LONG-TERM RESULTS OF AUTOLOGOUS RETINAL PIGMENT EPITHELIUM AND CHOROID TRANSPLANTATION FOR THE TREATMENT OF EXUDATIVE AND ATROPHIC MACULOPATHIES.

PURPOSE: To evaluate the long-term results of autologous retinal pigment epithelium (RPE) and choroid transplantation (RPE-choroid patch) for exudative and atrophic maculopathies. METHODS: Consecutive chart review of 120 eyes, which underwent RPE-choroid patch, from 2007 to 2017 for RPE atrophy or choroidal neovascular membrane secondary to exudative and hemorrhagic age-related macular degeneration, myopia, angioid streaks, and laser. Eyes were tested with best-corrected visual acuity (BCVA), reading ability, optical coherence tomography, fluorescein angiography and indocyanine green angiography, autofluorescence, and microperimetry. RESULTS: Eighty-eight eyes of 84 patients had complete data, with 2- to 10-year follow-up. Mean age was 71.9 ± 9.06 years. Mean preoperative and postoperative BCVA was 20/320 (1.2 ± 0.2 logMAR) and 20/200 (0.94 ± 0.36 logMAR), respectively (P = 0.009). Reading ability recovered in 43% of cases. Microperimetry showed central fixation. A gain of at least 15 letters was obtained in 40% of eyes. Integrity (P = 0.009) of external limiting membrane and higher preoperative BCVA (P = 0.001) predicted better final BCVA. Complications were retinal detachment (11.4%), macular atrophy (7%), subretinal hemorrhage (4.5%), epiretinal membrane (4.5%), recurrent choroidal neovascular membrane (4.5%), macular hole (3.4%), and cystoid edema (3%). CONCLUSION: Autologous RPE-choroid patch achieved long-lasting BCVA improvement and central fixation, in eyes with choroidal neovascular membrane and intact external limiting membrane. Atrophic maculopathies only obtained temporary visual benefit.

Partial thickness sclerectomy to treat exudative retinal detachment secondary a submacular choroidal hemangioma in a Sturge-Weber syndrome.

PURPOSE: To demonstrate the safety and efficacy of partial thickness sclerectomies to treat exudative retinal detachment secondary to choroidal hemangioma, non-suitable with photodynamic therapy in a 5-year-old child with Sturge-Weber syndrome. METHODS: A 5 year-old child presented exudative retinal detachment secondary to choroidal subfoveal diffuse hemangioma. The child was non-compliant to undergo a photodynamic therapy. A partial thickness sclerectomy was made in each quadrant under general anesthesia. RESULTS: The retina was re-attached with improvement in vision from 20/400 to 20/80. Two years after primary surgery, the retinal detachment relapsed. Drainage of the subretinal fluid was obtained by the revision of the sclerectomies. After obtaining retinal reattachment, photodynamic therapy was applied to treat the hemangioma. No complications were reported after treatment. CONCLUSION: Sclerectomies may be considered an efficient and safe surgical option for the management of exudative retinal detachment secondary to choroidal hemangioma in patients non-suitable for photodynamic therapy, waiting for photodynamic therapy to be practicable directly on the hemangioma.

COMBINED AUTOLOGOUS TRANSPLANTATION OF NEUROSENSORY RETINA, RETINAL PIGMENT EPITHELIUM, AND CHOROID FREE GRAFTS.

