25 vs. 27-gauge micro-incision vitrectomy surgery for visually significant macular membranes and full-thickness macular holes: a retrospective study.

BACKGROUND: To evaluate visual and safety outcomes for 25-gauge (25G) and 27-gauge (27G) micro-incision vitrectomy platforms (MIVS) for the treatment of epiretinal membrane and full-thickness macular holes. METHODS: Retrospective analysis of all patients who underwent internal limiting membrane (ILM) peel surgery from January 2017 through December 2018. 207 cases met the eligibility criteria for inclusion. Primary endpoint was post-operative Best-Corrected Distance Visual Acuity (BCVA) at 6 months. RESULTS: For all patients combined, mean logMAR BCVA improved from 0.57 (± 0.40) to 0.37 (± 0.36) post-operatively (p < 0.001). For 25G ERMs, logMAR BCVA improved from 0.51 (± 0.28) to 0.30 (± 0.25) post-operatively (p < 0.001). For 27G ERMs, logMAR BCVA improved from 0.33 (± 0.28) to 0.28 (± 0.27) post- operatively (p = 0.15). For 25G FTMHs, logMAR BCVA improved from 0.87 (± 0.48) to 0.51 (± 0.44) post-operatively (p < 0.001). For 27G FTMHs, logMAR BCVA changed from 0.89 (± 0.47) to 0.96 (± 0.60). CONCLUSION: Final visual outcomes improved for both 25G and 27G ERM groups and the 25G FTMH group. Both 25G and 27G were safe and well tolerated MIVS platforms for the treatment of ERM and FTMH.

Strategies for Improving Patient Comfort During Intravitreal Injections: Results from a Survey-Based Study.

INTRODUCTION: Many ocular diseases require intravitreal injections of pharmacological agents. Optimizing patients' experiences during injections is important to ensure compliance and maintenance of quality of life. The objective of this study was to identify strategies to help alleviate discomfort during intravitreal injections. METHODS: A cross-sectional study surveying 128 patients during clinic visits between 2014 and 2015 in two outpatient Retina Clinics (one academic and one private). Patients receiving an intravitreal injection(s) for any retinal disorder were given a questionnaire with 10-yes/no responses for various potential strategies. Responses were stratified by sex, age (<30 years, 30-60 years, and >60 years) and total number of prior injections (0-9 injections, 10-20 injections and >20 injections). RESULTS: A total of 128 patients were surveyed: 59 males, 41 females and 28 with no sex specified. Our results identified four favorable strategies as those receiving more than 50% "yes" votes. These included the presence of technician/staff during the procedure, the use of a neck pillow, a verbal warning before the injection and performing injections in both eyes on the same day. Other specific strategies were identified for females, younger patients and those with greatest experience. These included: females preferred having their hand held during injections (P = 0.001) and using a stress ball (P = 0.000) when compared to males. Stratifying by age, patients 30-60 years old preferred having their hand held (P = 0.008) and background music (P = 0.007). Stratifying by prior injections, patients with >20 prior injections preferred having their hand held (P = 0.001), using a stress ball (P = 0.021) and, if necessary, having bilateral injections performed the same day to improve comfort (P = 0.037). CONCLUSIONS: Having an extra staff member present during the injection, having a neck pillow, having a verbal warning prior to injection and having both eyes injected on the same day were indicated as favorable strategies by over half of those surveyed. Further, specific strategies were identified for females, younger patients (30-60 years old) and those with greatest experience (>20 injections).

Visual Acuity, Contrast Sensitivity and Color Vision Three Years After Iodine-125 Brachytherapy for Choroidal and Ciliary Body Melanoma.

PURPOSE: To report visual acuity, contrast sensitivity and color vision prior to, 1 year after, 2 years after and 3 years after iodine-125 brachytherapy for choroidal and ciliary body melanoma (CCM). DESIGN: Prospective interventional case series. PARTICIPANTS: Thirty-seven patients (37 eyes) with CCM. METHODS: Patients had best-corrected Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity, Pelli-Robson contrast sensitivity and Hardy-Rand-Rittler color vision measurement; comprehensive ophthalmology examination; optical coherence tomography; and ultrasonography at baseline prior to, 1 year after, 2 years after and 3 years after I-125 brachytherapy. MAIN OUTCOME MEASURES: Visual acuity, contrast sensitivity and color vision prior to, 1 year after, 2 years after and 3 years after brachytherapy. RESULTS: Nineteen (19) men and 18 women with mean age of 58 years (SD 13, range 30-78) prior to, 1 year after, 2 years after and 3 years after brachytherapy had mean best-corrected visual acuity of 77 letters (20/32), 65 letters (20/50), 56 letters (20/80) and 47 letters (20/125); contrast sensitivity of 30, 26, 22 and 19 letters; color vision of 26, 20, 17 and 14 test figures, respectively. Decrease in visual acuity, contrast sensitivity and color vision was statistically significant from baseline at 1 year, 2 years, and 3 years after brachytherapy. Decreased acuity at 3 years was associated with mid-choroid and macula melanoma location, ≥ 4.1 mm melanoma height, radiation maculopathy and radiation optic neuropathy. CONCLUSION: 1, 2 and 3 years after brachytherapy, eyes with CCM had significantly decreased visual acuity, contrast sensitivity and color vision.

