Coincident PAMM and AMN and Insights Into a Common Pathophysiology.

PURPOSE: To analyze imaging characteristics and the clinical course of patients demonstrating coincident lesions of paracentral acute middle maculopathy (PAMM) and acute macular neuroretinopathy (AMN) in the same eye. DESIGN: Retrospective, observational case series. METHODS: Lesions from patients presenting with coincident PAMM and AMN in the same eye were evaluated with multimodal imaging including optical coherence tomography (OCT). The association with ocular and systemic findings was also investigated. RESULTS: Fifteen subjects (17 eyes) were included in the study. The mean age was 44.4 ± 15.3 years and the follow-up period ranged from 1 to 32 weeks (mean, 11.9 ± 11.4 weeks). The mean visual acuity was 0.8 ± 0.6 logarithm of minimal angle of resolution (Snellen equivalent 20/126) at baseline and 0.3 ± 0.4 logarithm of minimal angle of resolution (Snellen equivalent 20/40) at the last follow-up. PAMM and AMN lesions occurred in the setting of Purtscher's retinopathy (4 eyes, 3 patients), retinal vein occlusion (7 eyes, 7 patients), central retinal artery occlusion (1 eye, 1 patient), and idiopathic retinal vasculitis (1 eye, 1 patient). In 4 eyes (3 patients), an association with other ocular disorders was not identified as evaluated with multimodal imaging. Of the total cohort, 11 eyes (64.7%) showed extension of the AMN hyperreflective bands in Henle's fiber layer with a Z-shaped morphology on OCT B-scan. CONCLUSIONS: The presence of coincident PAMM and AMN suggests a common pathophysiologic etiology. This may be the result of retinal vein impairment and hypoperfusion at the level of the deep retinal capillary plexus possibly leading to injury to the Müller glia or photoreceptors in Henle's fiber layer.

Aflibercept versus Ranibizumab as a Second Line Therapy After Bevacizumab for Diabetic Macular Edema.

PURPOSE: To compare the visual and anatomic outcomes of aflibercept versus ranibizumab as a second line treatment for persistent diabetic macular edema (DME) after initial bevacizumab injections. METHODS: In this retrospective cohort study, patients with center-involved DME of ≥ 300 µm thickness after bevacizumab intravitreal injections in 2015-2019 were included. Those treated with ranibizumab (R) and aflibercept (A) were grouped as group R and group A, respectively. The change in central macular thickness (CMT) measured by optical coherence tomography (OCT) and the best corrected distance visual acuity (BCVA) before and after three-monthly anti-VEGF injections (anti-VEGF) in group R and group A were compared and reviewed. RESULTS: There were 80 eyes of 75 patients in group R and 80 eyes of 72 patients in group A. The initial bevacizumab injections in group R and group A varied significantly (p = 0.01). The median change of the CMT after the three injections was not significantly different in group R (80 µm) and group A (81.5µm) (p = 0.7). The improvement of BCVA in group R and group A was not significant (p = 0.5). Dry macula was noted in 1 vs 14 eyes in group R vs group A. CONCLUSION: After treating refractory DME with initial bevacizumab injections, 3 injections of either aflibercept or ranibizumab had similar anatomic and functional outcomes. Aflibercept achieved dry macula in more eyes with refractory DME compared to ranibizumab.

Pars Plana Vitrectomy vs Combined Pars Plana Vitrectomy-Scleral Buckle for Primary Repair of Pediatrics Retinal Detachment.

PURPOSE: To evaluate the outcome of pars plana vitrectomy (PPV) and combined pars plana vitrectomy with scleral buckle (PPV-SB) in the primary pediatrics rhegmatogenous retinal detachment repair. DESIGN: A retrospective cohort study. METHODS: A retrospective study was conducted in patients under 18 years of age, who presented with rhegmatogenous retinal detachment at King Khaled Eye Specialist Hospital between January 2014 and October 2018. Primary measurable outcomes were single surgery success rate (SSSR) and rate of postoperative complications. RESULTS: A total of 122 eyes of 117 patients were included in the study; 80 eyes in PPV group and 42 eyes in PPV-SB group. Mean follow-up period after surgery was 18.2 months ±11 months. SSSR was 76.3% (n=61) and 66.7% (n=28) for PPV and PPV-SB, respectively. No statistically significant difference was found between the two methods of RRD repair in single surgery success rate with an OR of 1.3 (P=0.45). Complication rates were comparable in both groups in the last follow-up. CONCLUSION: In this series, PPV and PPV-SB have comparable results in regard to anatomical success and rate of postoperative complications. More complicated cases were selected to undergo PPV-SB upon surgeons' preference.

