Visual function and retinal morphological changes after single suprachoroidal delivery of fluocinolone acetonide (Iluvien®) implant in eyes with chronic diabetic macular edema.

BACKGROUND: To assess the efficacy and safety of supra-choroidal (SC) Iluvien in the management of chronic diabetic macular edema (DME). METHODS: A retrospective interventional non-comparative consecutive case series including patients with chronic DME who received an SC Iluvien implant. All patients had persistent central macular thickness (CMT) ≥ 300µ after previous treatment with anti-vascular endothelial growth factor (VEGF) agents or laser photocoagulation. The main outcome measures were improvement of best-corrected visual acuity (BCVA), reduction of CMT, and detection of ocular hypertension/glaucoma or cataract formation. Friedman's two-way ANOVA was used to analyze BCVA, intraocular pressure (IOP), and DME across different time points. P-value = 0.05. RESULTS: The study included 12 eyes of 12 patients. Six patients (50%) were males. The median age was 58 years (range 52-76 years). The median duration of DM was 13 years (range 8-20 years). Ten patients (83.3%) were phakic and 2 patients (17%) were pseudophakic. The median pre-operative BCVA was 0.07 (range 0.05-0.8). The median pre-operative CMT was 544µ (range 354-745µ). The median pre-operative IOP was 17 mmHg (range 14-21mmHg). The median follow-up period was 12 months, range (12-42). Post-operatively, the median final BCVA was 0.15 (range 0.03-1), p 0.02, the median CMT was 404µ (range 213-747), p 0.4 and the median IOP was 19.5 mmHg (range 15-22), p 1. Two out of 10 phakic patients (20%) developed nuclear sclerosis grade I by 12 months. Six patients (50%) developed a transient rise in IOP < 10 mmHg from the baseline that resolved within 3 weeks with antiglaucoma drops. CONCLUSION: SC Iluvien is potentially effective in improving visual function, reducing macular edema, and reducing the incidence of steroid-induced cataracts and glaucoma.

Typical and atypical clinical presentations of X-Linked retinoschisis: A case series and literature review.

X-linked retinoschisis (XLRS) is an X-linked inherited retinal dystrophy characterized by mild-to-severe visual impairment, splitting of the retinal layers, and a reduction in the dark-adapted b-wave amplitude on the electroretinogram. Typical clinical features include macular and peripheral schisis. Relatively common features reported include rhegmatogenous or tractional retinal detachment, vitreous hemorrhage, retinal pigment epithelial changes, vitreous veils, and various retinal vascular abnormalities with or without exudation. Macular hole and macular folds are atypical presentations of XLRS, along with several other rare findings. Here, we report 4 cases of XLRS with atypical clinical presentations and review the literature on XLRS, with a focus on the variable clinical features of this condition.

COMBINED HAMARTOMA OF THE RETINA AND RETINAL PIGMENT EPITHELIUM AT PEDIATRIC AGE: Surgical Versus Conservative Approach.

PURPOSE: To report outcomes of pediatric patients with combined hamartoma of the retina and the retina pigment epithelium followed up conservatively or after pars plana vitrectomy. METHODS: This retrospective multicenter study included 62 eyes of 59 pediatric patients with combined hamartoma of the retina and the retina pigment epithelium from 13 different international centers with an average age of 7.7 ± 4.7 (0.3-17) years at the time of the diagnosis and having undergone pars plana vitrectomy or followed conservatively. At baseline and each visit, visual acuity values, optical coherence tomography for features and central foveal thickness, and tumor location were noted. Lesions were called as Zone 1, if it involves the macular and peripapillary areas, and the others were called as Zone 2 lesions. RESULTS: Twenty-one eyes of 20 patients in the intervention group and 41 eyes of 39 patients in the conservative group were followed for a mean of 36.2 ± 40.4 (6-182) months. Best-corrected visual acuity improved in 11 (68.8%) of 16 eyes in the intervention group and 4 (12.9%) of 31 eyes in the conservative group ( P < 0.001). The mean central foveal thickness decreased from 602.0 ± 164.9 µ m to 451.2 ± 184.3 µ m in the intervention group, while it increased from 709.5 ± 344.2 µ m to 791.0 ± 452.1 µ m in Zone 1 eyes of the conservative group. Posterior location of tumor, irregular configuration of the foveal contour and ellipsoid Zone defect in optical coherence tomography, subretinal exudate and prominent vascular tortuosity were associated with poor visual acuity. CONCLUSION: Vitreoretinal surgery is safe and effective in improving vision and reducing retinal distortion in Zone 1 combined hamartoma of the retina and the retina pigment epithelium in children.

