SURGICAL OUTCOMES OF PARS PLANA VITRECTOMY FOR INTRAOCULAR COMPLICATIONS RELATED TO VASOPROLIFERATIVE TUMOR OF THE RETINA.

PURPOSE: To investigate the safety and efficacy of vitrectomy pars plana vitrectomy in managing intraocular complications relating to vasoproliferative tumors of the retina (VPL). METHODS: Retrospective study. 17 patients with VPL who underwent vitrectomy at Sheffield Teaching Hospital NHS Trust from 2005 to 2020 were included. Patient demographics, clinical characteristics, intraoperative data, and surgical outcomes were collected and evaluated. RESULTS: The mean age was 52 years. Indications for pars plana vitrectomy included epiretinal membrane (n = 7), vitreous hemorrhage (n = 5), retinal detachment (n = 3), diagnostic (n = 1), and others (n = 1). After pars plana vitrectomy, 14/17 (82.4%) have stabilized vision and 3/17 (17.6%) deteriorated. Subgroup analysis of epiretinal membrane peel had good outcomes with 6/7 (85.7%) noticing improvement or stabilization of symptoms and mean logarithm of minimal angle of resolution visual acuity improved from 0.719 [6/30] ± 0.267 [6/12] to 0.476 [6/19] ± 0.271 [6/12]. Patients undergoing surgery for vitreous hemorrhage also had good outcomes with resolution (and no recurrence) of the hemorrhage in 3/5 (60%) and 5/5 (100%) with one or more surgeries, respectively. Outcomes for retinal detachment surgery were logarithm of minimal angle of resolution 2.126 [HM] ± 0.301 [6/12] preoperatively and 1.185 [6/95] ± 0.522 [6/19] postoperatively, with one recurrence of retinal detachment. In the epiretinal membrane group, three patients had adjunctive treatment for VPL intraoperatively and four patients had none, and no difference found between the two groups in outcome or complications. Tumor with thickness of ≥2 mm exhibited inferior visual outcomes compared with <2 mm ( P < 0.05). CONCLUSION: This is one of the largest data sets in looking at outcomes of vitrectomy for complications of VPL. Pars plana vitrectomy is effective and safe in managing VPL-related intraocular complications with good outcomes and a low rate of complications, especially for patients with epiretinal membrane and vitreous hemorrhage.

Early vitrectomy in eyes with non-diabetic vitreous hemorrhage.

Background: Optimal management of non-diabetic vitreous hemorrhage (NDVH) is controversial, and reliability of B-scan ultrasonography in detecting retinal tears (RTs) has been reported to be highly variable by previous literature. Objectives: To report outcomes of conservative versus surgical management of NDVH and reliability of B-scan ultrasonography in detecting RTs and rhegmatogenous retinal detachment (RRD). Design: Retrospective observational single-center cohort study. Methods: Ninety-six consecutive NDVH from 96 eyes (96 patients) with minimum follow-up duration of 12 months were included. Results: Seventy-two eyes (75%) underwent early pars plana vitrectomy (PPV), 19 (20%) were managed conservatively and 5 (5%) underwent late PPV. Initial mean best corrected visual acuities (BCVAs) were 1.95 ± 1.19, 1.19 ± 1.38, and 1.14 ± 1.04 logMAR respectively, the difference was statistically significant (p = 0.039). Mean final BCVAs were 0.92 ± 1.19, 0.59 ± 0.87, and 1.25 ± 1.89 logMAR, respectively, the difference was not significant (p = 0.447). When comparing initial and final BCVAs, the difference was significant only in the early PPV group (p = 0.00001) and was not significant in the conservative group (p = 0.066) and in the late PPV group (p = 0.46). Complications included RRD (n = 2) and re-bleed in vitrectomized cavity (n = 1) in the early surgical group, need for additional laser or cryoretinopexy to RTs (n = 2), retinal detachment (n = 1), neovascular glaucoma (n = 1), persistent vitreous hemorrhage (n = 2) in the conservative group. B-scan ultrasound showed preoperative 11.53% sensitivity and a 60.0% positive predictive value for diagnosing retinal tears (RTs) in NDVH. Conclusion: The benefit of early PPV in NDVH seems to outweigh the risks of surgery, especially in the context of low sensitivity of B-scan in identifying RTs, and significant improvement in final BCVA following surgery may occur. NDVH should be promptly referred to vitreoretinal services, as surgery may be a safer and more advisable option.

