In a pickle: Cases of pickleball related ocular injuries.

Purpose: Although musculoskeletal involvement is the common presentation, studies have reported the incidence of sports related ocular trauma. Here we present the case reports of two patients who sustained injury in one of the fast growing sports - the pickleball, during play without eye protection. Observations: Two patients with history of injury during pickleball play presented to our clinic with varying spectrum of ocular presentations. First patient had an anterior segment involvement with hyphema and elevated intraocular pressure, and the second patient had both anterior and posterior segment involvement causing angle recession and commotio retinae. Conclusion: Ocular injuries related to various sports have been extensively described, our intent is to increase the awareness about the possible ocular injuries related to rising pickleball and that improved safety measures and appropriate education to the players could prevent such ocular injuries.

Long-Term Efficacy of Successful Excisional Goniotomy with the Kahook Dual Blade.

Purpose: To report clinical outcomes of successful excisional goniotomy with the Kahook Dual Blade (KDB), through 60 months. Patients and methods: This was a noncomparative, single-surgeon, retrospective review of eyes receiving successful KDB goniotomy with or without concomitant phacoemulsification between October 2015 and January 2016 with five years of uninterrupted follow-up. Intraocular pressure (IOP), number of glaucoma medications, best corrected visual acuity (BCVA), and complications were recorded. Primary outcomes included changes from baseline in IOP, medication use, and BCVA, through five years. Results: Fifty-two eyes of 28 patients were analyzed. Most eyes had mild primary open angle glaucoma (73%). Of the eyes analyzed, 41 underwent combined surgery and 11 underwent standalone surgery. With all eyes combined, mean (standard deviation) baseline IOP was 21.0 (4.1) mmHg and mean baseline medication use was 1.8 (1.1) medications per eye. Across time points at months 6, 12, 24, 36, 48, and 60, mean postoperative IOP ranged from 13.0 to 13.7 mmHg, representing mean reductions of 7.3-8.0 mmHg (34.7-38.3%; p <0.0001 at every time point). Similarly, mean medication use ranged from 0.4 to 0.6 medications per eye, representing mean reductions of 1.2-1.4 medications (66-75.5%; p <0.0001 at every time point). Mean logMAR BCVA improved from 0.321 (0.177) preoperatively to 0.015 (0.035) at month 60 (p < 0.0001). Conclusion: In eyes not requiring secondary surgical procedures (eg, long-term surgical successes), excisional goniotomy provided clinically and statistically significant reductions in both IOP and the need for medications that were highly consistent through five years of follow-up. KDB goniotomy appears to be highly successful in Caucasian patients with open angle glaucoma on ≥1 IOP-lowering medications at baseline and with no history of prior ocular surgery. Successful excisional goniotomy with the KDB can be expected to improve long-term glaucoma-related visual outcomes through IOP reduction and to improve quality of life through medication reduction.

IOP Elevation in Patients Treated With Fluocinolone Acetonide Insert for Chronic Noninfectious Uveitis Affecting the Posterior Segment.

BACKGROUND AND OBJECTIVE: Characterize timing of intraocular pressure (IOP) elevation in patients treated with fluocinolone acetonide insert (FAi) for uveitis. PATIENTS AND METHODS: A post-hoc subset analysis of data from a randomized, prospective, double-masked, sham-controlled, 3-year, phase 3 clinical trial with 129 participants with noninfectious posterior uveitis randomly assigned to receive 0.18-mg fluocinolone acetonide insert or sham injection. The number of eyes with IOP of 30 mm Hg or greater at different time points were recorded. RESULTS: The incidence of FAi eyes that reached IOP 30 mm Hg or greater was 17.2%. The mean number of days to first IOP response was 241. IOP elevations were divided into four time periods: under 1 month (33%), 3 to 6 months (33%), 6 to 18 months (26.7%), and greater than 18 months (6.7%). Ten cases of elevated IOP were managed medically and five required surgical management. Visual field analysis revealed no significant change in mean deviation compared to patients' own, untreated eyes (P > .05). CONCLUSIONS: IOP elevations occurred in 15 out of 87 patients treated with the FAi. The onset of elevated IOP was fairly evenly distributed across the 36-month trial. Patients should be regularly evaluated for increased IOP, which can be successfully managed by traditional means. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:387-390.].

The effects of temporary intraocular pressure spikes after intravitreal dexamethasone implantation on the retinal nerve fiber layer.

Background and objective: The dexamethasone (DEX) implant is known to cause temporary intraocular pressure (IOP) spikes after implantation. The purpose of this study is to determine if IOP spikes after DEX implant cause significant thinning in the retinal nerve fiber layer (RNFL). Study design, patients, and methods: A total of 306 charts were reviewed with 48 and 21 patients meeting inclusion criteria for the cross-sectional and prospective groups, respectively. Cross-sectional inclusion criteria: IOP spike ≥22 mmHg up to 16 weeks after DEX implant, DEX implant in only 1 eye per patient, and spectral-domain optical coherence tomography (OCT) RNFL imaging of both eyes ≥3 months after IOP spike. Prospective inclusion criteria: OCT RNFL performed within 1 year prior to DEX implantation, IOP spike ≥22 mmHg up to 16 weeks after DEX implant, and OCT RNFL performed ≥3 months after IOP spike. The average RNFL thickness in the contralateral eye was used as the control in the cross-sectional group. Institutional review board approval was obtained. Results: In the cross-sectional group, there was no statistically significant difference in the mean RNFL thicknesses in the treated vs untreated eyes (80.4±15.5 µm and 82.6±15.8 µm, respectively; P=0.33) regardless of treatment diagnosis, magnitude of IOP spike, or history of glaucoma. In the prospective group, mean RNFL thicknesses before and after IOP spikes ≥22 mmHg were similar (78.0±14.8 µm and 75.6±13.6 µm, respectively; P=0.13). Conclusion and relevance: Temporary elevation of IOP after DEX implantation when treated with topical IOP lowering drops does not appear to lead to a meaningful change in RNFL thickness.

