Advancements in Therapeutic Approaches for Proliferative Vitreoretinopathy: A Comprehensive Review.

Proliferative vitreoretinopathy (PVR) is a significant complication of retinal detachment surgery, characterized by the growth of fibrous membranes that can lead to recurrent retinal detachment and vision loss. This comprehensive review aims to summarize the latest advancements in the therapeutic approaches for PVR, encompassing historical perspectives, current surgical techniques, pharmacological interventions, biological and genetic therapies, and novel experimental treatments. Traditional surgical methods, such as vitrectomy, have been refined with advanced instrumentation and techniques to improve outcomes. Pharmacological treatments, including anti-inflammatory and anti-proliferative agents, are being explored to prevent and manage PVR. Emerging therapies, such as stem cell and gene therapy, offer promising new avenues for treatment. Despite these advancements, challenges remain in preventing recurrence and improving long-term outcomes. This review highlights the progress made and identifies areas for future research, emphasizing the importance of continued innovation to enhance patient care and reduce the burden of PVR.

Liquid Biopsy for Proliferative Diabetic Retinopathy: Single-Cell Transcriptomics of Human Vitreous Reveals Inflammatory T-Cell Signature.

Purpose: Current therapies for proliferative diabetic retinopathy (PDR) do not specifically target VEGF-independent, cell-type-specific processes that lead to vision loss, such as inflammatory pathways. This study aimed to identify targetable cell types and corresponding signaling pathways by elucidating the single-cell landscape of the vitreous of patients with PDR. Design: Case series. Subjects: Vitreous and peripheral blood obtained from 5 adult patients (6 eyes) undergoing pars plana vitrectomy for vision-threatening PDR. Methods: Single-cell RNA sequencing (scRNA-seq) was performed on vitreous cells obtained from diluted cassette washings during vitrectomy from 6 eyes and peripheral blood mononuclear cells (PBMCs, n = 5). Droplet-based scRNA-seq was performed using the Chromium 10x platform to obtain single-cell transcriptomes. Differences in tissue compartments were analyzed with gene ontology enrichment of differentially expressed genes and an unbiased ligand-receptor interaction analysis. Main Outcome Measures: Single-cell transcriptomic profiles of vitreous and peripheral blood. Results: Transcriptomes from 13 675 surgically harvested vitreous cells and 22 636 PBMCs were included. Clustering revealed 4 cell states consistently across all eyes with representative transcripts for T cells (CD2, CD3D, CD3E, and GZMA), B cells (CD79A, IGHM, MS4A1 (CD20), and HLA-DRA), myeloid cells (LYZ, CST3, AIF1, and IFI30), and neutrophils (BASP1, CXCR2, S100A8, and S100A9). Most vitreous cells were T cells (91.6%), unlike the peripheral blood (46.2%), whereas neutrophils in the vitreous were essentially absent. The full repertoire of adaptive T cells including CD4+, CD8+ and T regulatory cells (Treg) and innate immune system effectors (i.e., natural killer T cells) was present in the vitreous. Pathway analysis also demonstrated activation of CD4+ and CD8+ memory T cells and ligand-receptor interactions unique to the vitreous. Conclusions: In the first single-cell transcriptomic characterization of human vitreous in a disease state, we show PDR vitreous is primarily composed of T cells, a critical component of adaptive immunity, with activity and proportions distinct from T cells within the peripheral blood, and neutrophils are essentially absent. These results demonstrate the feasibility of liquid vitreous biopsies via collection of otherwise discarded, diluted cassette washings during vitrectomy to gain mechanistic and therapeutic insights into human vitreoretinal disease. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Traumatic retinal detachment: A contemporary update.

Retinal detachment following ocular trauma (TrRD) is one of the leading causes of blindness and visual impairment worldwide. In the absence of a standardized definition, the diagnosis of traumatic retinal detachment relies on identifying a history of trauma that precedes the detachment. There is an increasing pool of data regarding the etiology and epidemiology of TrRD.Various causes of TrRD mentioned in the literature include work-related eye trauma in construction and manufacturing industries, sports injuries, explosive eye injuries, road traffic accidents, and intraocular foreign bodies. Although there is extensive literature on post-trauma retinal detachments, a comprehensive discussion of its pathogenesis, management, outcomes, and complications is lacking. This article offers an in-depth review of the epidemiology, risk factors, pathogenesis, diagnosis, management, and outcomes of TrRD based on the current literature. A literature review was conducted in PubMed and Google Scholar using the keywords 'ocular trauma,' 'traumatic retinal detachments,' 'open globe injury,' 'closed globe injury,' and 'post-traumatic retinal detachment.'

