Outcomes in the Treatment of Subretinal Macular Hemorrhage Secondary to Age-Related Macular Degeneration: A Systematic Review.

Background: Subretinal macular hemorrhage (SRMH) secondary to age-related macular degeneration (AMD) is a relatively rare condition in ophthalmology characterized by blood collection between the neurosensory retina and the retinal pigment epithelium (RPE). Without prompt treatment, visual prognosis is poor. A plethora of treatment approaches have been tried over the past years ranging from intravitreal anti-vascular endothelial growth factor (anti-VEGF) monotherapy to direct subretinal surgery, with no conclusive superiority of one over the other. Materials and Methods: We conducted a systematic review of the outcomes and treatment modalities of SRMH from inception to 14 June 2022, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). The level of evidence was assessed for all included articles according to the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Results: A total of 2745 articles were initially extracted, out of which 1654 articles were obtained after duplicates were removed and their abstracts screened. A total of 155 articles were included for full-text review. Finally, 81 articles remained that fulfilled the inclusion criteria. Conclusions: Even though there are solid results supporting a variety of treatments for SRMH, the best treatment modality has still not been conclusively demonstrated and further research is needed.

Antiplatelets and Anticoagulants in Vitreoretinal Surgery: A Systematic Review.

Background: Antiplatelets and anticoagulants have substantially influenced contemporary vitreoretinal surgical practices. The availability of new oral blood thinners has recently spurred a renewed interest in the clinical approach to vitreoretinal surgical conditions since it may be difficult for the surgeon to collect sufficient evidence-based data to decide whether to discontinue or continue such medications. Materials and Methods: We conducted a systematic review on the use of antiplatelets and/or anticoagulants in the perioperative setting in vitreoretinal surgery and their possible complications, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The level of evidence, according to the Oxford Centre for Evidence-Based Medicine (OCEM) 2011 guidelines, and the quality of evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, were assessed for all included articles. Results: In total, 2310 articles were initially extracted, out of which 1839 articles were obtained after duplicates were removed and their abstracts were screened. A total of 27 articles were included in the full-text review. Finally, a remaining 22 articles fulfilled the inclusion criteria. Conclusions: Even though there is just a small number of studies with solid results, the advantage of using antiplatelets and/or anticoagulants in vitreoretinal surgery seems to outweigh the disadvantages, which are mainly related to postoperative hemorrhagic complications.

Variability of Visual Recovery with Time in Epiretinal Membrane Surgery: A Predictive Analysis Based on Retinal Layer OCT Thickness Changes.

PURPOSE: To correlate postoperative optical coherence tomography (OCT) thickness changes of each retinal layer with different patterns of visual recovery after idiopathic epiretinal membrane (ERM) surgery in a cohort of patients showing no known risk factors for poor visual recovery at preoperative imaging. METHODS: Best corrected visual acuity (BCVA) and OCT images were acquired preoperatively and 1 month, 3 months and 6 months postoperatively. Patients were divided into four groups according to postoperative BCVA improvement: improvement < 15 ETDRS letters (GROUP 1), immediate improvement of BCVA without further improvements at later follow-ups (GROUP 2), immediate improvement of BCVA with further improvements at later follow-ups (GROUP 3) and delayed improvement of BCVA (GROUP 4). RESULTS: Eighty-five patients were included. GROUP1 was the only one characterized by retinal nerve fiber layer (RNFL) thickness increase and ganglion cell layer/central macular thickness (GCL/CMT) ratio decrease at 1 month and outer nuclear layer (ONL) thickness decrease at 3 and 6 months. GROUP 2 was the only one showing a decrease in GCL/inner plexiform layer (GCL/IPL) ratio at 1 month. GROUP 3 and 4 showed higher preoperative RNFL thickness compared to the other, and GROUP 4 manifested a late increase in RNFL thickness at 6 months. CONCLUSIONS: Different patterns of VA recovery are associated with specific layer thickness changes. If further confirmed, this would help detect those cases characterized by poor or delayed visual recovery despite the absence of other known imaging risk factors.

Camellens FIL622-1 IOL Implantation in the Ciliary Sulcus: Refractive Outcomes and Optimization of A-constant.

