Combined epiretinal and internal limiting membrane retracting door flaps for large macular holes associated with epiretinal membranes.

PURPOSE: To assess the closure rate of large full-thickness macular holes (FTMH) associated with epiretinal membrane (ERM) with a combined epiretinal and internal limiting membrane retracting door flap. METHODS: Retrospective chart review of patients treated at a single tertiary retina practice between January 2017 and November 2019. Individuals with FTMH larger than 400 µm and co-diagnosis of ERM who underwent surgical repair with an ERM flap were included. Patients underwent pars plana vitrectomy with peeling of ERM that was positioned as a retracting door flap to cover the FTMH. Primary outcome was closure rate at 6 months following surgery. Final surgical success rate and visual acuity were secondary outcomes. RESULTS: Among 7 eyes of 7 patients, 6 eyes achieved primary surgical success and final surgical success rate was achieved in all 7 eyes with a large FTMH repaired with ERM flap. The mean minimum linear diameter of the FTMH was 681 µm ± 295. All patients had follow-up greater than 6 months, with a mean duration of 17 months (range 14-23 months). Visual acuity improved from a mean of 0.9 ± 0.3 logMar (20/160) before surgery to 0.3 ± 0.5 logMar (Snellen 20/40), postoperatively. CONCLUSION: Large FTMH with concurrent ERM that are managed with an ERM flap have high single-surgery success rate.

Current management strategies for atypical macular holes.

This review evaluates the current surgical management options for refractory and atypical macular holes (MH) and proposes a treatment paradigm for approaching complex cases. A review of literature was performed to deliver a thorough discussion of the epidemiology and pathophysiology of MH as well as the historic evolution of surgical management strategies. With this context established, an update on recent surgical advances for management of large, chronic, and highly myopic MH is provided. New small MH may be adequately treated with pars plana vitrectomy, while those ≥300 µm should undergo internal limiting membrane (ILM) peel. For MH ≥400 µm with risk factors for failure, primary intervention should involve creation of an ILM flap and various methods of flap creation are discussed. For very large MH ≥700 µm or in refractory cases, autologous retinal transplants and other recently proposed procedures should be considered. While typical MHs enjoy high initial surgical success rates, atypical and refractory MH require additional intraoperative and postoperative considerations to maximize surgical success and optimize vision. With many techniques at the surgeon's disposal, patient selection becomes critical to improving outcomes.

Paraneoplastic ocular sarcoidosis in the setting of recurrent rectal carcinoid tumor diagnosed by F18-fluorodeoxyglucose PET CT.

PURPOSE: Nuclear medicine imaging can provide a noninvasive means of distinguishing inflammatory mass lesions from oncologic intraocular tumors. OBSERVATION: We report a case of paraneoplastic ocular sarcoidosis with choroidal mass lesions that was initially concerning for choroidal metastasis of a primary carcinoid tumor. PET CT was utilized with two different tracers to characterize the choroidal mass as being FDG-avid, consistent with a sarcoid-like lesion, and lacking the Gallium (Ga-68) DOTATAE uptake of carcinoid tumor metastases. CONCLUSIONS AND IMPORTANCE: Functional imaging is valuable to distinguish clinically similar inflammatory verses oncologic intraocular pathology.

Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) Versus Standard of Care for Postsurgical Lagophthalmos and Exposure Keratopathy: Trends in Visual Outcomes.

