SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN MACULA-INVOLVING CYTOMEGALOVIRUS RETINITIS.

PURPOSE: To evaluate the microstructural features of cytomegalovirus (CMV) retinitis by spectral domain optical coherence tomography (OCT). METHODS: Subjects were patients with macula-involving CMV retinitis with OCT imaging. The leading edge of retinitis in the macula was identified based on fundus imaging, and OCT findings were longitudinally evaluated in three areas: within the area of active retinitis, at the leading edge of retinitis, and just beyond the leading edge of retinitis. RESULTS: Optical coherence tomography imaging of macular CMV retinitis identified vitreous cells in 10 eyes (100%), posterior vitreous detachment in four eyes (40%), broad-based vitreomacular traction in one eye (10%), epiretinal membrane in eight eyes (80%), and lamellar hole-associated epiretinal proliferation associated with an atrophic hole in one eye (10%). Retinal architectural disruption, disruption of inner retinal layers, disruption of the external limiting membrane, and ellipsoid zone abnormalities were noted within the area of retinitis in all eyes and decreased in frequency and severity at and beyond the leading edge of retinitis, although all 10 eyes (100%) exhibited one of these abnormalities, especially outer retinal microabnormalities, beyond the leading edge of retinitis. CONCLUSION: Microstructural abnormalities were frequently noted on OCT of CMV retinitis, including within the retina beyond the leading edge of retinitis identified by corresponding fundus imaging. Outer retinal abnormalities were noted more frequently than inner retinal abnormalities beyond the leading edge of retinitis. These findings provide insight into the effects of CMV retinitis on retinal microstructure and potentially on vision and highlight the potential utility of OCT for monitoring microprogression of macula-involving CMV retinitis.

ULTRA-WIDEFIELD IMAGING OF POSTERIOR SEGMENT PATHOLOGY IN THE SETTING OF THE BOSTON KERATOPROSTHESIS.

PURPOSE: To evaluate the ability to visualize and document posterior segment pathology through the Boston keratoprosthesis (KPro) using the Optos P200Tx ultra-widefield (UWF) scanning laser ophthalmoscope. METHODS: A retrospective chart review was conducted of patients who underwent Boston Type I keratoprosthesis implantation and who subsequently were imaged with an UWF system. Ultra-widefield images were reviewed to evaluate for vitreoretinal pathology and were compared with the clinical examination. RESULTS: In this series of 10 patients (10 eyes), 100% of vitreoretinal pathology found on clinical examination was detectable using the Optos system. In 4 cases (40%), UWF imaging provided superior detection of pathology compared with the clinical examination by imaging through retroprosthetic membranes (3 cases) and by detection of a retinal detachment (one case). In 1 case (10%), B-scan ultrasonography was needed to characterize vitreoretinal pathology that could not be definitively distinguished on UWF imaging and was difficult to detect on clinical examination. Ultra-widefield imaging detected the following vitreoretinal pathologies in KPro eyes: retinal hemorrhage, epiretinal membrane, retinal detachment, proliferative diabetic retinopathy, and choroidal folds. CONCLUSION: Ultra-widefield imaging provides a high-resolution view of the posterior pole and periphery despite the limitations of imaging through the narrow optic of Boston Type I keratoprosthesis, and it may improve visualization through retroprosthetic membranes. Detection and documentation of vitreoretinal complications in the setting of a permanent keratoprosthesis may be enhanced using UWF imaging.

Pars plana vitrectomy compared with pars plana vitrectomy combined with scleral buckle in the primary management of noncomplex rhegmatogenous retinal detachment.