Macular Hole-Related Retinal Detachment in Children with Knobloch Syndrome.

PURPOSE: To describe the findings and the management of macular hole (MH)-related retinal detachment (RD) in children with Knobloch syndrome. DESIGN: Retrospective interventional case series. PARTICIPANTS: Patients with Knobloch syndrome who presented with MH-related RD. METHODS: Retrospective chart review of patients with Knobloch syndrome who presented with MH-related RD from January 2012 to December 2018. Interventions included pars plana vitrectomy and silicone oil tamponade with or without scleral buckle, drainage retinotomy, or relaxing retinectomy. MAIN OUTCOME MEASURES: MH characteristics and surgical anatomical outcome. RESULTS: The study included 9 eyes of 5 patients (age range 2 months to 5 years; median age 5.5 months). Presenting symptoms were poor fixation and nystagmus. The fellow eye of 1 patient had RD due to peripheral breaks. The MH was clinically visible in 8 eyes and detected only by OCT in 1 eye. The RD was shallow and extended to the anterior equator in 7 eyes and localized to a punched-out atrophic lesion in 1 eye. Seven eyes underwent surgical repair. At the last follow-up examination (follow-up range 11 to 42 months; mean 24 months, standard deviation 11.8 months), retinal reattachment with MH closure was achieved in 5 eyes along with marked improvement in fixation. CONCLUSION: Patients with Knobloch syndrome may develop MH-related RD as early as infancy. The condition may be easily overlooked in children but should be suspected in the setting of high myopia, vitreoretinal degeneration, and encephalocele.

Incidence of Intraocular Lens Exchange after Cataract Surgery.

Intraocular lens (IOL) exchange after cataract surgery is unusual but may be associated with suboptimal visual outcome. The incidence of IOL exchange has not been consistently estimated. Such information is invaluable when counseling patients prior to cataract surgery. We examined the incidence of, and indications and risk factors for, IOL exchange after cataract surgery. We also assessed visual outcome of eyes that had an IOL exchange. A cohort design was used to estimate the incidence of IOL exchange and a case-control design to identify factors associated with it. All phacoemulsification surgeries with IOL (n = 17415 eyes) during 2010-2017 and those that had a subsequent IOL removal or replacement during the same time period were identified (n = 34 eyes). The incidence of IOL exchange was 2 per 1000 surgeries (95% confidence interval [CI] 1 to 3) over 8 years. Eyes that underwent subsequent IOL removal or replacement were compared with eyes that had cataract surgery only (n = 47) across demographic and clinical characteristics. In a binary logistic regression analysis, two factors were significantly associated with IOL exchange/removal: an adverse event during cataract surgery (adjusted odds ratio [aOR] 19.45; 95% CI 4.89-77.30, P < 0.001) and a pre-existing ocular comorbidity (aOR 10.70; 95% CI 1.69-67.63, P = 0.021). The effect of gender was marginally significant (P = 0.077). Eyes that underwent IOL exchange or explantation were nearly two and a half times more likely to have a final best-corrected visual acuity of <20/60 compared to those that had cataract surgery alone (adjusted RR 2.60 95% CI, 1.13-6.02; P = 0.025).

NOVEL TECHNIQUE FOR SUBRETINAL FLUID DRAINAGE WITH CHANDELIER-ASSISTED SCLERAL BUCKLE SURGERY: CANNULA-CONTROLLED DRAINAGE.

PURPOSE: To report a novel technique for subretinal fluid drainage in scleral buckle surgery. METHODS: A 26-gauge intravenous cannula with its needle was used to puncture the sclera; then, the needle (metallic part) was withdrawn to further introduce the cannula into the subretinal space. In addition, we describe using the 25-gauge microcannula of the chandelier light to inject the balanced salt solution to help restore the intraocular pressure and push the subretinal fluid through the intravenous cannula under direct visualization. RESULTS: An 82-year-old gentleman with chronic rhegmatogenous retinal detachment with subretinal bands who was at a high risk for intraoperative bleeding since he was on dual antiplatelet therapy. He underwent chandelier light-assisted scleral buckle with subretinal fluid drainage using cannula controlled drainage, which resulted in complete intraoperative subretinal fluid drainage with no complications and successful flattening of the retina in the postoperative follow-up. CONCLUSION: Subretinal fluid drainage using this technique with chandelier-assisted scleral buckle surgery is a new method which might improve the safety profile of subretinal fluid drainage during scleral buckle surgery.