STRUCTURAL AND FUNCTIONAL MACULAR CHANGES AFTER RETINECTOMY FOR RETINAL DETACHMENT COMPLICATED BY PROLIFERATIVE VITREORETINOPATHY.

PURPOSE: To report anatomical and functional outcomes of nonprimary retinectomy for rhegmatogenous retinal detachment with Grade C proliferative vitreoretinopathy, to assess the structural and functional macular changes in successful eyes. METHODS: Retrospective single-center cohort study: one hundred-one consecutive retinectomies of 101 eyes affected by rhegmatogenous retinal detachment with C proliferative vitreoretinopathy between January 2014 and February 2020 were included. RESULTS: The mean preoperative best-corrected visual acuity (BCVA) was 1.48 ± 0.71 logarithm of the minimal angle of resolution (20/604 Snellen equivalent). The anatomical success rate was 78.2% after one retinectomy and 83.1% after two retinectomies. The final BCVA ≥ 20/200 was achieved in 29% of cases, 8% gained ≥ 20/80. The final mean postoperative BCVA of successes with oil in situ was 1.68 ± 0.59 (20/957 Snellen equivalent) compared with 1.07 ± 0.63 logarithm of the minimal angle of resolution (20/235 Snellen equivalent) of successes after oil removal (P = 0.00005). Postoperative macular optical coherence tomography was obtained from 60/84 successes (71%). The normal macular profile was found in 3%, whereas majority demonstrated exudative maculopathy (51.5%), macular atrophy (22%), tractional maculopathy (21.5%), and macular disciform scar (2%). Bivariate linear relationship between final central foveal thickness and BCVA was statistically significant (P = 0.000013). CONCLUSION: Satisfactory anatomical and functional outcome is possible after retinectomy for C proliferative vitreoretinopathy. Positive prognostic factors include the removal of oil without redetachment, normal macular status, and lower central foveal thickness. The functional outcome was influenced by macular changes, as final BCVA and central foveal thickness correlated.

Cystoid Macular Oedema as a Presenting Feature of Vitreoretinal Lymphoma.

A 69-year-old female presented with right vitreous cells and cystoid macular oedema (CMO). One year previously, she had received two cycles of attenuated methotrexate-based chemotherapy for primary central nervous system (CNS) lymphoma, abandoned due to toxicity. There was no past ocular history of note aside from mild cataract. Due to her history of previous CNS lymphoma, we suspected vitreoretinal lymphoma (VRL), but the presence of the CMO made this unlikely. She underwent a diagnostic vitrectomy. Histology and immunohistochemistry showed the presence of a high-grade B-cell VRL.

Cutaneous Malignant Melanoma Metastasis to the Pseudophakic Lens Capsule with Associated Granulomatous Intraocular Inflammation.

Intraocular cutaneous melanoma metastasis (ICMM) is a rare event, accounting for only 5% of all metastases to the eye and orbit. The vast majority of such metastases primarily affect the choroid and vitreoretinal structures. Only three previous cases of predominant lens structure ICMM have been reported in the literature. Histological examination, in all three past cases, was performed on enucleation specimens of painful blind eyes. We present the first case of ICMM to the lens capsule in a comfortable, seeing, pseudophakic eye. This was histologically confirmed following diagnostic pars plana vitrectomy and capsulotomy, and was found to be associated with background granulomatous intraocular inflammation. The potential causes of the granulomatous inflammation are discussed.

Paraneoplastic Granulomatous Vitritis: Elaboration of 8 Cases.

PURPOSE: To describe the clinical features in a series of 8 patients with cytologically proven granulomatous vitritis in the context of systemic malignancy. DESIGN: Retrospective case review series from 2004 through 2018 to identify all cases of cytologically proven granulomatous vitritis and to analyze its disease associations and causes. PARTICIPANTS: Twenty-three patients with a cytologic diagnosis of granulomatous vitritis were identified, 8 of whom demonstrated systemic malignancy. MAIN OUTCOME MEASURES: To identify a clinical profile of the 8 cases of granulomatous vitritis occurring in the setting of systemic malignancy, focusing on the timing of the eye presentation compared with the timing of the systemic malignancy. METHODS: Patients with a cytologic diagnosis of granulomatous vitritis seeking treatment from 2004 through 2018 were included in this retrospective case series. Case notes were recalled and reviewed for demographic features, medical history, presenting symptoms, investigations, surgical procedures, and follow-up. RESULTS: Twenty-three patients were diagnosed cytologically with granulomatous vitritis. Ten of 23 patients (43%) showed autoimmune and infectious causes, 5 of 23 patients (22%) showed were idiopathic causes, and 8 of 23 patients' (35%) disease was associated with systemic malignancy. In the latter group, the median age at presentation was 70 years (range, 55-89 years). Six patients showed bilateral disease, and the remaining 3 showed unilateral disease. Three of 8 patients showed primary systemic malignancy diagnosed after eye symptoms and 5 of 8 showed malignancy before the eye symptoms. These latter 5 patients all demonstrated a major relapse, metastasis, or both at the time of eye symptoms. CONCLUSIONS: Paraneoplastic vitritis is primarily a disease of older age, with 67% of those affected older than 65 years. Ophthalmologists should maintain a high index of suspicion of paraneoplastic cause in bilateral posterior segment inflammation of uncertain origin, presenting for the first time, or heralding malignancy recurrence or metastasis in known cases of malignancy.

