Macular Retinoschisis from Optic Disc without a Visible Optic Pit or Advanced Glaucomatous Cupping (No Optic Pit Retinoschisis [NOPIR]).

PURPOSE: To review eyes with peripapillary and macular retinoschisis without a visible optic pit or advanced glaucomatous optic atrophy, or No Optic Pit Retinoschisis (NOPIR). DESIGN: Retrospective multicenter case series. SUBJECTS: The study included 11 eyes of 11 patients. METHODS: Retrospective study of eyes with macular retinoschisis without a visible optic pit, advanced optic nerve head cupping, or macular leakage on fluorescein angiography. MAIN OUTCOME MEASURES: Visual acuity (VA), retinoschisis resolution, months to resolution, and recurrence of retinoschisis RESULTS: The mean age was 68.1 ± 17.6 years, mean intraocular pressure was 17.4 ± 3.8 mmHg, and the mean spherical equivalent refractive error was -3.1 ± 2.9 diopters. No subject had pathologic myopia. Seven subjects were treated for glaucoma, and 9 subjects had nerve fiber layer defects on OCT. All eyes had retinoschisis in the outer nuclear layer (ONL) in the nasal macula and extending to the edge of the optic disc, and 8 subjects had fovea-involving retinoschisis. Three nonfoveal and 4 fovea-involved eyes were observed, and 4 fovea-involved eyes with vision loss underwent surgery. Surgery involved preoperative juxtapapillary laser followed by vitrectomy and membrane and internal limiting membrane peeling with intraocular gas and face-down position. The mean baseline VA was significantly worse in the surgery group than that in the observation group (P = 0.020). Retinoschisis resolved and vision improved in all surgical cases. The mean resolution time for the surgery group was 2.75 ± 0.96 months, which was shorter than that for the observation group (28.0 ± 21.2 months; P = 0.014). No eye developed recurrence of the retinoschisis after surgery. CONCLUSIONS: Peripapillary and macular retinoschisis can develop in eyes without a visible optic pit or advanced glaucomatous cupping. Eyes without foveal involvement and those with foveal involvement but only mild decrease in vision can be observed for spontaneous resolution. If there is persistent foveal involvement with vision loss, surgery can improve vision by resolving the macular retinoschisis. Surgery for fovea-involved macular retinoschisis without a visible optic pit resulted in faster anatomic resolution and better vision recovery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

TREATMENT OF HYPOTONY WITH AN INTRAVITREAL GAS BUBBLE.

PURPOSE: To describe a case of successful resolution of severe hypotony and choroidal detachments following nonfiltering glaucoma surgery with an intravitreal injection of C 3 F 8 gas after a poor response to topical steroids and cycloplegia. METHODS: Retrospective chart review of a case report. RESULTS: 89 year-old male presented with a central retinal vein occlusion, hyphema, vitreous hemorrhage and neovascular glaucoma. After initial intravitreal injection of aflibercept he was treated with pars plana vitrectomy with panretinal photocoagulation and endocyclophotocoagulation to the ciliary body, but he continued to have elevated intraocular pressure. Subsequent external cyclophotocoagulation was performed but severe hypotony with inflammation, choroidal detachments, and corneal edema developed one week later without response to cycloplegic and steroid medications. A therapeutic injection of perfluorpropane (C3F8) gas led to resolution of the hypotony and choroid detachment and long-term maintenance of intraocular pressure. DISCUSSION/CONCLUSION: An intravitreal gas bubble can be a very useful outpatient procedure to immediately reverse hypotony, resolve choroidal detachment, and decrease associated inflammation. When hypotony does not respond to medical therapy with cycloplegic drops and steroid medications, then an intravitreal gas bubble can rapidly resolve these complications and result in stabilization of intraocular pressure long-term.

Refractive Outcomes of Combined Cataract Surgery and Vitrectomy Compared to Cataract Surgery Alone.

PURPOSE: The aim of the study was to evaluate the refractive outcomes of combined cataract surgery and vitrectomy compared to cataract surgery alone. METHODS: This retrospective chart review study included two groups: (1) combined surgery in 103 eyes (101 patients) who underwent cataract surgery with posterior chamber intraocular lens (PCIOL) placement by a single cataract surgeon and vitrectomy by a single vitreoretinal surgeon at the same surgical setting; (2) cataract surgery alone by the same surgeon in 107 eyes (84 patients). Refractive outcomes and complications between the combined and cataract surgery alone group were compared. The predicted refractive error was compared to postoperative refractive outcomes in both groups, surgically induced astigmatism (SIA), intraoperative or postoperative complications of either cataract surgery or vitrectomy, and cystoid macular edema. RESULTS: There was no statistically significant difference between predicted and actual postoperative refractive outcomes between the combined and cataract surgery alone groups (within ±0.5 diopters [D], p = 0.099; within ±1.0 D, p = 0.721). There was no difference in SIA refractive outcomes between the two groups (p = 0.509). The use of intraoperative gas for retina tamponade did not significantly affect postoperative refractive outcomes. Both cataract surgery and vitrectomy were successfully performed without unexpected complications from either procedure affecting the other. DISCUSSION/CONCLUSION: Combined cataract surgery and vitrectomy allows excellent refractive outcomes equal to cataract surgery alone, allowing each procedure to be performed independently by separate anterior and posterior segment surgeons. Combined procedures can be performed in eyes with a variety of retinal indications and can include fluid-gas exchange with minimal risk of PCIOL malposition or change in targeted refraction.