A New Suggested Strategy for Safe Injection of Ozurdex.

BACKGROUND AND OBJECTIVES: Ozurdex intravitreal injection is performed via a patented injection device. However, there is a common misconception among ophthalmologists regarding the relation between the speed of applicator button depression and the speed of pellet injection. PATIENTS AND METHODS: Six dexamethasone intravitreal implants were injected into a calibrated ex vivo water bath. Three of the pellets were injected via rapid compression, whereas the other three implants were injected using a 3-second compression technique. The procedures were recorded using high-speed photography followed by calculation of pellet velocity and impact force. RESULTS: The mean impact velocity and force of the pellet insertion is significantly higher in the fast injection group compared to the slow injection group. CONCLUSIONS: By depressing the Ozurdex implant injector during a 3-second time interval, the impact force of the implant pellet is reduced by about 95%. This new technique will theoretically reduce the risk of retinal injury and vitreous hemorrhage from Ozurdex injections. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e23-e25.].

The effects of repeated Ozurdex injections on ocular hypertension.

PURPOSE: The purpose of this study was to correlate the degree of ocular hypertension with the number of Ozurdex injections. METHODS: Intraocular pressure (IOP) fluctuations for a total of 183 injections were studied over a period of at least 12 months. The main indications for treatment were uveitis, diabetic macular edema, and retinal vein occlusion. RESULTS: Results of the study demonstrate that repeated Ozurdex injections do not increase the frequency of IOP spikes beyond 30 mmHg. For lower IOPs, however, a positive correlation exists. Furthermore, patients with primary open angle glaucoma and uveitis had the highest IOP response to repeated injections. On average, patients with an IOP of ≥28.6 mmHg received pressure lowering medications, after which their IOP reached a stable level (16.7 mmHg) without the need for additional interventions. CONCLUSION: The data support the conclusion that multiple Ozurdex injections does not increase the frequency of IOP spikes beyond 30 mmHg, but patients still must be closely monitored if they have a history of primary open angle glaucoma.

Appointment Compliance in Patients With Diabetic Macular Edema and Exudative Macular Degeneration.

BACKGROUND AND OBJECTIVE: The purpose of this study is to compare cancellation and no-show rates in patients with diabetic macular edema (DME) and exudative macular degeneration (wet AMD). PATIENTS AND METHODS: An anonymous survey was sent to 1,726 retina specialists inquiring as to the number of appointments their patients with DME and wet AMD attended, cancelled, or did not show up for in 2014 and 2015. RESULTS: Data were obtained on 109,599 appointments. Patients with DME in the U.S. had a 1.591-times increased odds of cancelling or no-showing to their appointments than patients with wet AMD (P < .0001). Patients with DME in Europe had a 1.918-times increased odds of cancelling or no showing to their appointments than patients with wet AMD (P < .0001). CONCLUSION: Patients with DME in the U.S. and Europe cancelled and no-showed to their appointments significantly more often than patients with wet AMD. These findings can be taken into consideration when establishing treatment plans for patients with DME. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:186-190.].

Long-term results of combination therapy using anti-VEGF agents and dexamethasone intravitreal implant for retinal vein occlusion: an investigational case series.

BACKGROUND: One limitation of anti-VEGF therapy is the need for monthly retreatment to maintain efficacy. The purpose of this study was to determine the duration of effect in eyes with macular edema (ME) secondary to branch or central retinal vein occlusion (BRVO or CRVO) treated with anti-VEGF therapy plus sustained-release dexamethasone (DEX implant; Ozurdex). MATERIALS AND METHODS: This open-label, interventional case series included 62 eyes with ME due to RVO, central foveal thickness (CFT) >300 µm, and best-corrected visual acuity (BCVA) of 20/40 or worse. Each treatment cycle included an anti-VEGF injection followed 2 weeks later with DEX implant. Patients were eligible for retreatment if CFT increased to >290 µm or increased by >50 µm from the lowest measurement, or if BCVA decreased by six or more Snellen letters. Efficacy and safety were evaluated 2 and 4-6 weeks after the beginning of each treatment cycle and every 4 weeks thereafter until retreatment criteria were met. The primary outcome measure was time to retreatment. Secondary outcome measures included BCVA, CFT, and safety parameters. RESULTS: The mean reinjection interval for all patients was 135.5±36.4 days. There was no statistically significant difference in mean intertreatment interval for up to six cycles of treatment or between eyes with BRVO or CRVO (P≥0.058). Mean peak change in BCVA was 13.8 letters, and 47.6% of eyes gained three or more lines of BCVA. The mean peak decrease in CFT across all treatment cycles was 200.9 µm for eyes with BRVO and 219.2 µm for eyes with CRVO. The percentage of patients with CFT ≤300 µm at any time during a given treatment cycle ranged from 78% to 94% among eyes with BRVO and from 85% to 100% among eyes with CRVO. Intraocular pressure increased in 19 of 62 eyes, and 26 of 44 phakic eyes underwent cataract surgery. CONCLUSION: In eyes with ME due to RVO, treatment with an anti-VEGF agent plus DEX implant provided a predictable duration of effect, as well as significant improvements in BCVA and CFT.