The Epidemiology of Stargardt Disease in the United Kingdom.

PURPOSE: To establish the incidence of Stargardt disease (STGD) in the United Kingdom and define baseline characteristics of newly diagnosed patients. DESIGN: Prospective epidemiologic study undertaken under the auspices of the British Ophthalmological Surveillance Unit (BOSU). PARTICIPANTS: New incident cases of STGD in the United Kingdom reported by ophthalmologists to BOSU during a 12-month period, from June 1, 2012, to June 1, 2013. METHODS: Once a new case of STGD was reported, an incident questionnaire was sent to the reporting ophthalmologist, followed by a follow-up questionnaire (when required) 6 months later. MAIN OUTCOME MEASURES: Patient demographics, baseline characteristics including visual acuity, and findings on slit-lamp biomicroscopy, as well as diagnostic technologies undertaken at baseline and their findings, including electrophysiology, fundus autofluorescence, fluorescein angiography, and genetic testing. RESULTS: A total of 81 new cases of STGD were reported during the 12-month period of the study; baseline data were obtained on 70 (86%) of these. These results suggest an annual incidence in the United Kingdom of between 0.110 and 0.128 per 100 000 individuals. The median age of patients at presentation was 27 years, the majority were British (77%), and most (90%) were symptomatic, with a median visual acuity of 0.52 logMAR (Snellen equivalent 20/66). CONCLUSIONS: Even considering possible limitations related to incomplete ascertainment, this is the first prospective epidemiology study that provides indication of the incidence of STGD in the United Kingdom. The incidence of STGD estimated herein appears to be lower than that repeatedly quoted in the literature. Fundus autofluoresence and electrophysiology testing are most commonly used for the evaluation of patients with STGD.

Vitrectomy with internal limiting membrane peeling versus no peeling for idiopathic full-thickness macular hole.

OBJECTIVE: To determine whether internal limiting membrane (ILM) peeling improves anatomic and functional outcomes of full-thickness macular hole (FTMH) surgery when compared with the no-peeling technique. DESIGN: Systematic review and individual participant data (IPD) meta-analysis undertaken under the auspices of the Cochrane Eyes and Vision Group. Only randomized controlled trials (RCTs) were included. PARTICIPANTS AND CONTROLS: Patients with idiopathic stage 2, 3, and 4 FTMH undergoing vitrectomy with or without ILM peeling. INTERVENTION: Macular hole surgery, including vitrectomy and gas endotamponade with or without ILM peeling. MAIN OUTCOME MEASURES: Primary outcome was best-corrected distance visual acuity (BCdVA) at 6 months postoperatively. Secondary outcomes were BCdVA at 3 and 12 months; best-corrected near visual acuity (BCnVA) at 3, 6, and 12 months; primary (after a single surgery) and final (after >1 surgery) macular hole closure; need for additional surgical interventions; intraoperative and postoperative complications; patient-reported outcomes (PROs) (EuroQol-5D and Vision Function Questionnaire-25 scores at 6 months); and cost-effectiveness. RESULTS: Four RCTs were identified and included in the review. All RCTs were included in the meta-analysis; IPD were obtained from 3 of the 4 RCTs. No evidence of a difference in BCdVA at 6 months was detected (mean difference, -0.04; 95% confidence interval [CI], -0.12 to 0.03; P=0.27); however, there was evidence of a difference in BCdVA at 3 months favoring ILM peeling (mean difference, -0.09; 95% CI, -0.17 to-0.02; P=0.02). There was evidence of an effect favoring ILM peeling with regard to primary (odds ratio [OR], 9.27; 95% CI, 4.98-17.24; P<0.00001) and final macular hole closure (OR, 3.99; 95% CI, 1.63-9.75; P=0.02) and less requirement for additional surgery (OR, 0.11; 95% CI, 0.05-0.23; P<0.00001), with no evidence of a difference between groups with regard to intraoperative or postoperative complications or PROs. The ILM peeling was found to be highly cost-effective. CONCLUSIONS: Available evidence supports ILM peeling as the treatment of choice for patients with idiopathic stage 2, 3, and 4 FTMH.

