REFRACTIVE OUTCOMES AFTER SUTURELESS INTRASCLERAL FIXATION OF INTRAOCULAR LENS WITH PARS PLANA VITRECTOMY.

PURPOSE: To evaluate the refractive outcomes of sutureless intrascleral fixation of intraocular lens with pars plana vitrectomy. METHOD: A retrospective, consecutive cohort from multiple surgeons of a single center. Primary outcomes included spherical equivalent (SEQ) and change in SEQ (ΔSEQ) from preoperative intraocular lens power calculations. Secondary outcomes included refractive outcomes of fixation at 1.5 mm, 2 mm, and 2.5 mm posterior to the limbus. RESULTS: In total, 84 eyes of 80 patients were included. Preoperative logarithm of the minimum angle of resolution visual acuity was 1.21 ± 0.68 (20/320). The mean follow-up time was 2.33 ± 1.36 years. At 3 months, SEQ was -0.50 ± 1.59 D and ΔSEQ was 0.58 ± 1.49 D. At 1 year, SEQ was -0.55 ± 1.32 D and ΔSEQ was 0.39 ± 1.42 D. At the last follow-up, logarithm of the minimum angle of resolution visual acuity was 0.34 ± 0.34 (20/40), SEQ was -0.51 ± 1.44 D, and ΔSEQ was 0.57 ± 1.27 D. There was no difference between SEQ or ΔSEQ throughout follow-up (P = 0.97 and P = 0.96, respectively). At fixation distances more posterior to the limbus, mean ΔSEQ was more hyperopic at 3 months, 1-year, and the last follow-up (P = 0.02, P = 0.01, and P = 0.006, respectively). CONCLUSION: Refractive outcomes for sutureless intrascleral fixation of intraocular lens with pars plana vitrectomy were favorable and showed stability postoperatively. These results may aid surgeons achieve better desired refractive outcomes for this technique.

PERIPHERAL RETINAL ANGIOGRAPHIC FINDINGS IN MACULAR TELANGIECTASIS TYPE 2.

PURPOSE: To evaluate the retinal periphery in patients with idiopathic juxtafoveal telangiectasis or macular telangiectasis Type 2 (MacTel2), using widefield fluorescein angiography. METHODS: Single-center, retrospective, observational case series of 50 eyes of 50 patients with MacTel2 and 50 eyes of 50 age-matched controls. RESULTS: Thirty-seven eyes in the MacTel2 group (74%) showed peripheral capillary nonperfusion or dropout, compared with 37 eyes in the control group (74%, P = 1.0). Morphologically, the MacTel2 group trended toward having a higher proportion of pruning-type capillary dropout (44%) compared with controls (28%), but this was not statistically significant (P = 0.12). Patients with MacTel2 had a higher incidence of microaneurysms compared with controls (MacTel2 56%; controls 42%; P = 0.048), independent of age or systemic risk factors. There was no difference in the incidence of venous-venous shunts (MacTel2 10%; controls 10%; P = 1.0), arteriovenous shunts (MacTel2 14%; controls 18%; P = 0.60), venous tortuosity (MacTel2 60%; controls 66%; P = 0.58), or arterial tortuosity (MacTel2 54%; controls 68%; P = 0.20), which was mild in most cases. CONCLUSION: We note a high incidence of peripheral vascular and retinal findings in both patients with MacTel2 and age-matched controls, using widefield fluorescein angiography. Patients with MacTel2 had significantly more microaneurysms, independent of age or other systemic risk factors.

CLINICAL OUTCOMES AND TREATMENT COURSE OF EYES WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION FOLLOWING THE DEVELOPMENT OF ENDOPHTHALMITIS.

