Two-step versus 1-step subretinal injection to compare subretinal drug delivery: a randomised study protocol.

INTRODUCTION: There is increasing interest in subretinal injections as a surgical procedure, largely as a result of emerging treatments for ocular diseases which necessitate this manoeuvre. However, surgical variables in the efficacy of such treatments have to date been largely overlooked and the proportion of drug which reaches the intended compartment of the subretinal space remains unknown. Our aims are twofold: first, to determine the proportion of subretinally injected medication retained following surgical delivery and second, to compare two different techniques of injection ('1-step' vs '2-step'). METHODS: We outline a randomised controlled trial of subretinal injection of alteplase following vitrectomy for the management of submacular haemorrhage secondary to age-related macular degeneration. Patients will be randomised to receive either 1-step injection, where the therapeutic solution simultaneously defines the surgical plane or 2-step injection, where the surgical plane is first identified with balanced salt solution prior to injection of subretinal alteplase, as outlined below. Sodium fluorescein will be used as an optical label to track drug reflux into the vitreous cavity using quantitative protocols established in our laboratory. All patients will undergo fluid air exchange at the completion of surgery, with injection of bevacizumab 1.25 mg and 20% sulfahexafluoride gas as the vitreous substitute (both of which may help improve outcomes). Alteplase, sodium fluorescein and bevacizumab will all be used for off-label indications in the trial. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the South Eastern Sydney Local Health District's Human Research Ethics Committee (HREC 17/092). The results of this trial will be disseminated in peer-reviewed proceedings (associated with conference presentation) and in scholarly journals. TRIAL REGISTRATION NUMBER: ACTRN12619001121156.

Endophthalmitis: Changes in Presentation, Management and the Role of Early Vitrectomy.

Endophthalmitis is a sight-threatening condition, and its timely and appropriate management is essential in preventing permanent vision loss. Recent changes in clinical practice in endophthalmitis and advances in modern vitreoretinal surgery may limit the applicability of established randomised clinical trial evidence to current management. This review discusses the epidemiology, pathophysiology, changing patient presentation, diagnosis and advances in the management of endophthalmitis, presenting the existing literature on this topic and results from Sydney Eye Hospital.

Ab-externo drainage with continuous anterior chamber infusion for non-resolving exudative retinal detachment: a case report.

BACKGROUND: Drainage of exudative retinal detachment may be necessary for either therapeutic or diagnostic purposes (or both). Here, we describe an external drainage technique for non-resolving vision-threatening exudative retinal detachment which combines the advantages of internal drainage (widefield viewing and intraocular pressure control using continuous anterior chamber infusion) with those of external drainage (drainage of sub-retinal fluid without vitrectomy). CASE PRESENTATION: To illustrate this technique, we present a 13-year-old girl with macula-off exudative retinal detachment secondary to Vogt-Koyanagi-Harada syndrome, which was unresponsive to aggressive medical management. External drainage was undertaken using widefield viewing and chandelier illumination. Intraocular pressure was maintained with an anterior chamber infusion. Near-complete drainage of sub-retinal fluid was achieved, and retinal reattachment was maintained at 6 months postoperatively, with a corresponding improvement in visual acuity from 20/63 to 20/40. CONCLUSIONS: External drainage under chandelier-assisted viewing at the surgical microscope with anterior chamber infusion offers the ergonomic and optical advantages of the surgical microscope and widefield visualisation, continuous IOP control and drainage of sub-retinal fluid without the need for pars plana vitrectomy.

Topical Adrenaline (1: 1000) for the Management of Severe Tarsal Conjunctival Chemosis.

Severe, refractory tarsal conjunctival chemosis developed in a severely autistic 9-year-old boy with a history of allergic conjunctival chemosis. The child was initially treated with topical and oral antihistamines, topical steroids, lubricants, and topical phenylephrine 10% with worsening of condition until complete eyelid eversion secondary to gross conjunctival chemosis with total obstruction of vision in the affected eye. Subsequently, he was successfully treated with topical adrenaline (1:1000) with rapid and lasting effect. The authors suggest that topical (1:1000) adrenaline is an effective therapy when other conservative therapies fail and can be useful in avoiding examination under general anesthetic and invasive intervention. Such a case has not been previously reported in the literature.

Bilateral sequential non-arteritic anterior ischaemic optic neuropathy following repeat influenza vaccination.

A 68-year-old man developed bilateral sequential non-arteritic anterior ischaemic optic neuropathy, each episode occurring with a close temporal relationship to influenza vaccination.

Birdshot chorioretinopathy.

PURPOSE OF REVIEW: Birdshot chorioretinopathy remains incompletely understood, but new insights into its pathogenesis have been reported recently, and treatment and monitoring options have also expanded. Central visual acuity may remain good until the late stages of the disease, but loss of visual field and peripheral retinal function is common. RECENT FINDINGS: The underlying pathogenesis of the disease has long been believed to be T-cell driven, but examination of the IL-17 pathway has now further refined the potential underlying mechanism. New imaging techniques, including extended depth imaging of the choroid with optical coherence tomography, have demonstrated promise in detecting disease activity earlier, enabling targeted treatment to be given. Treatment options have expanded with the advent of the biological agents, and these may yet improve outcomes, particularly in refractory patients. SUMMARY: Laboratory research continues to investigate the underlying mechanisms of disease, but our understanding remains frustratingly incomplete for a disease with such a clear HLA association. Clinical research is increasingly being driven to improve the phenotyping of affected patients so that those at risk of visual loss can be identified early and treated more aggressively with individually targeted therapies such as the newer biological agents, but how successful this approach will ultimately prove to be remains to be seen.

Successful corticosteroid-sparing effect of rituximab in the treatment of refractory idiopathic orbital inflammatory disease.

Idiopathic orbital inflammatory disease (IOID) is an idiopathic inflammatory process within the orbit that can result in permanent visual impairment. Although high-dose oral corticosteroids are currently the mainstay of therapy, their long-term usage can cause significant toxicity. We present a case of IOID that was successfully treated with the anti-CD20 monoclonal antibody rituximab following failed steroid sparing with conventional second-line immunosuppressive agents.

Uveitis as a Result of MAP Kinase Pathway Inhibition.

We report the case of a patient treated with dabrafenib and trametinib (mitogen-activated protein kinase pathway inhibitors) for stage 3b cutaneous melanoma who developed bilateral uveitis. Although there have been reports of ocular side effects with this class of drugs, uveitis has not been previously reported to the best of our knowledge. This case indicates the wide range of side effects that can be seen with the newer targeted biological therapies.