INTRAVITREAL DEXAMETHASONE FOR THE TREATMENT OF MACULAR EDEMA SECONDARY TO HYDROXYCHLOROQUINE TOXICITY.

PURPOSE: Cystoid macular edema is a vision-threatening complication infrequently associated with hydroxychloroquine retinal toxicity. There are limited data on the best treatment for this pathology. METHODS: A retrospective case series is presented. RESULTS: In this series, we present three cases of cystoid macular edema in patients with diagnosed hydroxychloroquine maculopathy successfully treated with intravitreal dexamethasone implantation. CONCLUSION: Minimal literature has been published regarding the best management of cystoid macular edema related to hydroxychloroquine toxicity. Our case series suggests a possible new agent in the treatment of this rare occurrence.

Analysis of the Long-term Visual Outcomes of ForeseeHome Remote Telemonitoring: The ALOFT Study.

PURPOSE: To evaluate long-term visual acuity (VA) and performance of a monitoring strategy with a self-operated artificial-intelligence-enabled home monitoring system in conjunction with standard care for early detection of neovascular age-related macular degeneration (nAMD). DESIGN: Retrospective review. SUBJECTS: Patients with dry-age-related macular degeneration from 5 referral clinics. METHODS: Clinical data of patients monitored with ForeseeHome (FSH) device from August 2010 to July 2020 were reviewed. MAIN OUTCOME MEASURES: Visual acuity at baseline, VA at diagnosis of nAMD for eyes that converted while monitored, and VA from the final study follow-up, weekly frequency of use, duration of monitoring, modality of conversion diagnosis (system alert vs. detection by other standard care means), and duration and number of treatments since conversion to final study follow-up were collected. RESULTS: We reviewed 3334 eyes of 2123 patients with a mean (standard deviation [SD]) age of 74(8) years, monitored for a mean (SD) duration of 3.1 (2.4) years, with a total of 1 706 433 tests in 10 474 eye-monitoring years. The mean (SD) weekly use per patient was 5.2 (3.4), and it was persistent over the usage period. Two hundred eighty-five eyes converted while monitored at an annual rate of 2.72% and were treated with a mean (SD) 17.3 (16.5) injections over a mean (SD) 2.7 (2.0) years, with 6.4 (3.1) injections per year for eyes treated for > 1 year. The median VAs at baseline and at final follow-up for eyes that did not convert were 20/27 and 20/34 with a median change of 0.0 letters. The median VAs at baseline, conversion, and final follow-up for eyes that converted during the monitoring period were 20/30, 20/39, and 20/32 with a median change from baseline to conversion, baseline to recent, and conversion to recent of -4, -4, and 0 letters, respectively. Fifty-two percent of conversions detected had a system alert before conversion. Forty-eight percent of patients were detected by symptoms or routine visit. Patients experienced a non-nAMD alert on average every 4.6 years. At conversion and at final follow-up, the proportion (95% CI) of eyes that maintained ≥ 20/40 was 84% (78% to 88%) and 82% (76% to 86%), respectively. CONCLUSIONS: Patients in the FSH monitoring program showed excellent long-term VA years after conversion to nAMD.

Real-World Performance of a Self-Operated Home Monitoring System for Early Detection of Neovascular Age-Related Macular Degeneration.

The real-world performance of a home telemonitoring strategy (ForeseeHome AMD Monitoring System®, Notal Vision, Inc.,Manassas VA, USA) was evaluated and compared to the device arm of the AREDS2-HOME study among patients with intermediate AMD (iAMD) who converted to neovascular AMD (nAMD). All patients with confirmed conversion to nAMD who used the home monitoring system from 10/2009 through 9/2018 were identified by Notal Vision Diagnostic Clinic's medical records. Selected outcome variables were evaluated, including visual acuity (VA) at baseline and at conversion, and change in visual acuity (VA) from baseline to time of conversion. In total, 8991 patients performed 3,200,999 tests at a frequency of 5.6 ± 3.2 times/week. The 306 eyes that converted from iAMD to nAMD over the study period (a 2.7% annual rate) were included in the analyses. There was a median (interquartile range) change of -3.0 (0.0-(-10.0)) letters among converted eyes, 81% [95% confidence interval (72-88%)] maintained a VA ≥ 20/40 at the time of conversion, while 69% of the conversion detections were triggered by system alerts. The real-world performance of an at-home testing strategy was similar to that reported for the device arm of the AREDS2-HOME study. The home telemonitoring system can markedly increase early detection of conversion to nAMD.

Timing of Povidone-Iodine Application to Reduce the Risk of Endophthalmitis after Intravitreal Injections.