Vitrectomy with internal limiting membrane (ILM) peeling versus vitrectomy with no peeling for idiopathic full-thickness macular hole (FTMH).

BACKGROUND: Several observational studies have suggested the potential benefit of internal limiting membrane (ILM) peeling to treat idiopathic full-thickness macular hole (FTMH). However, no strong evidence is available on the potential benefit(s) of this surgical manoeuvre and uncertainty remains among vitreoretinal surgeons about the indication for peeling the ILM, whether to use it in all cases or in long-standing and/or larger holes.  OBJECTIVES: To determine whether ILM peeling improves anatomical and functional outcomes of macular hole surgery compared with the no-peeling technique and to investigate the impact of different parameters such as presenting vision, stage/size of the hole and duration of symptoms in the success of the surgery. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) which contains the Cochrane Eyes and Vision Group Trials Register (The Cochrane Library 2013, Issue 2), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to February 2013), EMBASE (January 1980 to February 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to February 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We searched the reference lists of included studies for any additional studies not identified by the electronic searches. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 28 February 2013.We searched reference lists of the studies included in the review for information about other studies on ILM peeling in macular hole surgery. We searched Proceedings for the following conferences up to February 2013: American Academy of Ophthalmology (AAO), Annual Meeting of the American Society of Retina Specialists (ASRS), Annual Meeting of the Retina Society, Congress of the Asia-Pacific Academy of Ophthalmology (APAO), European Association for Vision and Eye Research (EVER) Annual Congress, European Vitreoretinal Society (EVRS) Annual Meeting, Association for Research in Vision and Ophthalmology (ARVO) Meeting, International Vitreoretinal Meeting, and World Ophthalmology Congress. SELECTION CRITERIA: Only randomised controlled trials (RCTs) comparing ILM peeling with the no-peeling counterpart were included. DATA COLLECTION AND ANALYSIS: Two review authors (KSC and NL) independently assessed the titles and abstracts of all RCTs identified by electronic and manual searches.We obtained Individual patient data (IPD) from three of the four identified eligible trials. The fourth identified RCT had only been published in abstract form and no IPD were available; we included data from this published abstract for one outcome (macular hole closure).The primary outcome was distance visual acuity at six months. Secondary outcomes included distance and near  visual acuity at three and 12 months postoperatively, near visual acuity at six months postoperatively, primary (after a single surgery) and final (following more than one surgery) macular hole closure, need for additional surgical interventions, vision-related quality of life and intraoperative and postoperative complications.We performed meta-analysis using standard techniques (the Mantel-Haenszel odds ratio (OR) for binary outcomes, mean difference (MD) for continuous outcomes) using a fixed-effect model. For two outcomes we also used the IPD to perform adjusted analyses using regression methods. MAIN RESULTS: We identified and included four RCTs; these were conducted in Denmark, France, Hong Kong and the United Kingdom/Republic of Ireland and randomised 47, 80, 49 and 141 participants respectively.There was no evidence of a difference in the primary outcome (distance visual acuity at six months), nor in distance visual acuity at 12 months between randomised groups. However, there was evidence of improved best corrected distance visual acuity in the ILM peeling group at three months (WMD -0.09, 95% CI -0.17 to -0.02). We found no evidence for a difference in near vision between groups at any of the time points investigated.Overall, more participants in the ILM peeling group than in the no-peeling group had primary macular hole closure (OR 9.27, 95% CI 4.98 to 17.24); this held true when results were stratified by the stage of the macular hole. There was also evidence that those in the ILM peeling group were more likely to have final macular hole closure (OR 3.99, 95% CI 1.63 to 9.75). Fewer participants required further surgery in the ILM peeling group than in the no-peeling group (OR 0.11, 95% CI: 0.05 to 0.23).Rates of intraoperative and postoperative complications were similar in both groups.Based on the results of one study, there was no evidence that total VFQ-25 or EQ-5D scores differed between the groups at six months.  Based on this same study, ILM peeling is highly likely to be cost-effective. AUTHORS' CONCLUSIONS: Although we found no evidence of a benefit of ILM peeling in terms of the primary outcome (visual acuity at six months), ILM peeling appears to be superior to its no-peeling counterpart as it offers more favourable cost effectiveness by increasing the likelihood of primary anatomical closure and subsequently decreasing the likelihood of further surgery, with no differences in unwanted side-effects compared with no peeling. 