In office management of optic capture of scleral fixated posterior chamber intraocular lenses.

INTRODUCTION: Optic capture of sutured scleral fixated posterior chamber intraocular lenses (PC IOLs) is an occasional complication resulting in blurred vision and discomfort. METHODS: A retrospective study of the management of 18 eyes (3.6%) with optic capture out of 495 eyes with scleral fixated IOLs during the study period. 54 procedures were performed in the management of optic capture of sutured scleral fixated PC IOLs. An in-office technique was utilized to relieve the optic capture by repositioning the optic posterior to the iris. This technique was performed after topical anesthesia and topical 5% betadine with the patient stably positioned at the slit lamp. Using a 30-gauge needle, sometimes after a 15-degree paracentesis blade, the needle was advanced in a parallel plane above the iris until the tip reached the edge of the captured optic. The optic is engaged in the inferior periphery away from the central visual axis, and pushed gently posteriorly just enough to reposition the optic posterior to the iris. In some cases, pilocarpine 2% drops were utilized after the procedure to decrease the risk of recapture of the optic. RESULTS: All 54 procedures were successfully performed in the office without significant pain or discomfort. Vision before optic capture, during optic capture, and at the first office visit after optic capture were comparable. There were not any cases of endophthalmitis, hyphema, iris trauma, iris prolapse or keratitis. While eight patients only had one episode of optic capture, 10 patients had multiple episodes of optic capture, all managed with this in office procedure. Recurrent optic capture occurred more frequently in eyes with fixation at less than 2 mm from the limbus than eyes with scleral fixation at 2 mm from the limbus. CONCLUSION: Reposition of the optic after pupillary capture of a scleral fixated PC IOL can be successfully performed in the office without discomfort or significant complications and is an alternative management option to a return to the operating room. This procedure may be especially important when there is poor access to the operating room or restricted access to the operating room as during the COVID19 pandemic.

Vitrectomy With Internal Limiting Membrane Transplants in the Closure of 2 Adjacent Macular Holes.

Purpose: Two adjacent macular holes (MHs), which were noted in the highly myopic left eye of an 85-year-old woman, is an uncommon clinical presentation. This case report presents the successful closure of the 2 adjacent MHs using internal limiting membrane (ILM) transplants during vitrectomy that included. Methods: ILM transplants were placed within both MHs during vitrectomy that included ILM peeling and fluid gas exchange with 18% perfluoropropane (C3F8) and postoperative facedown positioning for 1 week. Results: Both MHs were successfully closed following surgery with improvement in vision and decrease in metamorphopsia. Conclusions: This case suggested that relief of traction by ILM peeling and placement of ILM transplants within both MHs to provide a scaffold and stimulate glial tissue proliferation may have facilitated closure of the 2 adjacent MHs, which is a difficult management problem to manage and not previously reported to the best of our knowledge.

Efficacy and safety of brolucizumab versus aflibercept in eyes with polypoidal choroidal vasculopathy in Japanese participants of HAWK.

PURPOSE: To compare the efficacy and safety of brolucizumab versus aflibercept in eyes with polypoidal choroidal vasculopathy (PCV) over 96 weeks in the HAWK study. DESIGN: HAWK was a global, 2-year, randomised, double-masked, multicentre phase III trial in participants with neovascular age-related macular degeneration. METHODS: Of the Japanese participants with PCV, 39 received brolucizumab 6 mg and 30 received aflibercept 2 mg. After 3 monthly loading doses, brolucizumab-treated eyes received an injection every 12 weeks (q12w) but were adjusted to q8w if disease activity was detected. Aflibercept-treated eyes received fixed q8w dosing. Mean change in best-corrected visual acuity (BCVA), the proportion of participants on q12w, retinal thickness, retinal fluid changes and safety were assessed to Week 96. RESULTS: Mean change in BCVA (early treatment diabetic retinopathy study (ETDRS) letters) from baseline to week 48/week 96 was+10.4/+11.4 for brolucizumab and +11.6/+11.1 for aflibercept. For brolucizumab-treated eyes, the probability of only q12w dosing after loading through week 48 was 76%, and 68% through week 96. Fluid resolution was greater with brolucizumab than aflibercept: respective proportions of eyes with intraretinal fluid and/or subretinal fluid were 7.7% and 30% at week 48% and 12.8% and 16.7% at week 96. Brolucizumab exhibited an overall well-tolerated safety profile despite a higher rate of intraocular inflammation compared with aflibercept. CONCLUSION: In Japanese eyes with PCV, brolucizumab q12w/q8w monotherapy resulted in robust and consistent BCVA gains that were comparable to q8w aflibercept dosing. Anatomical outcomes favoured brolucizumab over aflibercept, with 76% of brolucizumab participants maintained on q12w dosing after loading to week 48.