PURPOSE: To analyze comparatively the effect of different intravitreal injection (IVI) protocols on the incidence of endophthalmitis occurring after injection. DESIGN: Retrospective case-control series. PARTICIPANTS: Twenty-seven retina specialists in a large vitreoretinal practice performed 37 646 IVIs. METHODS: Multivariate analysis was used to identify risk factors for development of endophthalmitis occurring after injection. Before all injections, a technician applied 5% povidone-iodine (PI) to the eyelids and conjunctiva. There were 4 distinct aseptic protocols with regard to reapplication of PI by physicians: physicians who did not reapply PI, reapplication of PI without the use of a lid speculum, reapplication of PI before speculum placement, and reapplication of PI after speculum placement. Other analyzed variables included the use of gloves, a caliper to mark the injection site, and the class of medication (steroid vs. anti-vascular endothelial growth factor). MAIN OUTCOME MEASURES: Cases of presumed infectious endophthalmitis. RESULTS: Thirty-three cases of presumed infectious endophthalmitis occurred after 37 646 injections (0.088%). The method of PI application was found to be a statistically significant predictor of the incidence of endophthalmitis (P = 0.031). When compared with the incidence of endophthalmitis for physicians who did not reapply PI (0.124% [20/16 155]), there was no statistical difference for reapplication of PI without the use of a speculum (0.110% [6/5472]; P = 0.584) or reapplication before speculum insertion (0.122% [5/4067]; P = 0.863). However, reapplication of PI after insertion of the lid speculum was associated with a significantly decreased incidence of endophthalmitis (0.017% [2/11 952]; P = 0.004; odds ratio, 0.113). Use of gloves (P = 0.119) or a caliper to mark the injection site (P = 0.496) and the class of medication (P = 0.740) were not found to be statistically significant risk factors for endophthalmitis development. CONCLUSIONS: The application of PI after placement of the lid speculum reduced the incidence of endophthalmitis occurring after injection approximately 7-fold compared with other aseptic protocols. Preventing the eyelid from contacting the injection site after the final application of PI is an important step in improving the safety of intravitreal injections.

Atypical presentation of acute-onset endophthalmitis after uncomplicated pars plana vitrectomy.

A 70-year-old woman presented with signs of acute-onset endophthalmitis within 24 hours of surgery, with retinal hemorrhages and vascular changes in the absence of pain or significant inflammation. She had undergone uncomplicated 25-gauge pars plana vitrectomy for epiretinal membrane with presenting visual acuity of 20/40- and significant distortion. Vitreous culture revealed Staphylococcus epidermidis. Final visual acuity was no light perception with persistent pain, and the patient ultimately underwent enucleation. Although rarely, acute-onset postoperative endophthalmitis can present as retinal vasculitis with intraretinal hemorrhages and mild inflammation.

Randomized trial of the ForeseeHome monitoring device for early detection of neovascular age-related macular degeneration. The HOme Monitoring of the Eye (HOME) study design - HOME Study report number 1.

OBJECTIVE: To evaluate the effects of a home-monitoring device with tele-monitoring compared with standard care in detection of progression to choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD), the leading cause of blindness in the US. PATIENTS AND METHODS: Participants, aged 55 to 90 years, at high risk of developing CNV associated with AMD were recruited to the HOme Monitoring of Eye (HOME) Study, an unmasked, multi-center, randomized trial of the ForeseeHome (FH) device plus standard care vs. standard care alone. The FH device utilizes preferential hyperacuity perimetry and tele-monitoring to detect changes in vision function associated with development of CNV, potentially prior to symptom and visual acuity loss. After establishing baseline measurements, subsequent changes on follow-up are detected by the device, causing the monitoring center to alert the clinical center to recall participants for an exam. Standard care consists of instructions for self-monitoring visual changes with subsequent self-report to the clinical center. The primary objective of this study is to determine whether home monitoring plus standard care in comparison with standard care alone, results in earlier detection of incident CNV with better present visual acuity. The primary outcome is the decline in visual acuity at CNV diagnosis from baseline. Detection of CNV prior to substantial vision loss is critical as vision outcome following anti-angiogenic therapy is dependent on the visual acuity at initiation of treatment. DISCUSSION: HOME Study is the first large scale study to test the use of home tele-monitoring system in the management of AMD patients.

Pipeline embolization device: a new source for embolic retinal vascular occlusion.

A 57-year-old woman underwent treatment of a left internal carotid artery aneurysm with a Pipeline embolization device. She subsequently experienced multiple branch retinal artery occlusions in her left eye. Although rare, ophthalmic complications may follow this new technique in the treatment of intracranial aneurysms.

Same-day versus delayed vitrectomy with lensectomy for the management of retained lens fragments.