Validity, Usefulness and Cost of RETeval System for Diabetic Retinopathy Screening.

PURPOSE: We studied the validity, usefulness, and relative cost to detect diabetic retinopathy (DR) and sight-threatening DR (STDR) by using a hand-held electrophysiologic tool compared to digital fundus photography. METHOD: Patients with diabetes attending the screening unit of King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia were evaluated by "RETeval", Amsler grid, and digital dilated fundus photography. Fundus images were evaluated by a retina specialist to determine grade of DR. The sensitivity and specificity of STDR and DR screening compared to photography were calculated, as well as "RETeval" combined with Amsler grid testing. The area under the curve (AUC) of "RETeval" screening outcome was calculated. RESULT: We analyzed data of 400 diabetic patients. The prevalence of DR of any grade was 48.8% (95% confidence interval [CI], 43.9-53.7) while the prevalence of STDR was 27% (95% CI, 22.6-31.4). The outcome of RETeval test was "fail" (based on 20 µV or more amplitude of electrophysiologic spikes) in 351 (87.8%; 95% CI, 84.5-91.0) eyes. The sensitivity of the device was 95.4% and the specificity was 17.5%. Thus, the sensitivity of sequential testing with RETeval and Amsler grid test was 30.1% and the specificity was 80.1%. The AUCs for STDR and DR in general were 76.6% and 50.6%, respectively. CONCLUSIONS: "RETeval" is a rapid screening device with excellent sensitivity for detecting STDR. It has potential as a first level screening tool to detect patients who require further evaluation. TRANSLATIONAL RELEVANCE: Retinal function, such as electrophysiology, can be used as a new concept for screening for DR.

Atypical Presentation of Ocular Toxoplasmosis: A Case Report of Exudative Retinal Detachment and Choroidal Ischemia.

A 24-year-old healthy male presented with a chief complaint of blurred vision in the right eye for 1-week. Fundus examination indicated right exudative retinal detachment and choroidal ischemia. The patient responded well to anti-toxoplasmosis medications and steroids. Exudative retinal detachment and choroidal ischemia are atypical presentations of ocular toxoplasmosis. However, both conditions responded well to anti.parasitic therapy with steroid.

Retinal Complications After Anterior Versus Posterior Chamber Phakic Intraocular Lens Implantation in a Myopic Cohort.

PURPOSE: To compare the incidence and characteristics of retinal complications following implantation of two types of phakic intraocular lenses (PIOLs) in patients with myopia. METHODS: In this comparative, retrospective study, 603 eyes of 344 patients with myopia underwent implantation of either an Artisan iris-fixated phakic intraocular lens IOL (Artisan; Ophtec, Groningen, Netherlands) (Artisan group) or a Visian implantable collamer lens (ICL; STAAR Surgical Company, Monrovia, CA) (ICL group) between June 2005 and December 2013. Preoperative, operative, and postoperative clinical data were collected on the incidence of retinal complications, including rhegmatogenous retinal detachment (RRD) or choroidal neovascular membrane (CNVM). RESULTS: The Artisan lens was implanted in 185 (30.68%) eyes and 418 (69.32%) eyes underwent ICL implantation. Mean follow-up was 26.78 months (range: 9 days to 98 months). Mean preoperative spherical equivalent (SE) was -12.44 ± 4.43 D (range: -1.13 to -31.00 D). The overall rate of retinal complications was 1%. Postoperatively, 3 (0.7%) eyes developed RRD in the ICL group, and no eyes developed RRD in the Artisan group. Submacular hemorrhage was observed in 1 (0.24%) eye in the ICL group. Two (1%) eyes developed CNVM in the Artisan group. The mean time from PIOL implantation to retinal complications was 15.6 months (range: 0.03 to 43 months). CONCLUSIONS: Implantation of ICL or Artisan phakic IOL demonstrated comparable rates of retinal complications. Anterior chamber PIOL does not increase the risk of retinal detachment or CNVM in patients with myopia.

Polymerase chain reaction in unilateral cases of presumed viral anterior uveitis.