Intravitreal Antibiotics versus Early Vitrectomy plus Intravitreal Antibiotics for Post-Injection Endophthalmitis: an IRIS® Registry (Intelligent Research in Sight).

PURPOSE: To determine if intravitreal injection of antibiotics alone versus early pars plana vitrectomy (PPV) plus injection of intravitreal antibiotics predicted better or worse visual outcomes for patients with endophthalmitis after anti-vascular endothelial growth factor (anti-VEGF) injections. DESIGN: Retrospective cohort study PARTICIPANTS: Patients developing endophthalmitis after receiving an intravitreal anti-VEGF injection from the American Academy of Ophthalmology IRIS® Registry between 2016 and 2020. METHODS: Inclusion criteria were endophthalmitis diagnosis within 1 to 28 days after anti-VEGF injection and a recorded visual acuity (VA) at baseline, on the day of diagnosis, and post-treatment. Patients in the Injection Only group underwent intravitreal injection of antibiotics alone and in the Early Vitrectomy group received PPV with intravitreal antibiotics or intravitreal injection followed by PPV within 2 days of diagnosis. Patients were excluded if they had cataract surgery during the study, intravitreal steroids before endophthalmitis, or intermediate/posterior uveitis or cystoid macular edema. The study created a 1:1 matched cohort using Mahalanobis Distance Matching, accounting for the differences in VA at baseline and diagnosis. MAIN OUTCOME MEASURES: Post-treatment logMAR VA RESULTS: 1,044 patients diagnosed with post-injection endophthalmitis met the inclusion and exclusion criteria. In the unmatched cohort, there were 935 patients in the Injection Only and 109 in the Early Vitrectomy group. In 1:1 matched cohort 218 patients (109 in each group) were included; the median logMAR VAs were 0.32 [20/40-20/50] at baseline, 0.88 [∼20/150] at diagnosis, and 0.57 [20/70-20/80] post-treatment. There were no statistically significant differences in the visual outcomes between the two matched treatment groups (b = 0.05, p = 0.23); including the subgroup of patients with VA worse than 1.0 logMAR (b = 0.05, p = 0.452). CONCLUSIONS: There was no significant difference in final VA outcomes between patients receiving Injection Only and those treated with Early Vitrectomy for post-injection endophthalmitis. The findings support the use of either treatment strategy.

Two cases of avulsed retinal vessel syndrome with different course.

Purpose: To report two cases of vitreous hemorrhage caused by avulsed retinal vessel syndrome (ARVS), one of which was successfully treated without vascular occlusion. Observations: A 62-year-old female presented with vitreous hemorrhage of unknown origin. We performed vitrectomy and found a detached and ruptured retinal vein below the optic nerve head. After coagulating the peripheral side of the blood vessel, we were able to prevent the recurrence of vitreous hemorrhage. However, she developed branch retinal vein occlusion and subsequently macular edema. In the other case, a 71-year-old woman also had vitreous hemorrhage, but the fundus was partially visible. The retinal vein in the superior nasal quadrant was detached from the retinal surface and bled into the vitreous cavity. We performed vitrectomy to relieve the vitreous traction. Although we did not coagulate the vein, there was no recurrence of vitreous hemorrhage after surgery. Conclusions and Importance: By releasing the vitreous traction with vitrectomy, we were able to treat the patient with ARVS without vascular occlusion.

A Recurrent Case of Full-Thickness Macular Hole After Successful Closure With Primary Vitrectomy and Epiretinal Proliferation Embedding.

