure: phacoemulsification, intraocular lens implantation, and Descemet-stripping automated endothelial keratoplasty.

UNLABELLED: We report a case of complete regression of severe corneal neovascularization after a triple procedure-phacoemulsification, intraocular lens implantation, and Descemet- stripping automated endothelial keratoplasty. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.