PURPOSE: To evaluate the clinical course of patients with neovascular age-related macular degeneration (nAMD) after developing endophthalmitis during their treatment with intravitreal injections. METHODS: Multicenter, retrospective series. RESULTS: From April 2013 to October 2018, 196,598 intravitreal anti-vascular endothelial growth factor (VEGF) injections were performed, with 75 cases of endophthalmitis (incidence 0.0381%). There was no association between intravitreal anti-VEGF drug (P = 0.29), anesthetic method (P = 0.26), povidone concentration (P = 0.22), or any intraprocedure variable and endophthalmitis incidence. Seventy-two patients (96%) were treated with intravitreal tap and inject , while 3 underwent immediate pars plana vitrectomy. After endophthalmitis resolution, 17 patients (22.7%) were not re-treated for nAMD (in 10 cases due to inactive disease; follow-up, 115 ± 8.4 weeks). Patients required less frequent anti-VEGF injections after infection (7.4 ± 0.61 weeks vs. 11.5 ± 1.8 weeks; P = 0.004). Preinfection logarithm of the minimum angle of resolution visual acuity was 0.585 ± 0.053 (∼20/77). It worsened with endophthalmitis (1.67 ± 0.08, ∼20/935; P < 0.001) and again on postendophthalmitis treatment day 1 (1.94 ± 0.064; count fingers; P < 0.001), but improved after reinitiating nAMD therapy (1.02 ± 0.11; ∼20/209; P < 0.001). Better visual acuity on postendophthalmitis week 1 (P = 0.002) and reinitiation of nAMD treatment (P = 0.008) were associated with better final visual acuity, and streptococcal culture with worse visual acuity (P = 0.028). The postendophthalmitis treatment interval was associated with the anti-VEGF drug used (aflibercept = ranibizumab > bevacizumab; P < 0.001). CONCLUSION: Patients with nAMD required fewer injections after endophthalmitis, suggesting a biological change in disease activity. Neovascular age-related macular degeneration became quiescent in 13.3% of eyes. Most achieved better outcomes with anti-VEGF reinitiation.

Cytosolic reducing power preserves glutamate in retina.

Glutamate in neurons is an important excitatory neurotransmitter, but it also is a key metabolite. We investigated how glutamate in a neural tissue is protected from catabolism. Flux analysis using (13)C-labeled fuels revealed that retinas use activities of the malate aspartate shuttle to protect >98% of their glutamate from oxidation in mitochondria. Isolation of glutamate from the oxidative pathway relies on cytosolic NADH/NAD(+), which is influenced by extracellular glucose, lactate, and pyruvate.

Long-Term Use of a Temporary Keratoprosthesis and Perfluorocarbon in Traumatic Retinal Detachment Repair.

Purpose: To present a technique for optimizing repair of traumatic retinal detachments (RDs). Methods: A patient was followed in an outpatient setting with clinical examinations, optical coherence tomography, widefield fundus photography, and anterior segment imaging. Results: The patient presented with a total RD after ruptured globe repair. The patient had combined corneal and retinal surgery with placement of a temporary keratoprosthesis (TKP) and vitrectomy with perfluorocarbon liquid (PFCL) to reattach the retina. The TKP and PFCL were left in the eye for 2 weeks before a planned silicone oil exchange and penetrating keratoplasty were performed. Four months postoperatively, the patient presented with a partially attached retina and improved vision. Conclusions: In this case, a ruptured globe decompensated several months after primary repair. The prolonged use of the TKP allowed for optimal surgical visualization, enhanced office-based assessment, and limited endothelial cell loss of the donor corneal tissue.

Ocular Complications of Acute Worsening of Nephrotic Syndrome.

This report presents the case of a man aged 45 years who came into the emergency department with acutely worsening vision during the course of 1 week. He was found to have acutely worsening nephrotic syndrome secondary to focal segmental glomerulosclerosis despite systemic immunosuppression. His ophthalmic examination revealed large nerve fiber layer hemorrhages in the posterior pole, significant macular edema, and areas of polygonal retinal whitening sparing the blood vessels, consistent with a diagnosis of Purtscher-like retinopathy. The patient was started on intravenous methylprednisolone followed by an oral taper of prednisone with improvement in his visual acuity and clinical findings 2 weeks later. [Ophthalmic Surg Lasers Imaging Retina 2022; 53:393-396.].

Bilateral Exudative Retinal Detachments, Chemosis, and Impaired Ocular Motility in the Setting of Preeclampsia and HELLP Syndrome.

Purpose: We present a complication of preeclampsia and hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome including bilateral exudative retinal detachments, bullous chemosis, and impaired ocular motility. Methods: The patient was followed in the inpatient and outpatient setting with clinical examinations, optical coherence tomography, widefield fundus photography, neuroimaging including magnetic resonance imaging of the brain/orbits, as well as carotid artery ultrasonography. Results: Our patient was admitted with bilateral vision changes in the setting of preeclampsia and HELLP syndrome and was found to have bilateral exudative detachments, retinal exudation, severe bullous chemosis, and impaired motility. She was started on intravenous dexamethasone followed by an extended prednisone taper with resolution of her ocular findings and return of her vision to baseline. Conclusions: There is evidence that HELLP syndrome and preeclampsia are proinflammatory syndromes. Aggressive blood pressure control, corticosteroids, and a multidisciplinary approach might accelerate visual and systemic recovery in these complex cases.

Incidence of Endogenous Fungal Endophthalmitis in Screening Dilated Exams in Patients with Elevated Beta-D-Glucan Levels versus Positive Fungal Blood Cultures.

