A PROSPECTIVE, RANDOMIZED TRIAL COMPARING PLAIN GUT TO POLYGLACTIN 910 (VICRYL) SUTURES FOR SCLEROTOMY CLOSURE AFTER 23-GAUGE PARS PLANA VITRECTOMY.

PURPOSE: To report a prospective, randomized comparative study assessing clinical outcomes of plain gut versus polyglactin 910 (PG910) sutures for sclerotomy closure after 23-gauge pars plana vitrectomy. METHODS: A single-masked, randomized, prospective study was undertaken with 49 eyes of 49 patients undergoing 23-gauge pars plana vitrectomy randomized to sclerotomy closure with either plain gut suture, PG910 (Vicryl) suture or a combination of the two. Assessment was based on both a postoperative pain scale and a standardized assessment of scleral inflammation at each suture site. RESULTS: No wound leakage was noted postoperatively in any patient. Across all groups, scleral inflammation was significantly higher at the PG910 suture sites compared with the plain gut suture sites at both the 1-week (P = 0.04) and 1-month postoperative visits (P < 0.001). Patients with PG910 sutures reported greater pain at the 1-month postoperative visit than those with plain gut sutures (P = 0.018). CONCLUSION: This prospective study suggests improved tolerability and reduced inflammation using plain gut suture compared with an 8-0 PG910 suture to close 23-gauge sclerotomies.

Idiopathic Orbital Inflammation Associated With Necrotizing Scleritis and Temporal Bone Inflammation.

The authors present a case of aggressive idiopathic orbital inflammation producing necrotizing scleritis along with synchronous tumefactive fibroinflammatory lesion of the temporal bone. A young woman with no medical history presented with sectoral scleritis and mildly reduced vision. Response to initial treatment, which included topical and systemic corticosteroids, as well as systemic nonsteroidal anti-inflammatory drugs, was limited. Over the following months, signs of orbital inflammation developed, including ptosis, proptosis, and limited extraocular motility. MRI revealed both orbital and ipsilateral temporal bone masses. An orbital biopsy was performed revealing a mixed inflammatory infiltrate, whereas a biopsy of the temporal bone mass revealed a tumefactive fibroinflammatory lesion. Biopsy showed no histopathologic evidence of infection nor neoplasm. The patient eventually responded to treatment with systemic prednisone, azathioprine, and rituximab.

The oculocardiac reflex in an adult with a non-displaced orbital floor fracture.

The current dogma is that the oculocardiac reflex from orbital trapdoor fractures occurs only in children and young adults. We present the occurrence of the oculocardiac reflex in an adult with a non-displaced orbital floor fracture. CT demonstrated the adventitia surrounding the inferior rectus trapped in and below the orbital floor fracture. The patient's oculocardiac reflex resolved by early next morning, presumably from the tissue escaping from the orbital floor defect.

Characteristics of Pentosan Polysulfate Sodium-Associated Maculopathy and Similarities With Other Maculopathies Commonly Managed in a Retina Practice.

Purpose: This work describes characteristics of pentosan polysulfate sodium (PPS)-associated maculopathy and its similarities with common maculopathies in a retina practice cohort. Methods: Thirty-two patients were identified through electronic medical record query who were exposed to PPS. One patient was excluded for lack of retinal imaging. Thirty-one patients (62 eyes) were included. A retrospective review was used to obtain patient characteristics, examination findings, and retinal imaging of the study patients. Classification into "likely," "unlikely," or "possible" to have PPS-associated maculopathy groups was based on the fundus photography and retinal imaging. Main outcome measures were best-corrected visual acuity, age, sex, diagnosis of reason for referral, allocation into designated maculopathy group, and presence of choroidal neovascularization. Results: Of 31 patients (62 eyes), the median age was 70 years (range, 24-104 years) and the majority were women (87%). Mean best-corrected visual acuity was 0.3 ± 0.4 logMAR at presentation. The most common reason for referral was age-related macular degeneration (29%). Maculopathy grades were "likely" (29%, 9 total patients), "possible" (26%, 8 total patients), or "unlikely" (45%, 14 total patients). Choroidal neovascularization was noted in 9.7% of all eyes and 11% of eyes in the "likely" group. The "possible" and "likely" groups had older ages of presentation (P < .05) compared with the "unlikely" group. Conclusions: A high percentage (55%) of patients with a history of chronic PPS exposure showed features of "likely" or "possible" maculopathy. Similarities with common maculopathies such as age-related macular degeneration and the importance of screening and recognizing at-risk patients are highlighted.