PURPOSE: To compare baseline characteristics and visual acuity outcomes in patients treated with prosthetic replacement of the ocular surface ecosystem (PROSE) versus other standard-of-care (SOC) treatments for postsurgical lagophthalmos and exposure keratopathy. METHODS: An institutional review board-approved, retrospective cohort study of 45 consecutive patients (53 eyes) with postsurgical lagophthalmos and exposure keratopathy following oculoplastic or skull base surgeries treated between August 2011 and August 2017 was performed. Patients treated with PROSE (22 patients, 27 eyes) were identified by referrals made to the PROSE treatment program at Weill Cornell Medical College. Patients treated with SOC treatments (23 patients, 26 eyes) were identified by International Classification of Diseases-9 and International Classification of Diseases-10 search of billing records. SOC treatments included ocular surface lubrication (artificial tears and/or punctal plugs), tape tarsorrhaphy and/or moisture chamber, or surgical correction. The primary outcome measure was best-corrected visual acuity converted to logMAR at baseline and at 1, 3, 6, and 12 months. Secondary outcome measures were subjective patient reports of improvement in vision and comfort, as well as presence of punctate epithelial erosions and/or corneal haze on slit-lamp examination before and after treatment. RESULTS: Average age for all patients was 52 ± 22 years (range: 7-87). Twenty-eight (62%) of total patients were male. Baseline corrected logMAR visual acuity was 0.58 ± 0.40 (20/76) for PROSE and 0.27 ± 0.39 (20/37) for SOC cohorts (p < 0.001). Mean number of failed prior treatments was 8.3 ± 3 for PROSE and 2.1 ± 2 for SOC (p < 0.0001). Mean difference in logMAR visual acuity for PROSE versus SOC, respectively, from baseline to 1 month was 0.33 ± 0.26 (3-line improvement) versus 0.01 ± 0.17 (no line improvement; p < 0.0001), to 3 months was 0.31 ± 0.23 (3-line improvement) versus 0.08 ± 0.30 (4-letter improvement; p = 0.0004), to 6 months was 0.31 ± 0.28 (3-line improvement) versus 0.10 ± 0.36 (1-line improvement; p = 0.02), and to 12 months was 0.32 ± 0.28 (3-line improvement) versus 0.12 ± 0.34 (1-line improvement; p = 0.01). CONCLUSIONS: Patients with postsurgical lagophthalmos and exposure keratopathy treated with PROSE are more likely to have failed a higher number of treatments and have worse initial best-corrected visual acuities than those treated with SOC. Prosthetic replacement of the ocular surface ecosystem causes rapid and substantial visual improvement within 1 month of use compared with SOC, with little change beyond this time and sustained best-corrected visual acuity at 3, 6, and 12 months after treatment.

A novel optic nerve photograph alignment and subtraction technique for the detection of structural progression in glaucoma.

PURPOSE: To highlight changing features over time within a single static image through the auto-alignment and subtraction of serial optic nerve photographs. METHODS: Subtraction maps were generated from auto-aligned (EyeIC, Narbeth, PA) baseline and follow-up images using Adobe Photoshop software. They demonstrated progressive retinal nerve fibre layer (RNFL) defects, optic disc haemorrhage (DH), neuroretinal rim loss (RL) and peripapillary atrophy (PPA). A masked glaucoma specialist identified features of progression on subtraction map first, then assessed feature strength by comparison with original images using alternation flicker. Control images with no progression and parallax-only images (as determined by flicker) were included. RESULTS: Eighty eyes of 67 patients were used to generate subtraction maps that detected glaucoma progression in 87% of DH (n = 28, sensitivity (Se) 82%, specificity (Sp) 98%) and 84% of PPA (n = 30, Se 80%, Sp 98%) cases. The lowest rate of detection was seen with RL at 67% (n = 31, Se 65%, Sp 100%). The subtraction technique was most sensitive for detecting parallax (n = 39, Se 98%, Sp 94%). Features of glaucoma progression appeared equally strong in flicker and subtraction images, but parallax was often enhanced on subtraction maps. Among control images selected for absence of features of glaucomatous change (n = 9) in original flicker images, no features were detected on subtraction maps. CONCLUSIONS: Auto-alignment and subtraction of serial optic nerve photographs reliably detects features of glaucoma progression with a single static image. Parallax identification may also be facilitated. Auto-alignment and subtraction of serial optic nerve photographs may prove especially useful in education and printed publications when dynamic imaging is not feasible.

Association of blood and ocular perfusion pressure with structural glaucomatous progression by flicker chronoscopy.