Epiretinal proliferation (EP) is thought to be glial cell proliferation arising from the inner retina, seen in cases of lamellar or full-thickness macular holes (FTMH). Embedding EP within the macular hole is considered supportive for FTMH closure and functional recovery. We report a recurrent case of FTMH that was successfully closed after primary vitrectomy with the EP embedding technique. In the primary surgery, internal limiting membrane (ILM) peeling was avoided to reduce the potential risk of retinal nerve fiber layer damage associated with glaucoma. The FTMH was successfully closed, with complete recovery of macular layer structures. However, over one year later, the FTMH reopened, slightly dislocated from the position of the embedded EP scar. The reopened FTMH was closed again after the second surgery using the ILM inverted flap technique. This case indicates that macular hole closure with EP might not sufficiently support the tissue repair of FTMH as a new hole can form if tangential traction of the ILM remains.

Effect of anti-vascular endothelial growth factor on early-stage post-vitrectomy macular edema in patients with proliferative diabetic retinopathy.

PURPOSE: To investigate the effectiveness of anti-vascular endothelial growth factor (VEGF) therapy on post-vitrectomy macular edema (PVME) and determine the risk factors for PVME recovery. METHODS: This retrospective study included 179 eyes of 179 patients who underwent pars plana vitrectomy for proliferative diabetic retinopathy and developed PVME within 3 months after surgery. Eyes were grouped according to postoperative anti-VEGF treatment. RESULTS: Central retinal thickness (CRT) decreased significantly from baseline to 3-month follow-up in groups with (509.9 ± 157.2 µm vs. 401.2 ± 172.1 µm, P < 0.001) or without (406.1 ± 96.1 µm vs. 355.1 ± 126.0 µm, P = 0.008) postoperative anti-VEGF treatment. Best-corrected visual acuity (BCVA) did not differ between the two groups during follow-up. In the group not receiving anti-VEGF therapy, BCVA was significantly improved at 1, 2, and 3 months (P = 0.007, P < 0.001, and P < 0.001, respectively), while in the anti-VEGF group, BCVA was significantly improved at 1 and 3 months (P = 0.03 and P < 0.001). A thicker baseline CRT (ß = 0.44; 95% confidence interval, 0.26-0.61; P < 0.001) was significantly associated with decreasing CRT. CONCLUSION: PVME tends to spontaneously resolve in the early postoperative period. The effect of anti-VEGF therapy in the first 3 months after diagnosis appears to be limited.

Temperature control during pars plana vitrectomy.

PURPOSE: To evaluate the impact of temperature-controlled pars plana vitrectomy (PPV) on structural and functional outcomes in a rabbit eye model in vivo. METHODS: Ten healthy New Zealand White rabbits underwent temperature-controlled PPV in the right eye (group A), using a device specifically designed to heat the infusion fluid/air and integrated into the vitrectomy machine, and conventional PPV in the left eye (group B). Both eyes received ophthalmic examination and electroretinography (ERG) before and 1 week postoperatively. After 1-week ERG, rabbits were enucleated and then sacrificed. Histological and immunohistochemical examinations were performed on enucleated eyes and expression of glial fibrillary acidic protein (GFAP) and vimentin investigated. RESULTS: Postoperatively, only group B showed significantly decreased amplitude and increased latency of a-wave at 3 cd·s/m2 (p = 0.001 and 0.005, respectively). Significant increase of b-wave latency at 0.01 cd·s/m2 was detected in both groups (p = 0.019 and 0.023, respectively). Postoperatively, amplitude of oscillatory potentials (OPs) increased significantly in group A (p = 0.023) and decreased in group B. In both groups, OPs latency significantly increased at 1-week test (P < 0.05). A greater number of eyes without structural retinal alterations was detected in group A compared to group B (6 vs 5, respectively). GFAP expression was higher in group B than group A, even if the difference was not statistically significant. CONCLUSION: Temperature-controlled PPV resulted in more favorable functional and structural outcomes in rabbit eyes compared with conventional PPV, supporting the potential beneficial role of the intraoperative management of intraocular temperature in vitreoretinal surgery.

Ciliochoroidal Detachment After Intrascleral Lens Fixation Using the Yamane Technique.