Closure of Full-Thickness Macular Holes Associated with Macular Edema with Medical Therapy.

PURPOSE: The purpose of this study was to report the closure of macular hole without surgery in 7 cases using medical therapies. METHODS: The retrospective review of 7 cases of full-thickness macular holes, which closed after medical therapy without surgery. RESULTS: Seven eyes of 7 patients developed full-thickness macular holes, which initially closed on medical therapy without surgery. Six patients were kept on maintenance therapy; 1 recurred and 5 did not develop recurrence. One patient was taken off of maintenance therapy and later developed recurrent macular hole requiring macular hole surgery. CONCLUSIONS: Medical therapy to decrease macular edema may facilitate macular hole closure and should be considered, especially for small macular holes with significant edema. Reopening of macular holes may occur after stopping topical maintenance therapy for macular edema, which occurred at 10 weeks and 9 months after maintenance therapy was discontinued or markedly tapered.

The First Epiretinal Implant for Hereditary Blindness in the Asia-Pacific Region.

In February 2013, the Argus® II Retinal Prosthesis System (Second Sight Medical Products, Inc., Sylmar, CA, US) became the first "bionic eye" approved by the FDA to restore useful vision in patients previously blinded by end-stage retinitis pigmentosa, a hereditary, progressive degeneration of the outer retinal photoreceptor cells. The system captures and converts an external optical input into an electrical signal that activates an epiretinal electrode array on the inner surface of the retina. This signal bypasses dysfunctional photoreceptors and directly stimulates the functional inner retina, thus transmitting information to the visual cortex and creating artificial vision. This article describes the first implantation of the Argus II Retinal Prosthesis System in the Asia-Pacific region, which occurred in a deaf and blind 72-year-old Japanese American woman with Usher syndrome. At 57 months after her operation, the patient uses the device daily to perform visual tasks, and the microelectrode array remains in the proper position on the macula. This case demonstrates the long-term safety and efficacy of the Argus II epiretinal implant, which allowed a functionally blind patient to gain meaningful vision.

First Case of Subretinal Ocular Angiostrongyliasis Associated with Retinal Detachment in the United States.

Angiostrongylus cantonensis, commonly known as the rat lungworm, is mostly found in Asia, the Pacific Basin, and the Caribbean, but is also endemic in Hawai'i, especially on the Island of Hawai'i. Ocular angiostrongyliasis is an uncommon but previously reported complication associated with permanent vision loss. This is the first reported case of ocular angiostrongyliasis involving the retina or posterior segment of the eye in the US. A 24-year-old male from Chicago visited the Island of Hawai'i, where he worked on a farm and ate a vegetarian diet. When he returned to Chicago, he became sick and was hospitalized for eosinophilic meningitis. One month later, he developed a retinal detachment which required surgical repair involving a pars plana vitrectomy. During the reattachment of the retina during surgery, a live motile was identified nematode in the subretinal space. An endolaser probe immobilized and killed the nematode, and it was subsequently extracted through the sclerotomy. Thermal scars around all retinal holes including the retinotomy site were made to stabilize the retina, and perfluoropropane gas was injected to achieve temporary tamponade. Thereafter, the patient's cerebrospinal fluid returned positive for angiostrongylus cantonensis antibodies. During extended follow-up, the patient eventually lost all vision in the affected eye due to recurrent retinal detachment. This case of ocular angiostrongyliasis demonstrates the importance of obtaining travel history from endemic areas, knowing the risk of developing eosinophilic meningitis, and understanding the risk of permanent vision loss in cases involving the retina.

Long term observation of hydrogel buckle intrusion without vision loss.

Hydrogel buckle intrusion due to progressive swelling is a known complication, which usually requires surgical intervention due to vitreous hemorrhage, retinal detachment, or progressive encroachment into the optic nerve or macula. Hydrogel buckle surgery with successful retinal detachment repair was performed in this one-eyed physician in 1990, and there was slow progressive intrusion towards the macula and optic nerve without surgical intervention for 30 years and with visual acuity maintained at 20/40.