The short- and long-term effects on the visual system of children following exposure to maternal substance misuse in pregnancy.

PURPOSE: To document the prevalence of ophthalmic morbidities in babies born to mothers who misused substances in pregnancy and to assess whether it changes over 5 years. DESIGN: Retrospective comparative case series. METHODS: The series included: (1) a retrospective review of 301 children born between 2000 and 2004 to mothers misusing substances during pregnancy; (2) assessment at 5-year follow-up of this cohort; and (3) comparison with 7887 age-matched controls drawn from the preschool screening cohort in the north of Scotland in the same time period. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Following data collection in both patient and control groups, the following were calculated: (1) rate of referral to the ophthalmology department; (2) prevalence of nystagmus and strabismus at presentation in the study group and at 5 years of age in both patient and control group; (3) prevalence of reduced visual acuity and lack of stereopsis. RESULTS: Ophthalmology referrals, strabismus, and nystagmus were found to be statistically significantly higher in the study group compared with the control group. In the study group, at baseline referral, 46 of 301 (15.3%) had strabismus (2.8% in control group) and 11 of 301 (3.7%) nystagmus (0.004% in control group). At 5-year follow-up, the prevalence of strabismus was 14.0% (OR 5.70, 95% CI: 4.01-8.12) and that of nystagmus was 3.3% (OR 90.34, 95% CI 24.73-330.02). A total of 42.4% of these children at age 5 had no demonstrable binocular vision and 28.2% had visual acuity of 0.3 (logMAR) or worse in 1 or both eyes. Clinic attendance at last follow-up was poor (61.9%). CONCLUSIONS: Exposure to maternal drug misuse in utero is associated with a statistically significantly higher prevalence of strabismus and nystagmus. These abnormalities tend to persist at 5 years of age and are associated with long-term visual morbidity, such as lack of binocularity and poor visual acuity. Our study highlights the need for ophthalmologic surveillance of this population and supports attendance, as nonattendance may be linked to more problems with substance misuse in parents and greater pathology in the child.

Alternating Horner's syndrome in multiple sclerosis.

Horner's syndrome is well documented in multiple sclerosis (MS). However, alternating Horner's syndrome in MS had not been described before. Here, we report a possible first case of alternating Horner's syndrome in MS.

Combined amniotic membrane transplant and anterior stromal puncture in painful bullous keratopathy: clinical outcome and confocal microscopy.

OBJECTIVE: To report the outcomes of anterior stromal micropuncture (ASP) combined with amniotic membrane transplantation (AMT) in the management of painful bullous keratopathy (BK) with poor visual potential, and to assess amniotic membrane (AM) retention. DESIGN: Case series, retrospective review. PARTICIPANTS: Twelve eyes of 12 patients with BK causing intractable pain or discomfort and poor visual potential, treated between March 2006 and October 2008 at Gartnavel General Hospital, Glasgow. METHODS: Epithelial debridement was followed by ASP and the amniotic membrane was stabilized with a purse-string 10/0 nylon corneal suture and a bandage contact lens. During a mean follow-up of 67 weeks (range, 27-139 weeks), pain relief, epithelial healing, visual changes, confocal microscopy, and appearance of new bullae were evaluated. Success was defined as complete resolution or significant improvement in pain. RESULTS: Twelve eyes of 12 patients, mean age 61 years (range, 40-88 years), were identified. Corneal epithelial healing was complete in 11 eyes 1 month postoperatively. Pain and conjunctival inflammation resolved in 11 patients (91.67%) and improved from severe to mild in the remaining patient. Incorporation of the AMT was observed on slit-lamp biomicroscopy in all eyes and was confirmed using confocal microscopy at final follow-up. CONCLUSIONS: ASP combined with AMT is safe and effective, alleviates pain and discomfort, reduces ocular inflammation, and promotes epithelial healing and resolution of bullae in patients with BK with poor visual potential. There was long-term evidence of amniotic membrane graft retention in all eyes after the procedure, suggesting that ASP may improve the long-term retention rate of AM.