PURPOSE: To assess the refractive outcomes of patients who had sulcus implantation of the Camellens FIL622-1 intraocular lens (IOL) (Soleko) after posterior capsular rupture, and to optimize the A-constant suggested by the manufacturer. METHODS: This study included patients who underwent secondary Camellens FIL622-1 IOL implantation in the ciliary sulcus after complicated cataract surgery with posterior capsular rupture. IOL power was calculated by the SRK/T formula, using the recommended A-constant (118.8) for ciliary sulcus implantation. A new optimized A-constant was obtained and used to evaluate the refractive outcomes. The main outcome measures were mean prediction error (PE), median absolute error (MedAE), mean absolute error (MAE), and percentage of eyes with a PE within ±0.50, ±1.00, and ±2.00 diopters (D). RESULTS: Forty patients (40 eyes) were included in the study. The new optimized A-constant was 117.5, and the mean PE, MedAE, and MAE was -0.02 ± 0.73, 0.34, and 0.54, respectively. The percentage of eyes with a PE within ±0.50, ±1.00, and ±2.00 D was 65%, 87.5%, and 100%, respectively. CONCLUSIONS: The Camellens FIL622-1 IOL represents a valid option as sulcus implantation after posterior capsular rupture and it would guarantee the surgeon an on-label option with a more accurate biometric calculation, at the time of surgical implantation, with the new optimized A-constant. [J Refract Surg. 2022;38(12):806-811.].

Conjunctivitis as a sign of persistent SARS-COV-2 infection? An observational study and report of late symptoms.

PURPOSE: To investigate if symptomatic conjunctivitis during the recovery phase of the disease could be associated to a persistent presence of SARS-CoV-2 in the upper respiratory tract. Secondary end points were to analyze the presence of SARS-CoV-2 in the conjunctiva of ocular symptomatic patients and to record the presence of ocular disturbances at this point of the disease. METHODS: An observational study including consecutive COVID19 patients treated at Humanitas Clinical and Research Hospital who were attending for nasopharyngeal swab to confirm the resolution of SARS-CoV-2 infection and end of isolation. We examined 129 consecutive patients from May to June 2020. The primary end point was to determine if symptomatic conjunctivitis at this point of the disease could be associated to a persistent presence of SARS-CoV-2 in the upper respiratory tract. Secondary end points were to analyze the presence of SARS-CoV-2 in the conjunctiva of ocular symptomatic patients and to record the presence of ocular disturbances at this point of the disease. RESULTS: One hundred twenty eight patients were included, 9.38% had conjunctivitis, none resulted positive to conjunctival PCR swab test, while two of them had positive nasopharyngeal result. Mean time elapsed since the first COVID-19 positive swab to the time of examination was 6 weeks ( ± 3). The only significant association was the presence of conjunctivitis with older age (65.3 ± 12.7 vs 56.7 + 13.5. p = 0.046). Nasopharyngeal swab resulted positive in 22 patients (17.19%). While 88 patients (68.2%) did not have any ocular complain during their COVID19 disease. The 40 patients (31.8%) reporting ocular disturbances complained about: redness (25.43%), tearing (19.53%), burning (18.35%), foreign body sensation (17.18%), itching (15.62%), and discharge (12.5%). CONCLUSION: This study showed that late conjunctivitis cannot be considered as a marker of persistent infection when patients are sent to confirm the resolution of SARS-CoV-2 infection.

Management of an ophthalmology department during COVID-19 pandemic in Milan, Italy.