Differentiating Exudative Macular Degeneration and Polypoidal Choroidal Vasculopathy Using OCT B-Scan.

PURPOSE: Although polypoidal choroidal vasculopathy (PCV) is best diagnosed with indocyanine green angiography (ICGA), ICGA is often unavailable or not ordered. OCT is widely available, and OCT B-scan can visualize polypoidal lesions diagnostic of PCV as inverted U-shaped elevations of the retinal pigment epithelium (RPE) with heterogeneous reflectivity and sometimes ring-shaped lesions within the polypoidal lesion. This study aims to differentiate findings between eyes diagnosed with PCV or typical exudative age-related macular degeneration (AMD) using ICGA and then compares findings noted on the OCT B-scan line scan in each group. DESIGN: Retrospective, chart review. METHODS: Clinical features of eyes with PCV and typical exudative AMD were compared by using ICGA. Eyes with PCV were evaluated for inverted U-shaped polypoidal lesions, which are the main differentiating finding of PCV from typical exudative AMD. Data collected included presence of subretinal fluid (SRF), macular edema or intraretinal edema, subretinal hyperreflective material (SHRM), and retinal pigment epithelial detachment (RPED). These findings were evaluated in 2 parts: baseline and after 6 to 9 months of antiangiogenic therapy. Additionally, analysis was performed for the presence of polypoidal lesions before and after treatment. MAIN OUTCOME MEASURES: Presence of inverted U-shaped lesions on OCT B-scan following treatment. RESULTS: A total of 112 eyes of 106 patients were included. A total of 69 eyes were diagnosed with PCV, and 43 eyes were diagnosed with typical exudative AMD. Compared with AMD eyes, PCV eyes had an increased prevalence of SRF at baseline and after 6 to 9 months of treatment, but the prevalence of macular edema, SHRM, and RPED was similar at baseline and at 6 to 9 months after treatment. In PCV eyes, the presence of visible polypoidal lesions decreased from 56.5% to 24.6% after treatment. CONCLUSIONS: If PCV is suspected in an anti-vascular endothelial growth factor (VEGF)-resistant case of exudative AMD, in the absence of ICGA availability, it is important to look at the baseline OCT B-scan before therapy for evidence of polypoidal lesions. The characteristic inverted U-shaped elevation was present in more than half of PCV eyes on OCT B-scan at baseline but disappeared after antiangiogenic therapy in 56.4% of cases in which this was initially identified. Subretinal fluid was more prevalent in PCV eyes than non-PCV AMD eyes.

Long-Term Stability of Sutured Scleral Fixation of a Posterior Chamber Intraocular Lens With 10-0 Polypropylene for More Than 30 Years.

Purpose: We report the longest follow-up to our knowledge of stable scleral fixation of a posterior chamber intraocular lens (PC IOL) with 10-0 polypropylene sutures. Methods: A retrospective review is presented of a case with more than 30 years' follow-up after performing sutured scleral fixation with 10-0 polypropylene suture using 2 sutures tied together under a scleral flap. One suture was a cow-hitch looped around the haptic, and the other suture was passed through the sclera to create the scleral fixation. Results: The scleral fixation with 10-0 polypropylene suture knots for both haptics of the PC IOL allowed central optic positioning with excellent vision for more than 30 years without suture breakage. Conclusions: Polypropylene sutures for scleral fixation of PC IOLs remained stable for more than 30 years with central positioning of the PC IOL, without exposure of the fixation suture knots through the conjunctiva, and without suture breakage.

INVOLUTION OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION AFTER ENDOPHTHALMITIS.

PURPOSE: To report patients who demonstrated an alteration in the clinical and optical coherence tomography features of neovascular age-related macular degeneration after resolution of endophthalmitis. METHODS: Retrospective case series of the subsequent changes in the macula and need for anti-vascular endothelial growth factor therapy in patients with neovascular age-related macular degeneration who developed endophthalmitis after intravitreal injection. RESULTS: The study included seven eyes of seven patients with follow-up ranging between 3 months and 11 years. The vitreous cultures (n = 7) before intravitreal antibiotic injection were the following: culture-negative (4) and coagulase-negative Staphylococcus (3). Initial treatment included vitreous tap and injection (4) and pars plana vitrectomy (3). In 5/7 eyes, the optical coherence tomography showed resolution of subretinal fluid and serous pigment epithelial detachment, and there was no additional anti-vascular endothelial growth factor treatment administered. CONCLUSION: After successful treatment of endophthalmitis in patients with neovascular age-related macular degeneration, there was relative involution of the maculopathy and reduced anti-vascular endothelial growth factor treatment burden in this series.