BACKGROUND: Vascular risk factors have been associated with glaucomatous visual field progression. AIM: We determined the relationship between vascular risk factors and structural glaucomatous progression using serial flicker chronoscopy images. METHODS: Two glaucoma fellowship-trained ophthalmologists, masked to temporal sequence, independently graded serial flicker chronoscopy images from one eye of a cohort of glaucoma patients for features of structural progression in this retrospective cohort study. After adjudication, simple and multiple logistic models were constructed to determine variables associated with increased odds of progression, including systolic blood pressure (BP), diastolic BP and mean ocular perfusion pressure. RESULTS: Seventy-two eyes of 72 patients were analysed. Patients with any form of structural progression (n=40) were older (67.0 vs 58.8 years; p=0.005) and had lower diastolic BP (71.8 vs 76.5 mm Hg; p=0.02) than patients without progression (n=32). In the univariable model, diastolic BP was associated with progressive retinal nerve fibre layer (RNFL) loss (OR=0.2 per 10 mm Hg, 95% CI 0.1 to 0.6, p<0.006) and neuroretinal rim loss (OR=0.4 per 10 mm Hg, 95% CI 0.2 to 0.8, p<0.01). Diastolic BP was also significant in the multivariable model for RNFL loss (p=0.009) and neuroretinal rim loss (p=0.003). CONCLUSIONS: This study is the first to use structural progression and flicker chronoscopy to identify vascular glaucoma risk factors. Older age and lower diastolic BP were associated with progression. By multivariable analysis diastolic BP was associated with RNFL and neuroretinal rim loss. These findings suggest that diastolic BP is associated with structural glaucomatous progression which may have implications for management.

Brain photoreceptor pathways contributing to circadian rhythmicity in crayfish.

Freshwater crayfish have three known photoreceptive systems: the compound eyes, extraretinal brain photoreceptors, and caudal photoreceptors. The primary goal of the work described here was to explore the contribution of the brain photoreceptors to circadian locomotory activity and define some of the underlying neural pathways. Immunocytochemical studies of the brain photoreceptors in the parastacid (southern hemisphere) crayfish Cherax destructor reveal their expression of the blue light-sensitive photopigment cryptochrome and the neurotransmitter histamine. The brain photoreceptors project to two small protocerebral neuropils, the brain photoreceptor neuropils (BPNs), where they terminate among fibers expressing the neuropeptide pigment-dispersing hormone (PDH), a signaling molecule in arthropod circadian systems. Comparable pathways are also described in the astacid (northern hemisphere) crayfish Procambarus clarkii. Despite exhibiting markedly different diurnal locomotor activity rhythms, removal of the compound eyes and caudal photoreceptors in both C. destructor and P. clarkii (leaving the brain photoreceptors intact) does not abolish the normal light/dark activity cycle in either species, nor prevent the entrainment of their activity cycles to phase shifts of the light/dark period. These results suggest, therefore, that crayfish brain photoreceptors are sufficient for the entrainment of locomotor activity rhythms to photic stimuli, and that they can act in the absence of the compound eyes and caudal photoreceptors. We also demonstrate that the intensity of PDH expression in the BPNs varies in phase with the locomotor activity rhythm of both crayfish species. Together, these findings suggest that the brain photoreceptor cells can function as extraretinal circadian photoreceptors and that the BPN represents part of an entrainment pathway synchronizing locomotor activity to environmental light/dark cycles, and implicating the neuropeptide PDH in these functions.

Arabidopsis thaliana leaves with altered chloroplast numbers and chloroplast movement exhibit impaired adjustments to both low and high light.

The effects of chloroplast number and size on the capacity for blue light-dependent chloroplast movement, the ability to increase light absorption under low light, and the susceptibility to photoinhibition were investigated in Arabidopsis thaliana. Leaves of wild-type and chloroplast number mutants with mean chloroplast numbers ranging from 120 to two per mesophyll cell were analysed. Chloroplast movement was monitored as changes in light transmission through the leaves. Light transmission was used as an indicator of the ability of leaves to optimize light absorption. The ability of leaves to deal with 3 h of high light stress at 10 degrees C and their capacity to recover in low light was determined by measuring photochemical efficiencies of PSII using chlorophyll a fluorescence. Chloroplast movement was comparable in leaves ranging in chloroplast numbers from 120 to 30 per mesophyll cell: the final light transmission levels after exposure to 0.1 (accumulation response) and 100 micromol photons m(-2) s(-1) (avoidance response) were indistinguishable, the chloroplasts responded quickly to small increases in light intensity and the kinetics of movement were similar. However, when chloroplast numbers per mesophyll cell decreased to 18 or below, the accumulation response was significantly reduced. The avoidance response was only impaired in mutants with nine or fewer chloroplasts, both in terms of final transmission levels and the speed of movement. Only mutants lacking both blue light receptors (phot1/phot2) or those with drastically reduced chloroplast numbers and severely impacted avoidance responses showed a reduced ability to recover from high light stress.