Spontaneous Conversion of Lamellar Macular Holes to Full-Thickness Macular Holes: Clinical Features and Surgical Outcomes.

PURPOSE: To describe the clinical features and surgical outcomes of patients experiencing a spontaneous conversion of a lamellar macular hole (LMH) to a full-thickness macular hole (FTMH). DESIGN: Retrospective, multicenter, observational case series. PARTICIPANTS: Patients with LMH who experienced a spontaneous conversion to FTMH and underwent FTMH surgery. METHODS: Clinical charts and OCT features of 20 eyes of 20 patients were reviewed. MAIN OUTCOME MEASURES: OCT features and surgical outcomes of FTMH derived from LMH. RESULTS: The mean baseline visual acuity (VA) was 0.21 ± 0.19 logarithm of the minimum angle of resolution (logMAR) (20/32 Snellen equivalent [SE]). Epiretinal proliferation was noted in 18 eyes (90%), and 14 eyes (75%) had an epiretinal membrane. At the diagnosis of FTMH, the mean VA decreased to 0.61 ± 0.50 logMAR (20/81 SE) (P = 0.001). The mean FTMH diameter was 224.4 ± 194.8 µm, with 15 (75%) small (≤250 µm), 2 (10%) medium (>250-≤400 µm), and 3 (15%) large (>400 µm) FTMHs. Eighteen (90%) FTMHs were sealed after 1 surgery, and 2 (10%) required an additional procedure. At the last follow-up, the mean VA was increased to 0.29 ± 0.23 logMAR (20/38 SE) (P = 0.003), but did not significantly differ from the baseline VA (P = 0.071). CONCLUSIONS: Patients with LMH may develop an FTMH with no evidence of vitreomacular traction. A tangential traction from an epiretinal membrane may contribute to its genesis, but a progressive loss of retinal tissue and an inherent weakness of the foveal architecture in LMH eyes could be sufficient. Most FTMHs derived from LMH had a small diameter, showed epiretinal proliferation, showed limited retinal hydration, and were associated with relatively poor surgical outcomes compared with idiopathic FTMH.

Prognostic Utility of Whole-Genome Sequencing and Polymerase Chain Reaction Tests of Ocular Fluids in Postprocedural Endophthalmitis.

PURPOSE: To associate detection of potential pathogen DNA in endophthalmitis with clinical outcomes. DESIGN: Prospective cohort study. METHODS: Patients in whom endophthalmitis was diagnosed following an intraocular procedure were recruited. Clinical outcome data from baseline, week-1, month-1, and month-3 visits were collected. Intraocular biopsy samples were cultured by standard methods. Quantitative polymerase chain reaction (qPCR) was performed for specific pathogens and whole-genome sequencing (WGS). RESULTS: A total of 50 patients (mean age 72 years old; 52% male) were enrolled. Twenty-four cases were culture-positive and 26 were culture-negative. WGS identified the cultured organism in 76% of culture-positive cases and identified potential pathogens in 33% of culture-negative cases. Month-1 and -3 visual acuities did not vary by pathogen-positive versus pathogen-negative cases as detected by either culture or WGS. Visual outcomes of Staphylococcus epidermidis endophthalmitis were no different than those of pathogen-negative cases, whereas the patients infected with other pathogens showed worse outcome. Higher baseline bacterial DNA loads of bacteria other than those of S epidermidis detected by WGS were associated with worse month-1 and -3 visual acuity, whereas the S epidermidis loads did not appear to influence outcomes. Torque teno virus (TTV) and Merkel cell polyomavirus (MCV) were detected by qPCR in 49% and 19% of cases, respectively. Presence of TTV at presentation was associated with a higher rate of secondary pars plana vitrectomy (P = .009) and retinal detachment (P = .022). CONCLUSIONS: The presence and higher load of bacteria other than S epidermidis detected by WGS or DNA from TTV by qPCR in ocular fluids is associated with worse outcomes in post-procedure endophthalmitis.