PURPOSE: The purpose of this study was to compare the incidence of ciliochoroidal detachment (CCD) after intrascleral lens fixation using the Yamane technique and other vitrectomy procedures. METHODS: This retrospective study evaluated patients who underwent intrascleral lens fixation using the Yamane technique at Hiroshima University Hospital between March 2023 and February 2024 and who could be followed up for at least one month. Patients who underwent vitrectomy for macular disease without air-fluid exchange comprised the control group. The frequency of CCD was compared using anterior segment optical coherence tomography imaging. RESULTS: Forty-five eyes of 45 patients (26 men and 19 women, mean age 70.8 years) were included. There were no significant differences in the population means or proportions between the intrascleral fixation and control groups for age, sex ratio, right-to-left eye ratio, preoperative visual acuity, preoperative intraocular pressure (IOP), ocular axis, and corneal thickness. The population mean of IOP on the day after surgery was significantly lower in the Yamane intrascleral fixation group (8.4 mmHg) than in the control group (11.5 mmHg) (P < 0.05). There was no significant difference in the population proportions of CCD on the day after surgery between the Yamane intrascleral fixation group and the control group. However, the CCD incidence was 20 eyes (80%) for the Yamane intrascleral fixation group and 12 eyes (60%) for the control group, which was higher in the intrascleral fixation group. There was no significant difference in population means of IOP or population proportions of CCD at one week and one month. CONCLUSIONS: There was no significant difference in population proportions of CCD on the day after surgery, although the CCD rate for the Yamane intrascleral fixation group was higher, and the population mean of the IOP was significantly lower. The Yamane technique assumedly lowered IOP because of the stress placed on the ciliary body. One week after the procedure, the IOP in the intrascleral fixation group normalized.

Endophthalmitis caused by Hathewaya histolytica: A diagnostic dilemma.

A 76-year-old male presented with pain, redness, and decreased vision in the left eye for 5 days. The patient had undergone combined cataract extraction and vitrectomy for a macular hole 2 weeks back. The vision had reduced to the perception of light in the left eye. Clinical examination revealed lid edema, conjunctival congestion, hazy cornea, and exudative membrane in the pupillary axis with no view of the fundus. Ultrasound examination of the left eye showed plenty of moderate reflective dot echoes. The patient was diagnosed with postoperative endophthalmitis and underwent vitrectomy with intravitreal injection of antibiotics. Growth of Hathewaya histolytica was obtained from the vitreous sample. The organism was sensitive to imipenem. Three weeks following the presentation, visual acuity had improved to counting fingers at one meter in the left eye. This is the first report of endophthalmitis due to H. histolytica. Ophthalmologists should be aware of such ocular infections due to a rare microorganism.

Use of intravitreal antiviral injection during vitrectomy in the treatment of acute retinal necrosis: anatomic and visual outcomes.

PURPOSE: To investigate whether intravitreal antiviral injection (IAI) during vitrectomy reduces the postsurgical retinal detachment (RD) rate and improves the visual prognosis of patients with acute retinal necrosis (ARN). METHODS: This retrospective cohort study included ARN patients treated at a tertiary hospital between January 2013 and December 2020. Patients who underwent pars plana vitrectomy (PPV) alone or combined with intraoperative IAI were classified in PPV-only group and PPV + IAI group, respectively. The incidence of postsurgical RD and the best corrected visual acuity (BCVA) between the groups was compared. A multivariate Cox hazard analysis was employed to explore the risk factors of postsurgical RD. A multivariate logistic regression analysis was applied to assess the impact of intraoperative IAI on preventing severe vision loss (SVL). RESULTS: Fifty-seven eyes with ARN with a median follow-up of 18.5 months were included in the study. There was no significant association between intraoperative IAI during vitrectomy and a reduced risk of postsurgical RD (hazard ratio [HR], 2.65; 95% CI, 0.71-9.89) or SVL at the 6-month follow-up visit (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.25-3.35). Better baseline best-corrected visual acuity (BCVA) was identified to associate with a higher risk of postsurgical RD (HR, 0.33; 95% CI, 0.14-0.81) and a lower risk of SVL at 6 months (OR, 2.28; 95% CI, 1.10-4.89). CONCLUSION: We did not observe a significant effect of intraoperative IAI on the anatomic and visual outcomes of ARN patients in this study. Intraoperative IAI may not be a necessary treatment option for ARN patients who receive vitrectomy.