Multi-layer internal limiting membrane plug technique for management of large full-thickness macular holes.

BACKGROUND: To evaluate the efficacy of the multi-layer internal limiting membrane plug (MIP) technique in promoting the closure of large full-thickness macular holes (FTMH) and improvement of visual function. METHODS: A prospective interventional non-comparative consecutive case series including patients with surgically naïve large FTMH whether primary or secondary. All macular holes were > 400 µm. All patients had 23-gauge pars plana vitrectomy (PPV), MIP technique, and sulfur hexafluoride (SF6) 20% gas tamponade. The main outcome measures were the closure of the hole, improvement of best-corrected visual acuity (BCVA), and detection of complications that might develop due to surgery. RESULTS: The study included 15 eyes of 15 patients. The mean age was 44 years (range 10-68; SD 21.5). Primary FTMH constituted 53% of cases. The mean pre-operative minimum linear diameter (MLD) was 702 µm (range 401-1068 µm; SD 154). The mean duration of the macular hole was 6 months (range 1-24; SD 6). The mean pre-operative BCVA was 0.06 decimal units (range 0.01-0.1; SD 0.03). Post-operatively, the macular hole was closed in all patients. U- and V- type closure developed in 93% and 7% of patients, respectively. None of the patients developed W-type closure. Post-operatively, the mean post-operative BCVA was 0.2 decimal units (range 0.05-0.5; SD 0.1). The mean improvement was 5 lines of vision. The mean postoperative follow-up period was 4 months (range 1-10; SD 2.5). None of the patients developed complications attributed to the surgical technique described. CONCLUSION: MIP technique is effective in promoting macular hole closure and improvement of visual function in large FTMH.

SUPRACHOROIDAL BUCKLING FOR THE MANAGEMENT OF RHEGMATOGENOUS RETINAL DETACHMENTS SECONDARY TO PERIPHERAL RETINAL BREAKS.

PURPOSE: To evaluate functional and anatomical outcomes of eyes undergoing suprachoroidal buckling for the management of peripheral retinal breaks in rhegmatogenous retinal detachment. METHODS: Retrospective cohort study of 41 eyes of 41 patients undergoing suprachoroidal buckling for the management of rhegmatogenous retinal detachment secondary to single or multiple retinal breaks. Suprachoroidal indentation was achieved through the introduction of filler material using a 23-gauge (23-G) olive-tipped, suprachoroidal cannula. This allowed for the creation of a suprachoroidal dome and chorio-retinal apposition. Healon5 (Abbott Medical Optics) was used as filler material in all eyes. Combined 25-G vitrectomy was performed in 5 eyes. Cryopexy and laserpexy were used in 37 and 4 eyes, respectively. RESULTS: Mean visual acuity gain was the primary outcome measure. Final retinal reattachment rate, single-surgery reattachment rate, and complications were secondary outcome measures. Mean best-corrected distance visual acuity improved from 20/1,100 to 20/42. Single surgery reattachment rate was 92.7% (38/41 eyes). Final retinal reattachment was achieved in all 41 eyes (100%). There was no statistically significant difference in visual acuity gain or anatomical reattachment in terms of retinal break quadrant or extent. No major complications were observed. Two localized suprachoroidal hemorrhages occurred at the entry site for the cannula. These resolved without further intervention. CONCLUSION: Suprachoroidal buckling using a specially designed cannula is a safe and effective procedure for the management of rhegmatogenous retinal detachment secondary to peripheral retinal breaks.

Catheter-guided suprachoroidal buckling of rhegmatogenous retinal detachments secondary to peripheral retinal breaks.