Comparison of Residual Subfoveal Fluid by Intraoperative OCT After Macula-Involving RRD Repair Using Direct Drainage, Drainage Retinotomy, or Perfluoro-n-Octane.

BACKGROUND AND OBJECTIVE: This study evaluated the residual subfoveal fluid (SFF) immediately after rhegmatogenous retinal detachment (RRD) repair using intraoperative optical coherence tomography (iOCT). PATIENTS AND METHODS: This retrospective cohort study assessed fovea-involving RRD repaired by pars plana vitrectomy (PPV) using different drainage techniques. iOCT images were acquired through the fovea at the start of the case prior to initiating vitrectomy and then again immediately prior to introduction of tamponade. RESULTS: Ten eyes (32.3%) received perfluoro-n-octane (PFO), 12 (38.7%) underwent a posterior drainage retinotomy, and nine (29.0%) had drainage through the retinal break. There was no significant difference in the mean SFF thickness between eyes in either group (P = .85). There was no significant association between SFF thickness on iOCT and functional or anatomic outcomes (P > .05). CONCLUSION: There is no difference in the amount of residual SFF as measured on iOCT during RRD repair with pars plana vitrectomy using either direct drainage, drainage retinotomy, or PFO. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:497-503.].

Patient Comfort with Yellow (577 nm) vs. Green (532 nm) Laser Panretinal Photocoagulation for Proliferative Diabetic Retinopathy.

PURPOSE: Pain associated with panretinal photocoagulation (PRP) can adversely affect the number and quality of retinal burns delivered and subsequently increase the number of treatment sessions required to achieve regression of proliferative diabetic retinopathy (PDR). We assessed comfort in patients undergoing treatment with yellow (577 nm) vs. green (532 nm) PRP for PDR. DESIGN: Prospective, single-center, randomized crossover clinical trial. SUBJECTS: Patients with PDR with high-risk characteristics. METHODS: Subjects were equally randomized to first receive PRP with a laser indirect ophthalmoscope with either green (IQ 532; IRIDEX, Mountain View, CA) or yellow (IQ 577; IRIDEX) laser, followed by additional treatment with the opposite laser using standardized settings in the superior hemisphere of a single treatment eye per patient. Topical anesthetic was used in all study eyes before each treatment and power was titrated until moderate grey-white retinal burns were achieved. MAIN OUTCOME MEASURES: The primary outcome measure was patient's perceived pain as measured with a standardized 10-point pain scale. Secondary outcome measures included laser power, treatment time, number of treatment shots with each laser, and physician ease-of-use score with each laser on a 10-point scale. RESULTS: Forty patients (40 eyes) with a mean age of 54.0 years were enrolled. Mean pain scores were similar when comparing treatment with yellow and green laser (3.1 ± 2.3 vs. 2.8 ± 2.6; P = 0.40). No significant difference was seen in visual acuity (P = 0.44) or central macular thickness (P = 0.39) 1 month after PRP. Additionally, there were no significant differences when comparing minimum power required (243.2 ± 74.2 vs. 234.0 ± 59.6 mW; P = 0.55), treatment time (5.1 ± 3.6 vs. 5.6 ± 3.9 minutes; P = 0.384), and number of treatment shots (257.6 ± 12.6 vs. 258.0 ± 2.3; P = 0.68). Six of 7 co-investigators (85%) preferred using yellow laser over green and reported ease-of-use scores of 9.0 ± 1.2 and 7.6 ± 1.4, respectively (P = 0.07). No severe adverse events occurred. CONCLUSIONS: Patient comfort during PRP for PDR utilizing laser indirect ophthalmoscopy is similar for green and yellow wavelengths.

Loss to Follow-up Among Patients With Neovascular Age-Related Macular Degeneration Who Received Intravitreal Anti-Vascular Endothelial Growth Factor Injections.