Bilateral Idiopathic Solitary Granuloma of the Uveal Tract: Diagnosis and Treatment.

We present a case of sequential bilateral idiopathic solitary granuloma of the uveal tract in a 51 year-old woman, who underwent enucleation in one eye due to complications of this condition, but was then successfully treated in the contralateral eye with anti-tumor necrosis-alpha therapy followed shortly by intraocular steroids and a steroid-releasing implant. Her visual acuity at its worst was 20/200 due to vitreous haze and cystoid macular edema, but then stabilized after successful treatment with a final visual acuity of 20/25 in her only seeing eye at 1 year follow-up. This represents the first known biopsy-proven case of bilateral idiopathic solitary granuloma, which additionally, has responded favorably to treatment.

Rituximab therapy for refractory scleritis: results of a phase I/II dose-ranging, randomized, clinical trial.

OBJECTIVE: To determine whether rituximab, a monoclonal antibody against the B-lymphocyte antigen CD20, is effective in the treatment of refractory noninfectious scleritis. DESIGN: Prospective, dose-ranging, randomized, double-masked phase I/II clinical trial. PARTICIPANTS: Twelve patients with noninfectious scleritis refractory to systemic corticosteroid and ≥1 other systemic immunosuppressive agent were enrolled from January 2007 to March 2010. INTERVENTION: Subjects were randomly assigned to 500 (n = 5) or 1000 mg (n = 7) dosing arms of rituximab intravenous infusions (500 or 1000 mg), given at study days 1 and 15. Initial responders with breakthrough inflammation after study week 24 were offered treatment with an additional cycle of 2 open-label rituximab 1000 mg infusions. MAIN OUTCOME MEASURES: Primary outcomes were reduction of inflammation, as measured with a validated scleritis disease grading scale (SGS) and reduction in corticosteroid dose by ≥50%. Patients were characterized as responders to study therapy if ≥1 of these endpoints showed improvement and neither showed evidence of worsening. Secondary outcomes were improvement in visual acuity, reduction in pain, and improvement in patient and physician-reported global health assessment. RESULTS: Of 12 enrolled patients, 9 met the SGS endpoint at or before week 24, and 4 additionally were able to reduce corticosteroid dose by ≥50%. With regard to secondary outcome measures, 11 and 9 patients showed improvement in patient and physician global health scores, respectively, and 7 patients had reduction in pain. Of 9 initial responders, 7 experienced breakthrough inflammation after 24 weeks and were treated with a second cycle of rituximab infusions. Four patients had significant objective or subjective worsening within 8 weeks of receiving rituximab; this event was averted in subsequent patients by treatment with peri-infusional oral corticosteroid. No other significant adverse events were noted. No differences in efficacy, toxicity, or likelihood of retreatment were noted between the dosing arms. CONCLUSIONS: Rituximab was effective treatment for 9 of 12 enrolled patients with refractory, noninfectious scleritis at 24 weeks, although 7 required reinfusion with rituximab to maintain inflammatory control. The treatment was well-tolerated, and peri-infusional inflammatory exacerbations were managed successfully with oral corticosteroids. Further long-term studies are warranted to determine the safety and efficacy of rituximab in treating noninfectious scleritis and other ocular inflammatory diseases.

Rituximab therapy for refractory orbital inflammation: results of a phase 1/2, dose-ranging, randomized clinical trial.