Purpose: Endogenous endophthalmitis is a severe intraocular infectious condition requiring rapid diagnosis and treatment. This study examines the incidence of fungal endophthalmitis in patients with elevated beta-D-glucan (BG) levels and those with positive blood culture and the utility of ophthalmology consultation in these patients. Methods: Single center retrospective consecutive cohort study was conducted on patients at Beaumont Health from 2016-2021 who either had positive fungal blood cultures or an elevated BG level. Results: A total of 147 patients were examined by the ophthalmology department where 30 patients had an elevated BG level and 100 patients had a positive fungal blood culture. Incidence of fungal endophthalmitis was 0% in the elevated BG group and 1.5% in the positive fungal culture group, corresponding to a relative risk ratio of 0.0 (p = 0.31). Conclusion: BG testing may be useful in diagnosing isolated cases outside the standard screening paradigm, however the data within this study support the conclusion that there is no compelling evidence at this time to add or use BG as a surrogate for endophthalmitis screening. Further studies are required to further elucidate the role of BG in the care of critically ill patients.

An Atypical Optic Nerve Head Mass.

A 47-year-old man presented with a sudden decrease in vision in the right eye and a history of binocular diplopia, bilateral cranial nerve 6 palsies, and an undifferentiated pontine mass. Examination revealed a large optic nerve head mass with optic disc hyperemia, scattered dot hemorrhages, a placoid lesion in the posterior pole, and a mass protruding out of the optic nerve head. What would you do next?

Coronary Artery Embolism: Two Case Reports and a Review of the Literature.

Coronary embolism (CE) is an uncommon and unique cause of acute myocardial infarction. In this report, we review 216 cases of CE including 2 new cases from our institution. The mean patient age was 52.5 years and 62% of the patients were males. Chest pain was the most common presenting symptom followed by dyspnea, and the most commonly affected vessel was the left anterior descending artery. Leading etiologies of the embolus were atrial fibrillation, septic emboli, and iatrogenic causes. Treatment approaches varied with thrombus aspiration being used in 30% of cases. In-hospital mortality rate was 36% and 13% of the cases were complicated by cerebrovascular accident. CE is a unique pathology that leads to acute myocardial infarction. It portends a high mortality rate and requires a high level of suspicion as symptoms may be misleading. Further research is needed in order to improve recognition and management and to lower associated mortality.

Cigarette smoke induced autophagy-impairment regulates AMD pathogenesis mechanisms in ARPE-19 cells.

Age related macular degeneration (AMD) is one of the leading causes of blindness. Genetics, environmental insult, and age-related factors all play a key role in altering proteostasis, the homeostatic process regulating protein synthesis, degradation and processing. These factors also play a role in the pathogenesis of AMD and it has been well established that cigarette smoking (CS) initiates AMD pathogenic mechanisms. The primary goal of this study is to elucidate whether CS can induce proteostasis/autophagy-impairment in retinal pigment epithelial (RPE) cells. In our preliminary analysis, it was found that cigarette smoke extract (CSE) induces accumulation of ubiquitinated proteins in the insoluble protein fraction (p < 0.01), which was subsequently mitigated through cysteamine (p < 0.01) or fisetin (p < 0.05) treatment. Further, it was verified that these CSE induced ubiquitinated proteins accumulated in the peri-nuclear spaces (p<0.05) that were cleared- off with cysteamine (p < 0.05) or fisetin (p < 0.05). Moreover, CSE-induced aggresome-formation (LC3B-GFP and Ub-RFP co-localization) and autophagy-flux impairment was significantly (p<0.01) mitigated by cysteamine (p<0.05) or fisetin (p<0.05) treatment, indicating the restoration of CSE-mediated autophagy-impairment. CSE treatment was also found to induce intracellular reactive oxygen species (ROS, p < 0.001) while impacting cell viability (p < 0.001), which was quantified using CMH2DCFDA-dye (ROS) and MTS (proliferation) or propodium iodide staining (cell viability) assays, respectively. Moreover, cysteamine and fisetin treatment ameliorated CS-mediated ROS production (p < 0.05) and diminished cell viability (p < 0.05). Lastly, CSE was found to induce cellular senescence (p < 0.001), which was significantly ameliorated by cysteamine (p < 0.001) or fisetin (p < 0.001). In conclusion, our study indicates that CS induced proteostasis/autophagy-impairment regulates mechanisms associated with AMD pathogenesis. Moreover, autophagy-inducing drugs such as cysteamine or fisetin can ameliorate AMD pathogenesis mechanisms that warrant further investigation in pre-clinical murine models.