Importance: Loss to follow-up (LTFU) after anti-vascular endothelial growth factor (anti-VEGF) injections increases the risk of vision loss among patients with neovascular age-related macular degeneration (nAMD). Objective: To report rates of LTFU among patients with nAMD after anti-VEGF injections and to identify risk factors associated with LTFU in this population. Design, Setting, and Participants: This retrospective cohort study of data from 9007 patients who received anti-VEGF injections for treatment of nAMD was performed at an urban, private retina practice with multiple locations from April 1, 2012, to January 12, 2016. Main Outcomes and Measures: Rates of LTFU after anti-VEGF injections. Loss to follow-up was defined as receipt of 1 or more injections with no subsequent follow-up visit within 12 months. Results: Among the 9007 patients (mean [SD] age, 81.2 [8.8] years; 5917 [65.7%] female; 7905 [87.8%] white), 2003 (22.2%) were LTFU. Odds of LTFU were greater among patients 81 to 85 years of age (odds ratio [OR], 1.58; 95% CI, 1.38-1.82; P < .001), 86 to 90 years of age (OR, 2.29; 95% CI, 2.00-2.62; P < .001), and more than 90 years of age (OR, 3.31; 95% CI, 2.83-3.86; P < .001) compared with patients 80 years of age and younger. Odds of LTFU among African American patients (OR, 1.47; 95% CI, 1.00-2.16; P = .05), Asian patients (OR, 2.63; 95% CI, 1.71-4.03; P < .001), patients of other race (OR, 3.07; 95% CI, 1.38-6.82; P = .006), and patients of unreported race (OR, 2.29; 95% CI, 1.96-2.68; P < .001) were greater than odds of LTFU among white patients. Odds of LTFU were greater among patients with regional adjusted gross income of $50 000 or less (OR, 1.52; 95% CI, 1.30-1.79; P < .001), $51 000 to $75 000 (OR, 1.35; 95% CI, 1.17-1.56; P < .001), and $76 000 to $100 000 (OR, 1.28; 95% CI, 1.08-1.50; P = .004) compared with patients with incomes greater than $100 000. Odds of LTFU for patients living 21 to 30 miles (OR, 1.33; 95% CI, 1.05-1.69; P = .02) and more than 30 miles (OR, 1.55; 95% CI, 1.28-1.88; P < .001) from clinic were greater compared with patients who lived 10 miles or less from the clinic. Odds of LTFU were greater among patients who received unilateral injections (OR, 1.44; 95% CI, 1.28-1.61; P < .001) than among patients who received bilateral injections. Conclusions and Relevance: We found a high rate of LTFU after anti-VEGF injections among patients with nAMD and identified multiple risk factors associated with LTFU among this population. Although our results may not be generalizable, data on LTFU in a clinical practice setting are needed to understand the scope of the problem so that interventions may be designed to improve outcomes.

HEMORRHAGIC OCCLUSIVE RETINAL VASCULITIS AND NONHEMORRHAGIC VASCULITIS AFTER UNCOMPLICATED CATARACT SURGERY WITH INTRACAMERAL VANCOMYCIN.

PURPOSE: To describe two cases of vasculitis: one hemorrhagic and one nonhemorrhagic after uncomplicated cataract surgery with intracameral vancomycin. METHODS: Retrospective case series. RESULTS: A 74-year-old female and a 54-year-old female developed severe visual loss within 2 weeks of uncomplicated cataract surgery with intracameral vancomycin. The first patient developed a fulminant hemorrhagic vasculitis, whereas the second patient developed a less severe nonhemorrhagic vasculitis. Partial visual recovery and prevention of neovascular glaucoma was achieved using a combination of topical, oral, and intravitreal corticosteroids, along with intravitreal antivascular endothelial growth factor agents in the first patient and a combination of topical and oral corticosteroids alone in the second patient. CONCLUSION: Hemorrhagic occlusive retinal vasculitis and nonhemorrhagic vasculitis after uncomplicated cataract surgery with intracameral vancomycin have been rarely reported. Early recognition and treatment may prevent devastating visual outcomes.

BILATERAL OCCIPITAL POLE HYPERTENSIVE STROKE DIAGNOSED WITH MACULAR INTEGRITY ASSESSMENT (MAIA) MICROPERIMETRY.