PURPOSE: To evaluate whether performing same-day pars plana vitrectomy versus delayed pars plana vitrectomy affects visual outcomes and ocular morbidity of patients with retained lens fragments after a complicated cataract surgery. METHODS: Retrospective, comparative case series of 172 eyes of 171 patients with retained lens fragments undergoing 3-port pars plana vitrectomy using 20-, 23-, or 25-gauge instrumentation between 2005 and 2008. Outcome measures included best-corrected visual acuity at 6 months, final best-corrected visual acuity, and postoperative complications such as cystoid macular edema, intraocular pressure elevation, retinal detachment, vitreous hemorrhage, choroidal hemorrhage, and endophthalmitis. RESULTS: The median age was 75 ± 0.8 years. The mean time to vitrectomy for the delayed group was 15 ± 2 days. The preoperative logarithm of the minimum angle of resolution best-corrected visual acuity for immediate vitrectomy was 0.73 ± 0.09 versus 0.72 ± 0.06 for delayed vitrectomy. Six-month logarithm of the minimum angle of resolution acuity was 0.44 ± 0.09 for same-day vitrectomy compared with 0.44 ± 0.05 for delayed vitrectomy (P = 0.97, 2-tailed t-test). Of 59 eyes undergoing immediate vitrectomy, 17 (29%) experienced postoperative complications, while 38 of 113 eyes (34%), experienced complications if undergoing delayed vitrectomy (Fisher exact test, P = 0.61). Overall, the most common complication was cystoid macular edema occurring in 25 of 172 eyes (15%). CONCLUSION: The outcomes of same-day pars plana vitrectomy appear to be similar to non-same-day pars plana vitrectomy. The risks and benefits related to the timing of vitrectomy after a complicated cataract surgery should be carefully discussed with each patient. Further investigation is warranted to establish an optimal time for surgical planning.

Incidence and characteristics of macular pucker formation after primary retinal detachment repair by pars plana vitrectomy alone.

PURPOSE: To evaluate postoperative macular pucker formation in patients who underwent pars plana vitrectomy (PPV) for repair of primary rhegmatogenous retinal detachment (RD). METHODS: A retrospective, observational case series of 141 consecutive patients who underwent primary RD repair by PPV alone was performed. Patient charts were selected based on coding searches of a database from May 1, 2002, to December 31, 2003, in a large retina referral practice. Patients with a history of retinal surgery, silicone oil tamponade, or another visually significant ocular condition were excluded. RESULTS: Of 141 patients, 18 (12.8%) were noted to have a postoperative epiretinal membrane at clinical examination. Of 18 patients, 6 (33.3%) underwent a second vitrectomy procedure with membrane peeling for macular pucker removal. The mean time from RD surgery to membrane peeling surgery was 5.4 months. The average improvement in vision after repeated surgery was 5.6 Snellen chart lines. CONCLUSIONS: In our series, 12.8% of patients who underwent repair of a primary RD by PPV alone developed a postoperative macular pucker. Overall, the 4.3% of patients who underwent repeated surgery for removal of macular epiretinal membranes benefited with visual acuity improvement.

Treatment of choroidal neovascularization through the implantable miniature telescope.

PURPOSE: To report a case of thermal laser photocoagulation of a choroidal neovasacular membrane through the implantable miniature telescope (IMT). DESIGN: Interventional case report. METHODS: Focal thermal laser photocoagulation was performed. Complete ablation of the neovascular lesion, visual acuity, and integrity of the IMT were assessed. RESULTS: An 81-year-old woman with a history of IMT implantation for advanced geographic atrophy related to age-related macular degeneration developed an extrafoveal choroidal neovascular lesion. The patient underwent focal laser photocoagulation through the telescope without complication. Three months after treatment, no evidence of recurrence was noted, and visual acuity remained at 20/200. The IMT was not altered by the treatment. CONCLUSIONS: Focal thermal laser photocoagulation through an IMT can successfully treat choroidal neovascularization without damaging the device.

Corticosteroid-induced modulation of acute syphilitic posterior placoid chorioretinitis.

PURPOSE: To report a case of corticosteroid-induced modulation of acute syphilitic posterior placoid chorioretinitis. DESIGN: Interventional case report. METHOD: A 38-year-old homosexual male who presented with a unilateral uveitis secondary to syphilis developed large placoid macular lesions after treatment with oral prednisone that resolved when the corticosteroids were discontinued. RESULTS: A cause-and-effect relationship was demonstrated between oral prednisone and the appearance of acute syphilitic posterior placoid chorioretinitis. CONCLUSIONS: The clinical appearance of posterior placoid chorioretinitis in syphilis may be modulated by the immune status of the patient.