IMPORTANCE: Orbital inflammation is a potentially blinding and disfiguring disease process that is often treated with systemic corticosteroids and immunosuppression; better treatments are needed. OBJECTIVE: To determine whether rituximab, a monoclonal antibody against the B-lymphocyte antigen CD20, is effective in the treatment of refractory orbital inflammation. DESIGN, SETTING, AND PARTICIPANTS: A dose-ranging, randomized, double-masked phase 1/2 clinical trial was conducted at a tertiary referral ophthalmology clinic. Ten individuals with orbital inflammation refractory to systemic corticosteroids and at least 1 other immunosuppressive agent were enrolled from January 2007 to March 2010. INTERVENTIONS: Rituximab infusions were administered on study days 1 and 15 at doses of either 500 mg or 1000 mg. Initial responders with recurrent inflammation after week 24 were permitted reinfusion with an additional cycle of 2 open-label 1000-mg rituximab infusions. MAIN OUTCOMES AND MEASURES: The primary outcomes were reduction of inflammation measured with a validated orbital disease grading scale and corticosteroid dose reduction by at least 50%. The secondary outcomes were visual acuity, reduction in pain, and participant- and physician-reported global health assessment. RESULTS: Of 10 enrolled patients, 7 demonstrated improvement on the orbital disease grading scale at the 24-week end point with rituximab therapy. Of these 7 individuals, 4 were receiving corticosteroids at study inception and all achieved successful dose reduction. For the secondary outcome measures in the 10 participants, 7 patients and 8 patients improved in self-rated and physician global health scores, respectively, and 7 patients had reduction in pain by 25% or more at 24 weeks. Four patients who were positive responders at the week 24 end point experienced breakthrough inflammation after week 24 and received reinfusions between 24 and 48 weeks. Vision remained stable in all participants. Three of 10 patients had short-term objective or subjective worsening 2 to 8 weeks after receiving rituximab infusions, which was averted in subsequent patients with oral corticosteroids administered during the infusion and did not affect the eventual positive treatment outcome. No significant differences with regard to efficacy, toxicity, or likelihood of retreatment were noted between the dosing arms. CONCLUSIONS AND RELEVANCE: Rituximab was safe and effective in 7 of 10 patients with noninfectious orbital disease, although 4 required reinfusion with rituximab to maintain control of orbital inflammation. Substantial toxicity was not noted. Rituximab should be considered in the treatment of refractory orbital inflammation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00415506.

Grading of posterior staphyloma with spectral-domain optical coherence tomography and correlation with macular disease.

OBJECTIVE: To develop a novel grading system for posterior staphyloma imaged by spectral-domain optical coherence tomography (SD-OCT) and to correlate the incidence of macular disease (vitreomacular traction, epiretinal membrane, macular schisis, lamellar macular hole, and full-thickness macular hole) with each grade. DESIGN: Retrospective chart review. PARTICIPANTS: A total of 150 eyes from 89 patients with posterior staphylomas were examined at Jules Stein Eye Institute, University of California Los Angeles. METHODS: Retrospective analysis of the Cirrus SD-OCT (Carl Zeiss Meditec, Dublin, Calif.) database at a large institution (Jules Stein Eye Institute) was performed and eyes with a posterior staphyloma involving the macula were evaluated for the presence of macular pathology. The radius of each circle was measured and graded, and the incidence of macular pathology was correlated with each staphyloma grade. Statistical analysis was done using Fisher exact and Kruskal-Wallis tests. RESULTS: The overall incidence rate of macular disease was 50.6% (76/150 eyes). The incidence rate of macular schisis was 17.3% (26/150) and was significantly greater with steeper (grade 3 [25.0%] and grade 4 [30.3%] staphyloma) versus shallower grade (grade 1 [5.6%]) staphyloma (p = 0.016). CONCLUSIONS: Imaging of staphyloma via SD-OCT is a valuable tool for determining the severity of posterior staphyloma and for determining risk stratification for various macular diseases.

Fluocinolone acetonide intravitreal implant for the treatment of diabetic macular edema.

Diabetic macular edema (DME) remains one of the leading causes of moderate to severe vision loss. Although laser photocoagulation was the standard of care for several years, few patients achieved significant improvements in visual acuity. As a result, several pharmacotherapies and surgeries have been investigated. The fluocinolone acetonide devices are one of the latest therapies considered for the treatment of DME. Despite bringing significant improvements in visual acuity, fluocinolone devices are associated with cataract formation, increased intraocular pressure (IOP), and surgery to lower IOP. Due to the risk of complications, fluocinolone acetonide devices should be considered only in cases refractive to first-line therapies. In this review, we evaluate current and emerging therapies for DME, with special emphasis on fluocinolone acetonide intravitreal devices.

Recurrent leakage after Visudyne photodynamic therapy for the treatment of circumscribed choroidal hemangioma.

BACKGROUND: To report on the recurrence of serous retinal detachment following verteporfin photodynamic therapy for circumscribed choroidal hemangioma. PATIENTS AND METHODS: A single-center chart review was performed for patients with circumscribed choroidal hemangioma (CCH) treated with Visudyne (verteporfin injection; QLT Ophthalmics, Menlo Park, CA) photodynamic therapy (PDT). Initial and post-treatment visual acuity, ultrasound and ocular coherence tomography were evaluated. RESULTS: Four patients who were treated with PDT for symptomatic serous retinal detachment secondary to CCH were managed for recurrent leakage and followed for an average of 47.5 months. Two patients required three re-treatments and two required four re-treatments for recurrent detachment. Average time to re-treatment was 23.4 months, with successive re-treatment intervals decreasing to 13 months, then 9.5 months, and finally 3.5 months. CONCLUSION: Visudyne PDT is a successful initial treatment modality for CCH with serous retinal detachment; however, those patients who require multiple re-treatments may experience recurrent leakage at more frequent intervals.