Late-onset capsular bag distension syndrome 33 years after cataract surgery.

Purpose: Describe the clinical features and management of this uncommon case of late-onset Capsular bag distension syndrome that occurred 33 years after cataract surgery. Observation: An 87-year-old male was referred to our clinic complaining of blurred and gradual, painless reduction in vision in his left eye over the past year. A complete ophthalmological examination, Ultrasound biomicroscopy (UBM), anterior segment optical coherence tomography (AS-OCT), and optical biometry were performed to confirm the diagnosis. A 25-gauge pars plana vitrectomy combined with posterior capsulotomy was performed. The aspirated fluid was sent for microbiological analyses. After surgery, the patient's visual acuity returned to previous values, and anterior chamber depth slightly deepened. Samples taken were negative for bacteria. Conclusions and Importance: Late-onset Capsular bag distension syndrome may occur up to 33 years following cataract surgery. A surgical approach offers the advantage of complete clearance of the turbid fluid, also removing the residual cortical material and enabling microbial and pathological testing.

Clinical outcomes of radial optic neurotomy versus pars plana vitrectomy in recent onset non-arteritic anterior ischemic optic neuropathy.

INTRODUCTION: This study investigated the effect of pars plana vitrectomy (VIT) versus pars plana vitrectomy combined with radial optic neurotomy (RON) on recent onset non-arteritic anterior ischemic optic neuropathy (NAION). METHODS: In this prospective interventional case series, individuals with recent-onset NAION, lower than one month and low vision (lower than 20/200) were recruited. Patients randomly underwent either VIT, or RON. RESULTS: 34 eyes of 34 patients were included in this study. 10, 9, and 15 eyes were randomly included in VIT, RON, and control groups, respectively. The BCVA of the VIT group improved significantly from 1.84 ± 0.5 logMAR at baseline to 1.29 ± 0.67, 0.93 ± 0.53, and 0.77 ± 0.47 logMAR at 1, 3, and 6 months, respectively (Ps < 0.05). The corresponding values for RON group were 1.73 ± 0.53 logMAR at baseline, which improved to 1.04 ± 0.65, 0.64 ± 0.28, and 0.61 ± 0.26 logMAR at the same follow-up visit times (P < 0.05).The corresponding values for the control group were 1.6 ± 0.58 log MAR at baseline, which improved to 1.03 ± 0.29, 1.00 ± 0.32, and 0.32 ± 0.83 log MAR at the same follow-up visit times. There was no significant statistical difference in BCVA between the three groups. However, both interventions resulted in statistically significant improvement in mean deviation (MD) of visual field (VF) compared with the control group at the end of 6 months (VIT P = 0.006, RON P = 0.043). RNFLT decreased from baseline 235.3 ± 44.01 to 75.6 ± 17.68 at 1 month in the VIT group (P < 0.001), from baseline 268.22 ± 65.9 to 76.67 ± 10.59 at 1 month in RON (P < 0.001), while it decreased from baseline 179.48 ± 39.02 to 112.92 ± 44.51 at 1 month in the control group. CONCLUSION: VIT and RON showed promising results in terms of MD of VF, and optic disc edema resolved faster in these groups compared to the control group in recent onset NAION. A larger sample size study is deemed necessary to generalize the results of this study.

Electroretinograms Recorded with Skin Electrodes from Post-Vitrectomy Silicone Oil Filled Eyes with Proliferative Diabetic Retinopathy.

Purpose: To determine the physiological status of the retina by electroretinography (ERG) using skin electrodes and the RETevalTM system in eyes that had undergone pars plana vitrectomy (PPV) with silicone oil (SO) tamponade. The vitrectomy was performed for a retinal detachment and proliferative diabetic retinopathy (PDR). Design: Retrospective case series. Methods: ERGs were recorded with the RETevalTM system (LKC Technologies Inc. Gaithersburg, MD; Welch Allyn, Inc. Skaneateles Falls, NY) from eight eyes with PDR before and after the SO removal. The amplitudes and implicit times of the a- and b-waves of the ERGs before the SO removal were compared to that after the SO removal. Results: ERGs were recordable in four eyes before and after the SO removal and the a- and b-amplitudes improved in three eyes and worsened in one eye after the SO removal. In the remaining four eyes, ERGs were non-recordable both before and after the SO removal. Conclusion: These results indicate that ERGs picked up by skin electrodes can be used to assess the physiology of the retina in eyes with a SO tamponade. The flat ERGs in the SO-filled eye indicated the presence of diffuse retinal damage which was confirmed by the flat ERGs after the SO removal.