PURPOSE: To compare pars plana vitrectomy (PPV) with PPV combined with scleral buckle (PPV/SB) in the treatment of primary, noncomplex rhegmatogenous retinal detachment in an academic setting. METHODS: Retrospective review of 74 consecutive cases that underwent either PPV or PPV/SB for primary rhegmatogenous retinal detachment at New York Presbyterian Hospital, Weill Cornell Medical College. Fifty-two eyes underwent PPV alone while 22 eyes had PPV combined with SB. All eyes had a minimum of 2 months of follow-up. The main outcome measure was single surgery anatomical success. RESULTS: Patients in the PPV/SB group were less likely to be phakic (P = 0.05) and more likely to have an inferior retinal break (P = 0.001) when compared with the PPV group. Between groups, there was no difference in eyes with peripheral retinal lattice degeneration (P = 0.929), multiple breaks (P = 0.801), breaks seen preoperatively (P = 0.095), or those presenting with the macula off retinal detachment (P = 0.548). The majority of patients in both groups underwent small-gauge surgery (23 G or 25 G) (P = 0.65). Attachment of the retina was obtained in 100% of the patients in both groups at most recent follow-up. Single surgery anatomical success was similar between groups (83% PPV vs. 86% PPV/SB; P = 0.695). Mean best-corrected Snellen visual acuity improved in both groups (P = 0.75), with a final best-corrected Snellen visual acuity of 0.418 logMAR in the PPV group and 0.479 logMAR in the PPV/SB group (P = 0.61). When comparing PPV with PPV/SB, no difference in single surgery anatomical success existed after evaluating eyes with inferior breaks (P = 0.68), pseudophakia (P = 0.75), or when small-gauge surgery was performed (P = 0.76). CONCLUSION: We did not find significant differences in single surgery anatomical success, final anatomical success, or change in visual acuity when comparing PPV with PPV/SB in the repair of primary noncomplex rhegmatogenous retinal detachment in an academic setting where vitreoretinal fellows participate in key aspects of all cases.

Intravitreal injection technique and monitoring: updated guidelines of an expert panel.

PURPOSE: To review evidence and provide updated guidelines on intravitreal (IVT) injection technique and monitoring. METHODS: A review of the published literature on IVT injection from 2004 to 2014 formed the basis for round table deliberations by an expert panel of ophthalmologists. RESULTS: The dramatic increase in the number of IVT injections has been accompanied by a comparable increase in evidence surrounding IVT practice patterns and techniques. The expert panel identified a number of areas that have evolved since publication of the original IVT injection guidelines in 2004, the most notable of which were a lack of evidence to support the routine use of pre-, peri-, and postinjection antibiotics to reduce the risk of endophthalmitis, and the role of aerosolized droplets containing oral contaminants from the patient and/or providers as a potential source of infection. The panel emphasized the continued importance of applying povidone-iodine to and avoiding eyelid contact with the intended injection site and needle. CONCLUSION: Updated guidelines on IVT injection technique and monitoring are proposed based on a review of published literature and expert panel deliberations.

Chemical Burns of the Eye: The Role of Retinal Injury and New Therapeutic Possibilities.

PURPOSE: To propose a new treatment paradigm for chemical burns to the eye - in the acute and chronic phases. METHODS: Recent laboratory and clinical data on the biology and treatment of chemical burns are analyzed. RESULTS: Corneal blindness from chemical burns can now be successfully treated with a keratoprosthesis, on immediate and intermediate bases. Long term outcomes, however, are hampered by early retinal damage causing glaucoma. New data suggest that rapid diffusion of inflammatory cytokines posteriorly (TNF-α, etc) can severely damage the ganglion cells. Prompt anti-TNF-α treatment is markedly neuroprotective. Long term profound reduction of the intraocular pressure is also vital. CONCLUSION: A new regimen, in addition to standard treatment, for severe chemical burns is proposed. This involves tumor necrosis factor alpha (TNF-α) inhibition promptly after the accident (primarily for retinal neuroprotection), prophylactic maximal lowering of the intraocular pressure (starting immediately), and keratoprosthesis implantation in a later quiet state.

PERIPHERAL VASCULAR ABNORMALITIES IN ß-THALASSEMIA MAJOR DETECTED BY ULTRA WIDE-FIELD FUNDUS IMAGING.

PURPOSE: To describe peripheral retinal vascular abnormalities in two patients with ß-thalassemia major. METHODS: Visual acuity testing, slit-lamp biomicroscopy, dilated fundus examination, ultra wide-field fundus photography, and fluorescein angiography were performed in two consecutive patients with ß-thalassemia major. RESULTS: Both patients had excellent visual acuity (20/20 and 20/25). Anterior segment examination was unremarkable. There were no lenticular changes noted in either patient. Dilated fundus examination was only remarkable for peripheral neovascular changes with preretinal hemorrhage in one patient and white without pressure in the other patient. Ultra wide-field fluorescein angiography revealed peripheral ischemia, vascular remodeling, active neovascularization, and arteriovenous anastomosis at the junction of perfused and nonperfused peripheral retina. One patient had sea fan neovascularization with active vitreous hemorrhage requiring peripheral laser photocoagulation. CONCLUSION: As with patients with sickle cell disorder, patients with ß-thalassemia major may require surveillance for peripheral vascular abnormalities, with treatment of these abnormalities before they result in permanent visual loss.