BACKGROUND AND OBJECTIVES: Anterior uveitis is the most common form of intraocular inflammation. The main aim of this study was to determine the viral etiology in patients with unilateral cases of anterior uveitis. PATIENTS AND METHODS: A total of 12 consecutive patients with the diagnosis of idiopathic unilateral anterior uveitis were included prospectively. Aqueous specimens were obtained from each patient by anterior chamber paracentesis and subjected to the detection of viral DNA/RNA genome by polymerase chain reaction assay for herpes simplex virus, varicella zoster virus, cytomegalovirus, Epstein-Barr virus, and rubella virus. RESULTS: There were six male and six female patients. The mean age was 43 years, with an age range of 11-82 years. All 12 cases presented with unilateral anterior uveitis. In four (33%) patients, polymerase chain reaction was positive for viral genome. Two patients were positive for herpes simplex virus type 1, one patient was positive for cytomegalovirus and one for Epstein-Barr virus. CONCLUSION: Recent molecular diagnostic assays would help in the identification of the causative agent in patients with unilateral anterior uveitis.

Endophthalmitis Caused by Rhizobium radiobacter After Posterior Chamber Phakic Intraocular Lens Implantation to Correct Myopia.

PURPOSE: To describe a 29-year-old man presenting with acute-onset endophthalmitis caused by Rhizobium (formerly Agrobacterium) radiobacter after uneventful implantable collamer lens implantation for myopia. METHODS: Case report. RESULTS: The patient was treated with intravitreal injections of vancomycin and ceftazidime, as well as topical and systemic antibiotics. The patient had a good response with a final visual acuity of 20/50 at the last follow-up visit 25 months postoperatively. CONCLUSIONS: This case represents the first case report of endophthalmitis caused by Rhizobium radiobacter following implantable collamer lens implantation.

Intraocular pressure trends after intravitreal injections of anti-vascular endothelial growth factor agents for diabetic macular edema.

PURPOSE: To study intraocular pressure (IOP) trends and risk factors of IOP elevation after intravitreal anti-vascular endothelial growth factor injections in diabetic macular edema. METHODS: A retrospective review of 760 eyes treated with intravitreal anti-vascular endothelial growth factor injections for diabetic macular edema was performed. The rate and risk factors of IOP elevation were assessed. Intraocular pressure elevation was defined as an increase above baseline IOP by ≥ 6 mmHg, increase above baseline by > 20%, or IOP elevation to > 24 mmHg on 2 or more consecutive visits after treatment. When more than one pretreatment IOP reading was available, baseline IOP was calculated as the mean of the available pretreatment IOP readings (up to a maximum of three last IOP readings). Intraocular pressure elevation was considered transient unless it was maintained throughout the follow-up or required treatment (persistent elevation). RESULTS: Over a mean follow-up of 18 months, persistent and transient IOP elevation occurred in 44 (5.8%) and 53 (7%) eyes, respectively. The majority of eyes with persistent IOP elevation (70.4%) showed IOP elevation of > 20% from baseline. Only 13 eyes (1.71%) met the more strict criteria (> 6 mmHg from baseline or an IOP elevation > 24 mmHg). Final IOP was higher in the persistent IOP elevation group than the rest of the eyes (P < 0.001). Only the number of injections was associated with IOP elevation (P < 0.001). CONCLUSION: Persistent IOP elevation after intravitreal anti-vascular endothelial growth factor injections for diabetic macular edema is uncommon but may be associated with a higher number of injections.

Resolution of bilateral corneal neovascularization and lipid keratopathy after photodynamic therapy with verteporfin.

PURPOSE: The aim of this study was to describe the result of photodynamic therapy with verteporfin (Visudyne(®), Novartis Ophthalmics AG, Hettingen, Switzerland) on bilateral corneal neovascularization (CN) and lipid keratopathy. METHODS: A 36-year-old man with bilateral CN and visually significant lipid keratopathy presented to the King Khaled Eye Specialist Hospital with decreased visual acuity in both eyes; bilateral refractive surgery had been done several years before. He was wearing hard contact lenses and had a history of repeated keratitis in both eyes. Eyes were treated with nonthermal laser light at 689 nm delivered 15 minutes after an intravenous infusion of verteporfin, 6 mg/m(2) of body surface area, which was repeated 2 months after his first session. He was followed up regularly for 4 years with ophthalmic examinations and photographic documentation. RESULTS: Successful occlusion of the CN was observed by the third month, and a dramatic resorption of lipid keratopathy was noticed by the end of the first year in both eyes. Best-corrected visual acuities improved from 20/80 in the right eye and 20/100 in the left eye to 20/30 with each eye. During the 4-year follow-up period, neither recurrence nor complications of the treatment was observed. CONCLUSIONS: Laser therapy with verteporfin can be added to the armamentarium of treatments for CN as a safe and effective option.