There has been an increasing number of reports on evaluating the retinal function using electroretinography (ERG) with skin electrodes. The main advantage of this system is the ability to record ERGs with a skin electrode that does not touch the cornea and ocular surface. This reduces the risk of infection especially in the postoperative period and in clinical situations where infection is suspected. In addition, there have been only a few reports evaluating the function of the retina by ERG in SO-filled eyes. We recorded ERGs with the RETeval (LKC Technologies Inc. Gaithersburg, MD; Welch Allyn Inc. Skaneateles Falls, NY) device, a relatively new ERG recording system that uses skin electrodes and is less invasive. We recorded ERGs from eight SO-filled eyes with proliferative diabetic retinopathy (PDR). In 4 SO filled eyes, the amplitudes increased in three eyes after the SO removal. In the other four eyes, ERGs were non-recordable before and after the SO removal. These results suggest that the RETeval system that uses skin electrodes can be used to assess the retinal function in PDR eyes with a SO tamponade. We suggest that the absence of ERGs in the SO filled eyes was not due to the electrical non-conductive effects of SO but may indicate the presence of diffuse retinal damage which was confirmed after the SO removal.

A novel approach to remove retained lens material: Suction-assisted elevation and anterior chamber phacoemulsification.

PURPOSE: To describe and evaluate the feasibility of a novel pars plana vitrectomy (PPV) technique for the removal of retained lens material (RLM), which obviates the need for either 20-gauge intravitreal fragmentation or perfluorocarbon-assisted elevation. METHODS: Interventional case series. After thorough 23-gauge PPV, the hard lens material is engaged and held adherent to the vitreous cutter using aspiration, then raised into the anterior chamber. There, a standard phacoemulsification probe, inserted through a corneal incision, is used to fragment and remove the material. RESULTS: Three eyes of 3 patients were operated on. In all eyes, RLM could be removed completely. Postoperatively, 2 of 3 eyes (67%) achieved 20/20 best-corrected visual acuity. No complications such as glaucoma, cystoid macular edema, corneal edema, or retinal detachments were recorded. Intraoperatively, retinal tears were detected in 2 of 3 (67%) eyes and treated with endolaser retinopexy and fluid-air exchange. One eye subsequently developed macular hole requiring further surgery. CONCLUSION: Suction-assisted lens elevation may be a viable and convenient technique to remove RLM during PPV. Although the comparison with other methods is beyond the scope of this preliminary study, visual outcomes and complication rates were encouraging and should be validated in a larger group of patients.

Differential distribution of fibrovascular proliferative membranes in 25-gauge vitrectomy for proliferative diabetic retinopathy.

AIM: To analyze the distribution of fibrovascular proliferative membranes (FVPMs) in proliferative diabetic retinopathy (PDR) patients that treated with pars plana vitrectomy (PPV), and to evaluate the outcomes separately. METHODS: This was a retrospective and cross-sectional study. Consecutive 25-gauge (25-G) PPV cases operated for PDR from May 2018 to April 2020. According to the FVPMs images outlined after operations, subjects were assigned into three groups: arcade type group, juxtapapillary type group, and central type group. All patients were followed up for over one year. General characteristics, operation-related variables, postoperative parameters and complications were recorded. RESULTS: Among 103 eyes recruited, the FVPMs distribution of nasotemporal and inferiosuperioral was significantly different (both P<0.01), with 95 (92.23%) FVPMs located in the nasal quadrants, and 74 (71.84%) in the inferior. The eyes with a central FVPM required the longest operation time, with silicon oil used in most patients, generally combined with tractional retinal detachment (RD) and rhegmatogenous RD, the worst postoperative best-corrected visual acuity (BCVA) and the highest rates of recurrent RD (all P<0.05). FVPM type, age of onset diabetes mellitus, preoperative BCVA, and combined with tractional RD and rhegmatogenous RD were significantly associated with BCVA improvement (all P<0.05). Compared with the central type group, the arcade type group had higher rates of BCVA improvement. CONCLUSION: FVPMs are more commonly found in the nasal and inferior mid-peripheral retina in addition to the area of arcade vessels. Performing 25-G PPV for treating PDR eyes with central FVPM have relatively worse prognosis.