PURPOSE: Spreading from China, COVID-19 pandemic reached Italy, the first massively involved western nation. At the beginning of March, 2020 in Northern Italy a complete lockdown of activities was imposed. Access to all healthcare providers, was halted for patients with elective problems. We present the management experience of the Humanitas Clinical and Research Center Ophthalmology Department in Rozzano, Milan, Italy, during the lockdown. METHODS: Containment measures were taken to reduce viral transmission and identify infected patients. All planned visits were canceled but for those not deferrable. Social distancing was introduced reducing number of visits per hour. Minor surgery for progressive pathologies was continued. As the lockdown prolonged, we reorganized patient care. All canceled cases were evaluated by electronic medical records analysis and telephonic triage, to identify, recall, and visit patients at risk of vision loss. RESULTS: From March 9, to April 30, 2020 we performed a total of 930 visits and 612 exams. Some visits (n = 698) and exams (n = 160) were deemed as necessary for continuity of care and performed as planned. Among the remaining 1283 canceled appointments, after evaluation 144 visits and 32 instrumental exams were classified as urgent and rapidly rescheduled. Performed surgical activities were limited to corneal collagen cross linking (n = 39) and intravitreal injections (n = 91), compared to 34 and 94, respectively, in the same period of 2019. CONCLUSION: In-office activities deemed not deferrable were performed safely. The recall service was highly appreciated by all patients. No patient or staff member reported symptoms of COVID-19.

OCT changes of idiopathic epiretinal membrane after cataract surgery.

BACKGROUND: We reviewed our experience in the management of cataract and idiopatic epiretinal membrane surgeries at the Humanitas Research Institute-Milan, Italy- over the past 3 years. METHODS: We conducted a single center retrospective observational case series of patients that underwent sequential cataract and idiopatic epiretinal membrane (ERM) surgeries from 2012-2015 in Humanitas Research Institute. Full data was obtained for 53 eyes of 57 patients. Patients with ERM secondary to uveitis or trauma or associated with simultaneous retinal detachment were excluded. Diabetic retinopathy, glaucoma, age-related macular degeneration, and myopia of more than 6 diopters were exclusion criteria as well. RESULTS: Cataract surgery was not associated with an ERM stage progression at one month follow up, but caused retinal inflammation that resulted in a significant increase in central macular thickness (CMT), macular volume (MV), central macular edema (CME), IS/OS disruption (IS/OS) and neurosensory detachment (NSD). However, there was no significant change in Best corrected visual acuity (BCVA). CONCLUSION: We suggest that patients undergoing cataract surgery in the presence of epiretinal membranes need tight follow up to treat and control eventual macular inflammatory changes and eventual prompt vitrectomy if BCVA is threatened.

Complications of Macular Peeling.

Macular peeling refers to the surgical technique for the removal of preretinal tissue or the internal limiting membrane (ILM) in the macula for several retinal disorders, ranging from epiretinal membranes (primary or secondary to diabetic retinopathy, retinal detachment…) to full-thickness macular holes, macular edema, foveal retinoschisis, and others. The technique has evolved in the last two decades, and the different instrumentations and adjuncts have progressively advanced turning into a safer, easier, and more useful tool for the vitreoretinal surgeon. Here, we describe the main milestones of macular peeling, drawing attention to its associated complications.

Vitreous diagnosis in neoplastic diseases.

Vitreous body is an intraocular structure, origin of diverse pathologies, but is also the place where cells and inflammatory mediators are released coming from several pathologic processes. These inflammatory reactions can happen in any other ocular location like choroid, retina, optic nerve, or ciliary body and vitreous humor constitutes a stagnant reservoir for these resulting substances and debris. Through the recent techniques of vitreous collecting, handling, and analysis, increasingly more sophisticated and with fewer complications, cellularity and molecules in the vitreous of challenging pathologies for the ophthalmologist can now be studied. The most usefulness for vitreous diagnosis would be the masquerade syndromes, and the best exponent in this group is the primary vitreoretinal lymphoma (PVRL), in which cytology and an IL-10/IL-6 ratio more than 1 is fundamental for the diagnosis.

Pneumatic tools for vitreoretinal surgery.

One of the difficulties of microsurgery is learning how to control physiological tremors. The pneumatic tool eliminates the physiological tremor, but no tactile feedback is provided. The manual tremor when closing the forceps is completely eliminated and the exact target can be more easily grabbed. Forceps closure pressure can rise up to 50 psi, whereas the scissors can be used in two modes: multicut and proportional. When performing bimanual surgery the pedal range is divided into two steps: in the first step, the forceps are controlled, and in the second step, the forceps remain closed. At the same time the scissors start to work in the preselected mode. No adverse events occurred and no iatrogenic retinal breaks were produced. Precision and control sensation were a grateful surprise.