Pharmacotherapy of scleritis: current paradigms and future directions.

INTRODUCTION: Scleritis is an inflammatory condition affecting the eye wall that may be associated with a number of systemic inflammatory diseases. Because scleritis can be refractory to standard treatment, knowledge of the body of available and emerging therapies is paramount and is reviewed here. AREAS COVERED: This review focuses on both traditional and emerging therapies for noninfectious scleritis. The authors cover the mechanisms of action and potential adverse effects of each of the treatment modalities. In addition, a summary of the significant MEDLINE indexed literature under the subject heading 'scleritis', 'treatment', 'immunomodulator' will be provided on each therapy, including commentary on appropriate use and relative contraindications. Novel treatments and potential drug candidates that are currently being evaluated in clinical trials with therapeutic potential will also be reviewed. EXPERT OPINION: While oral nonsteroidal anti-inflammatory drugs and oral corticosteroids are widely used, effective, first-line agents for inflammatory scleritis, refractory cases require antimetabolites, T-cell inhibitors, or biologic response modifiers. In particular, there is emerging evidence for the use of targeted biologic response modifiers, and potentially, for local drug delivery.

Desiccating stress decreases apical corneal epithelial cell size--modulation by the metalloproteinase inhibitor doxycycline.

PURPOSE: We investigated the effects of desiccating stress on murine corneal apical epithelial cell area and desquamation by using 4 defined parameters and evaluated the effects of the metalloproteinase inhibitor doxycycline on this process. METHODS: C57BL/6 mice were subjected to experimental dry eye (EDE) for 5 days without or with topical therapy with doxycycline 0.025% or 0.0025% or vehicle 4 times a day. C57BL/6 mice that were not exposed to desiccating stress served as controls. Whole mount corneas from each group were immunostained for occludin and visualized by laser scanning confocal microscopy. The images were analyzed in a masked fashion, and mean individual cell area, apical cell density, average cell number loss, and average percent loss were recorded. RESULTS: EDE caused a significant decrease in apical corneal cell area (1073 +/- 135.9 microm2), an increase in apical cell density (895.8 +/- 115.4 cells per mm2) and a greater percent of epithelial loss (21.29% +/- 13.40%) than controls (1341 +/- 95.28 microm2, 714.4 +/- 55.60 cells per mm2, 2.897% +/- 3.452%, P < 0.001 for all, respectively). Treatment with 0.025% doxycycline preserved cell area (1337 +/- 144.6 microm2) and the apical cell density (721.0 +/- 91.62 cells per mm2) and decreased percentage loss (5.117% +/- 6.757%) compared with the vehicle control group (1154 +/- 88.10 microm2, 830.2 +/- 49.76 cells per mm2, 22.14 +/- 9.616%, P < 0.001 for all, respectively). CONCLUSIONS: Desiccating stress decreases apical corneal epithelial cell area, increases apical cell density, and promotes epithelial cell loss. Treatment with the metalloproteinase inhibitor doxycycline during desiccating stress preserves cell area and apical cell density and prevents EDE-induced corneal epithelial cell loss. These findings suggest that metalloproteinases mediate apical corneal epithelial loss during desiccating stress.

Long-term stability of circumferential silicone sponge scleral buckling exoplants.

PURPOSE: The historical extrusion/explantation rate of silicone sponge scleral buckle exoplants is 3.5 to 24.4%. This contrasts with the published 0.6 to 1.2% explantation rate of solid silicone elements. Previously reported silicone sponge exoplants studies were noncircumferential (quadrantic or multiple). This study was undertaken to assess the long-term stability of 360 degrees circumferentially placed 3 x 5 mm silicone sponge exoplants. METHODS: Interventional case series of 840 consecutive circumferentially placed 3 x 5 mm silicone sponge exoplants. A retrospective review of operative reports and patient charts was performed. RESULTS: A total of 552 patients had documented follow-up over 1 year. Median follow-up was 32.8 months. Six patients underwent removal of the scleral buckling element (two for diplopia, one acute postoperative infection, and three for extrusion). Median time to removal was 7.3 months. Extenuating circumstances contributed to two of the three extrusions. Of the entire series, fewer than 1% of patients required removal of the silicone sponge implant. Excluding patients with less than 1 year of documented follow-up, the long-term infection/extrusion rate was 0.7%. CONCLUSIONS: Circumferentially placed silicone scleral buckling sponge elements are very stable and are well tolerated. The explantation/extrusion rate is comparable to published solid silicone element series.