Removal of Subinternal Limiting Membrane Hemorrhage Secondary to Valsalva Retinopathy Using a Fovea-Sparing Internal Limiting Membrane Fissure Creation Technique.

Introduction: Valsalva retinopathy can cause submacular hemorrhage (SMH), which may lead to visual disturbances. SMH can extend into the subinternal limiting membrane (ILM) and vitreous spaces, sometimes occurring concomitantly with full-thickness macular holes (FTMHs). Herein, we describe a case in which sub-ILM hemorrhage was removed without peeling the ILM of the central fovea, thus preserving the foveal ILM. Case Presentation: A 48-year-old female patient developed rapid-onset bilateral visual impairment due to SMH secondary to Valsalva retinopathy. The SMH predominantly consisted of sub-ILM hemorrhage. However, detailed observation was challenging due to the dense sub-ILM hemorrhage in the left eye. Initial best-corrected visual acuity (BCVA) in the right and left eyes were 1.2 and 0.03, respectively. Intravitreal tissue plasminogen activator (tPA) and sulfur hexafluoride (SF6) gas injections were initially administered to displace the SMH in the left eye; however, the SMH could not be successfully displaced. A vitrectomy was then performed. Intraoperatively, an ILM fissure beyond the foveal region was created using ILM forceps. The balanced salt solution was sprayed onto the ILM, and the sub-ILM hemorrhage was drained into the vitreous cavity from the ILM fissure. The surgery successfully displaced the sub-ILM hemorrhage while preserving the foveal ILM. No postoperative complications were observed. Visual acuity remained at 1.2 in the right eye and improved to 1.2 in the left eye 6 months postoperatively. Conclusion: Removing foveal sub-ILM hemorrhage without peeling the foveal ILM can be a viable treatment option to preserve the foveal ILM.

CO2 laser-assisted sclerectomy surgery for secondary open-angle glaucoma after vitrectomy.

Purpose: To explore the efficiency and safety of carbon dioxide (CO2) laser-assisted sclerectomy surgery (CLASS) in Chinese patients with glaucoma secondary to vitrectomy. Methods: This retrospective study consisted of 16 eyes from 16 patients with glaucoma secondary to vitrectomy who underwent CLASS and were followed up for 12 months. Main outcome measures included preoperative and postoperative intraocular pressure, best corrected visual acuity (BCVA), number of anti-glaucoma medications, and postoperative surgical success rate and complications. Results: The postoperative IOP and number of anti-glaucoma medications used at all follow-up time point were significantly lower than those preoperatively. The difference in BCVA was not significant before and after surgery. The main complicatios were peripheral anterior synechiae (PAS) and scleral reservoir reduction, which were controlled after neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, 2 (12.50%) patients underwent re-operation. The complete and total success rates at 12 months were 68.75% and 87.50%, respectively. Conclusion: CLASS is a safe and effective procedure for Chinese patients with glaucoma secondary to vitrectomy. PAS and scleral reservoir reduction is a major contributor to postoperative IOP elevation, and trabecular minimally invasive perforation with the Nd:YAG laser is effective in lowering IOP and increasing scleral cistern volume.

Risk of ocular neovascular conversion and systemic bleeding complications in patients with AMD on DOACs or Warfarin.