PURPOSE: To evaluate functional and anatomic outcomes of eyes undergoing suprachoroidal buckling (SCB) using a specially designed catheter for the management of rhegmatogenous retinal detachment (RRD) secondary to peripheral retinal breaks. METHODS: Retrospective cohort study of 62 eyes of 62 patients. Subjects underwent SCB for the management of RRD secondary to single or multiple retinal breaks. Suprachoroidal indentation was achieved through the introduction of viscoelastic material in the suprachoroidal space overlying the break using an illuminated, 450 µm-wide, flex-tip catheter. This allowed for the creation of a suprachoroidal dome and chorio-retinal apposition. Forty-seven eyes (80 %) underwent SCB alone, while 15 eyes (20 %) were combined with 25-G pars-plana vitrectomy. Cryopexy and laserpexy were used in 38 (61 %) and 24 of eyes (39 %) respectively. RESULTS: Mean pre-operative best-corrected visual acuity (BCVA) improved from logMAR 0.82 (20/132) to 0.22 (20/33) (p < 0.0001). The single surgery reattachment rate was 92 % (57/62.) Final retinal reattachment was achieved in all eyes (100 %). No significant difference was observed in single-surgery anatomic success rates when stratified by lens status, macular involvement, or break location. There were no major intra- or post-operative complications. CONCLUSION: Suprachoroidal buckling using a special-design, flexible catheter is a safe and effective procedure for the management of RRD secondary to peripheral retinal breaks.

Suprachoroidal buckling.

PURPOSE: To evaluate the feasibility of suprachoroidal buckling procedure using a suprachoroidal catheter, or cannula, as a new approach to treating different forms of retinal detachment, including myopic traction maculopathy, myopic macular holes, and peripheral retinal breaks by creating a suprachoroidal indentation (buckling effect) using a suprachoroidal filler. METHODS: We used specially designed devices, guided in the suprachoroidal space to reach the target space (retinal tear). Then we injected a suprachoroidal filler (long-lasting hyaluronic acid) to indent the choroid creating a suprachoroidal buckle to close retinal tears and support the retina. This was done to both central (myopic macular) holes in areas of the staphyloma as well as for treating peripheral retinal breaks. This technique can be used alone or during vitrectomy. RESULTS: In myopic patients, retinal layer restoration was achieved in all eyes with myopic foveoschisis. Of the 12 eyes, 10 with macular hole detachment (83%) showed closure of the holes in association with the resolution of the detachment; 2 eyes showed resolution of the detachment and flattening of the edge of the holes, but with incomplete closure on optical coherence tomography. Eight eyes (66.6%) showed improvement in visual acuity by one or more lines with no recurrence of retinal detachment over the 24-month follow-up period. The indentation effect was sufficient over the 24-month follow-up period. For peripheral retinal breaks, tears treated with this technique were all adequately buckled and closed from one procedure. A well-controlled location and support distribution of the buckle was possible through the suprachoroidal space. The buckling effect was enough to seal the tears and support the chorioretinal scarring time needed for tear healing. This also could be controlled by the filler duration time (filler type). The procedure was safe and relatively simple in reaching the treatment area and injecting it. CONCLUSION: The indentation effect achieved by the suprachoroidal approach can be used as a method for managing myopic foveoschisis and myopic macular hole with detachment even in eyes with failed primary vitrectomy, counteracting the role of posterior staphyloma in the role of the disease. This technique is also feasible for treating retinal tears, supporting the retina, and treating selected forms of retinal detachment including subsilicone inferior recurrent retinal detachment. It can be done separately or in association with vitrectomy procedures. It adds to our surgical options in treating selected cases of rhegmatogenous retinal detachment and avoids some potential problems of episcleral buckles as well as vitrectomy in selected cases of rhegmatogenous retinal detachment.

Supra choroidal buckling in managing myopic vitreoretinal interface disorders: 1-year data.