PURPOSE: To describe the utility of microperimetry testing in the diagnosis of a bilateral occipital stroke. METHODS: Retrospective case report. RESULTS: A 57-year-old male with hypertension presented with complaints of bilateral blurred central vision and bilateral hypertensive retinopathy with cotton-wool spots. Automated perimetry demonstrated a central scotoma in both eyes that did not respect the vertical midline; however, microperimetry testing revealed a bilateral homonymous hemianopia that suggested cerebrovascular disease which was subsequently confirmed with magnetic resonance imaging. DISCUSSION: In cases of unexplained central visual loss, microperimetry testing may be a useful ancillary test for the diagnosis of cerebrovascular disease.

Accuracy of CO2 conductance predicted using a morphometric model of the middle ear mucosa.

CONCLUSION: These results hold promise that morphometric analysis can be used to generate transMEM (middle ear mucosa) gas conductance estimates for MEM geometries representative of the shift from healthy to pathologic states (e.g. increased MEM thickness and capillary density). OBJECTIVES: Novel strategies to treat otitis media with effusion require a better understanding of how MEM geometry affects gas transport. Earlier studies developed techniques to empirically measure transMEM gas conductance and to estimate conductance using morphometric models of MEM geometry. We used chinchillas to determine the correspondence between experimentally measured transMEM CO2 conductance and that predicted by morphometric study of the MEM. MATERIALS AND METHODS: TransMEM CO2 conductance was measured unilaterally in 10 chinchillas; the animals were killed and the ME was removed and processed for morphometric analyses of MEM geometry. RESULTS: The average measured and estimated transMEM CO2 conductances were 4.87+/-2.30 x 10-10 and 1.75+/-0.29 x 10-10 mol/s/mmHg, respectively. The magnitude and direction of the estimate error were similar for all ears, suggesting a fixed, negative bias to the estimate. A theoretically consistent source for this bias was identified as the representation of the true diffusional length within a 3-D geometry using a 2-D modeling platform. Best estimate correction for this effect based on available data significantly reduced the estimate bias.

MULTIFOCAL RETINAL INFILTRATES WITH PHLEBITIS AND OPTIC NEUROPATHY IN AN HIV-POSITIVE PEDIATRIC PATIENT.

PURPOSE: To describe an unusual presentation of bilateral HIV-associated multifocal retinal infiltrates with phlebitis and optic neuropathy in a pediatric patient from Zimbabwe, Africa. METHODS: Retrospective case report of a 15-year-old boy from Zimbabwe, Africa. RESULTS: The patient was found to have bilateral vitritis, multifocal retinitis with phlebitis, and optic neuropathy in the setting of previously unrecognized HIV infection. Vision improved and the clinical findings resolved after treatment with intravenous corticosteroids and highly active retroviral therapy (HAART). CONCLUSION: The authors describe the occurrence and treatment of bilateral, HIV-associated multifocal retinal infiltrates with phlebitis and HIV-associated optic neuropathy in a pediatric patient from Zimbabwe, Africa.

Effectiveness of medial rectus advancement alone or in combination with resection or lateral rectus recession in the management of consecutive exotropia.

PURPOSE: To prospectively determine the long-term success of medial rectus advancement alone or in combination with other procedures in the management of consecutive exotropia. METHODS: All patients with consecutive exotropia who underwent medial rectus advancement alone or in combination with medial rectus resection or lateral rectus recession or both, performed by a single surgeon between 1999 and 2010, were included. Initially, a retrospective review was performed. Patients were then recalled and examined by a masked observer. Good results were defined as final alignment within 10(Δ) of orthotropia. RESULTS: A total of 46 patients were enrolled in the study with a mean age of 43 ± 15.5 years (range, 14-76) and a mean exotropia of 32 ± 18(Δ) (range, 10-90). Good results were achieved in 33 patients (72%) at a mean follow-up time of 2.5 years. Of the 21 patients returning for prospective examination, 15 (71%) had good alignment at an average follow-up of 4.2 years (range, 6.9 months to 8.6 years). Adduction deficits were improved in 30 of 33 (91%) patients at final follow-up. CONCLUSIONS: In patients with consecutive exotropia, surgery including medial rectus advancement alone or in combination with resection or lateral rectus recession or both usually is effective.