PURPOSE: Conversion to neovascular disease in patients with non-neovascular age-related macular degeneration (AMD) initiated on direct oral anticoagulants (DOAC) compared to matched patients treated with warfarin. DESIGN: Retrospective cohort study. SUBJECTS, PARTICIPANTS, AND/OR CONTROLS: The study included 20,300 patients and 13,387 patients with non-neovascular AMD initiated on DOACs or warfarin, respectively, before propensity score matching (PSM). METHODS, INTERVENTION, OR TESTING: TriNetX (Cambridge, MA, USA), was used to identify patients diagnosed with non-neovascular AMD stratified by treatment with DOACs or warfarin with at least six months of follow-up. Propensity score matching was performed to control for baseline demographics and medical comorbidities. MAIN OUTCOME MEASURES: Relative risk (RR) of developing neovascular AMD, macular hemorrhage (MH), vitreous hemorrhage (VH), and requiring an ocular intervention (intravitreal anti-vascular endothelial growth factor (VEGF) therapy or pars plana vitrectomy (PPV)) within six months and one year. Patients with chronic atrial fibrillation (AF) on anticoagulation were separately evaluated for the same measures within 5 years after initiating therapy. RESULTS: Treatment with warfarin was associated with higher risk of developing neovascular AMD at six months (RR,1.24, 95% CI, 1.12 - 1.39; P<.001) and one year (RR, 1.26, 95% CI, 1.14 - 1.40; P<.001) when compared to matched patients treated with DOACs. There was an increased risk of requiring intravitreal anti-VEGF therapy (6 months: RR, 1.30; 95% CI, 1.13-1.49; P<.001; 1 year: RR, 1.31, 95% CI, 0.72 - 2.05; P<.001) and PPV (6 months: RR, 1.16; 95% CI, 1.16-3.94; P = .01; 1 year: RR, 2.29, 95% CI, 1.30 - 4.05; P=.003). Among patients with AMD and AF treated with warfarin, there was an increased risk of ocular complications (neovascular AMD: RR, 1.25; 95% CI, 1.14-1.38; P<.001; MH: RR, 1.86; 95% CI, 1.47-2.35; P<.001; VH: RR, 2.22; 95% CI, 1.51-3.26; P<.001) and need for intravitreal anti-VEGF therapy (RR, 1.34; 95% CI, 1.18-1.52; P<.001) over an extended 5-year period. There was no significant difference in the development of major systemic hemorrhagic events between the two cohorts over five years. CONCLUSIONS: Patients with non-neovascular AMD treated with warfarin were more likely to develop neovascular disease and require ocular intervention for hemorrhagic complications when compared to matched patients initiated on DOACs.

Xen gel stent implant for persistent glaucoma after silicone oil removal.

PURPOSE: To evaluate the effectiveness and safety of the XEN-Stent for managing unresponsive to medical therapy secondary glaucoma after silicone oil (SO) removal. METHODS: This retrospective chart reviewed 12 patients who underwent vitrectomy and SO endotamponade. They experienced intraocular pressure (IOP) elevation after SO removal despite taking the maximum tolerated glaucoma medication. Eleven eyes underwent an XEN-implant, while 1 underwent an XEN-implant with phacoemulsification/IOL implantation. The primary outcome was to achieve success criteria: IOP <18 mmHg and >20% IOP reduction without medication (complete success) or with medication (qualified success) and without a secondary IOP-lowering procedure. IOP, best-corrected visual acuity (BCVA), and the number of glaucoma medications (Glaucoma Medication Score-GMS) were recorded at baseline, 1 day, 1 week, 1 (M1), 3 (M3), 6 (M6), and 12 (M12) months postoperatively. RESULTS: Baseline characteristics included males percentage 66.6%, mean age of 61.8 ± 5.7 years, BCVA 0.69 ± 0.3 logMAR, IOP 30 ± 4.2 mmHg, and GMS 3.1 ± 0.5. There was a significant reduction in IOP by 14 ± 1.9 mmHg and GMS by 0.27 ± 0.6 at M12 compared to baseline (p < 0.01), but no significant change in BCVA (p = 0.21). Complete success dropped to 50% (M3), rising to 75% (M6, M12) after needling. Two patients achieved qualified success at M12. Needling was performed in 6 eyes, with 3 requiring a second procedure. Ex-PRESS was required in 1 eye. One eye experienced hypotony and hyphema, which resolved within a week. CONCLUSION: XEN implant may be an initial treatment for persistent post SO removal glaucoma with minimal complications. Needling procedures can help maintain or restore surgical success.