PURPOSE: To evaluate the efficacy of supra choroidal buckling procedure using a supra choroidal catheter, as a new approach in treating myopic vitreomacular interface disorders specially in difficult cases of myopic traction maculopathy with or without macular hole retinal detachment in posterior staphyloma depending on the concept of indenting the choroid only, from a 1-year data study. METHODS: A newly developed supra choroidal catheter was used to deliver stabilized, cross-linked, long-acting hyaluronic acid as a filler in the supra choroidal space in the area of the staphyloma forming a choroidal indenting effect. Before the injection, pars plana vitrectomy was performed without internal limiting membrane peeling to avoid the risk of break of the roof of foveal detachment in case of foveoschisis. This indentation was used to treat 11 patients with myopic foveoschisis and 12 patients with myopic macular hole retinal detachment, 5 of whom had failed primary repair by vitrectomy before inclusion in this trial. Clinical and optical coherence tomographic evaluations of these patients were performed over 1-year follow-up. RESULTS: Retinal layer restoration was achieved in all 11 eyes with myopic foveoschisis. This was gradual over a period of 2 to 6 weeks postoperatively. No recurrence over the 12-month follow-up was observed. Visual acuity improved by 1 line or more in 9 eyes (81.8%). Of the 12 eyes, 10 with macular hole detachment (83%) showed closure of the holes in association with the resolution of the detachment; 2 eyes showed resolution of the detachment and flatting of the edge of the holes but with incomplete closure on optical coherence tomography. Eight eyes (66.6%) showed improvement in visual acuity by 1 or more lines with no recurrence of retinal detachment over the 12-month follow-up period. The indentation effect was sufficient over the 12-month follow-up period. CONCLUSION: The indentation effect achieved by supra choroidal approach can be used as a method of managing myopic foveoschisis and myopic macular hole with detachment even in eyes with failed primary vitrectomy, counteracting the role of posterior staphyloma in the role of the disease. The indentation effect is sufficient for first year of follow-up.

Suprachoroidal buckling: technique and indications.

The authors herein report the feasibility of suprachoroidal buckling (SCB) procedure as a new approach for treating different forms of retinal detachment (RD) by creating suprachoroidal indentation (buckling effect). With this technique, specially designed devices, i.e. a catheter or cannula, are guided in the suprachoroidal space to reach the target area. Then, a suprachoroidal filler (long lasting hyaluronic acid) is injected to indent the choroid creating SCB, thereby closing retinal tears and supporting the overlying retina. This procedure was performed to treat both myopic tractional maculopathy (MTM), including myopic macular holes, as well as peripheral retinal breaks. SCB may be used alone or in conjunction with vitrectomy. In myopic patients, restoration of retinal layers was achieved in all eyes with myopic foveoschisis. Most eyes with macular hole detachments demonstrated closure of the holes. All peripheral retinal breaks were adequately buckled and closed in a single procedure. The buckling effect was long enough in duration to seal the tears and promote adequate chorioretinal scarring. The procedure was safe and relatively simple in terms of reaching the treatment area and injecting the filler. SCB adds to our surgical options for treating selected cases of peripheral retinal tears and rhegmatogenous RD, and avoids potential problems of episcleral buckles. Moreover it may avoid vitrectomy in selected cases of rhegmatogenous RD.

Three-year anatomic and visual outcomes after vitrectomy for stage 4B retinopathy of prematurity.

PURPOSE: To assess anatomic and visual outcome following vitrectomy for stage 4B retinopathy of prematurity (ROP) after 3 years follow-up. METHODS: Retrospective analysis of 56 eyes (46 infants) with stage 4B ROP-related retinal detachment. Eyes underwent either lens-sparing vitrectomy (LSV) or combined lensectomy and vitrectomy (LV). Visual outcome after a minimum follow-up of 36 months was ascertained by using either Teller or Snellen acuities, or sweep visual evoked potential. RESULTS: LSV was performed in 42.9% and LV in 57.1% of eyes. Retinal reattachment was achieved in 73.2% overall (LV 71.8% versus LSV 75%) (P = 0.96). Ambulatory vision (VA better than 20/1900) and near reading vision (better than 20/800) were attained in 97.4% and 42.8% of eyes respectively. Attached retina, LSV, and pretreatment with retinal ablation were associated with a higher incidence of near reading or better vision compared to detached (P < 0.001), undergoing LV (P < 0.001), and non pretreated eyes (P = 0.011). CONCLUSION: After 3 years, more than 40% of eyes operated for ROP stage 4B in this series had a visual acuity compatible for near reading or better. Eyes undergoing LSV and with prior peripheral retinal ablation had better visual outcomes.