PURPOSE: To evaluate the feasibility and initial functional and anatomical outcomes of transplanting a full-thickness free graft of choroid and retinal pigment epithelium (RPE), along with neurosensory retina in advanced fibrosis and atrophy associated with end-stage exudative age-related macular degeneration with and without a concurrent refractory macular hole. METHODS: During vitrectomy, an RPE-choroidal and neurosensory retinal free graft was harvested in nine eyes of nine patients. The RPE-choroidal and neurosensory retinal free graft was either placed subretinally (n = 5), intraretinally to cover the foveal area inside an iatrogenically induced macular hole over the RPE-choroidal graft (n = 3) or preretinally (n = 1) without a retinotomy wherein both free grafts were placed over the concurrent macular hole. Silicone oil endotamponade was used in all cases. RESULTS: Mean follow-up was 7 ± 5.5 months (range 3-19). The mean preoperative visual acuity was ∼count fingers (logarithm of the minimum angle of resolution = 2.11, range 2-3), which improved to ∼20/800 (logarithm of the minimum angle of resolution 1.62 ± 0.48, range 0.7-2, P = 0.04). Vision was stable in 5 eyes (55.6%) and improved in 4 eyes (44.4%). Reading ability improved in 5 eyes (55.6%). Postoperative complications were graft atrophy (n = 1), epiretinal membrane (n = 1), and dislocation of neurosensory retina-choroid-RPE free graft (n = 1). CONCLUSION: Combined autologous RPE-choroid and neurosensory retinal free graft is a potential surgical alternative in eyes with end-stage exudative age-related macular degeneration, including concurrent refractory macular hole.

Cystoid macular edema after pars plana vitrectomy for idiopathic epiretinal membrane.

BACKGROUND: To evaluate the incidence of cystoid macular edema (CME) after 23-gauge pars plana vitrectomy (PPV) with or without combined cataract surgery for the treatment of idiopathic epiretinal membrane (ERM). METHODS: Retrospective, non-comparative, interventional case series. Data included patient age, indication for surgery, and intra- and post-operative complications. The follow-up lasted 1 year. Best-corrected visual acuity (BCVA logMAR), central foveal thickness (CFT micron-µ) and the incidence of intra-retinal cysts were evaluated. CME was defined as post-operative observation of intra-retinal cysts at optical coherence tomography, preventing improvement or causing reduction of BCVA when compared to the pre-operative value. Statistical analysis was performed to identify the risk factors of CME. RESULTS: Two hundred and forty two eyes of 242 patients underwent PPV for the treatment of idiopathic ERM. Statistical analysis showed that the presence of preoperative intra-retinal cysts were associated with persistent CME following surgery (odds ratio 3.89; 95%CI: 1.63-9.28, P = 0.0004). However, postoperative CME occurred in 10 % of eyes that did not show preoperative CME. In addition, there was a significant correlation between the baseline value of CFT and the values of CFT at each time point during the follow up (p < 0.0001), with greater values of the pre-operative thickness correlating to greater values of post-operative thickness. CONCLUSIONS: Persistent or new CME following surgery for idiopathic ERM are frequently identified after PPV for ERM. The statistical results of the current study suggest that intraretinal cysts and increased preoperative CFT are associated with reduced visual acuity after surgery.

INDICATIONS AND RESULTS OF A NEW L-SHAPED MACULAR BUCKLE TO SUPPORT A POSTERIOR STAPHYLOMA IN HIGH MYOPIA.

BACKGROUND: The efficacy of a macular buckle in treating myopic traction maculopathy was studied. METHODS: Fifty eyes with myopic traction maculopathy, in the form of macular detachment with macular hole (MHMD), or without macular hole (MD) and macular foveoschisis (MF), were treated with vitrectomy combined with macular buckle or with a macular buckle without vitrectomy. RESULTS: Combined group: The combined group comprised 10 eyes with MHMD, 6 eyes with MD, and 4 eyes with MF. The retina was attached in 100% of MD and MHMD and the MF was improved in 100% of cases. The hole was closed in 60% of MHMD. The mean initial and final Snellen best-corrected visual acuity was 20/500 and 20/100 for MHMD, 20/200 and 20/60 for MD, and 20/200 and 20/50 for MF. The mean surgical time was 80 ± 35 minutes. Fundus angiography or indocyanine green revealed no alteration of the chorioretinal blood flow. Buckle shortening was required in 6/20 (30% of cases) patients for lateral extrusion of the sponge through the conjunctiva with the first sponge model. This complication was overcome by changing the arm of the buckle. Buckle group: The buckle group comprised 5 eyes with MHMD, 11 with MD, and 14 with MF. The retina was attached in 100% of MHMD, MD, and MF. The macular hole was closed in 60%. The mean initial and final Snellen best-corrected visual acuity was 20/800 and 20/60 for MHMD, 20/125 and 20/50 for MD, and 20/200 and 20/63 for MF. The mean postoperative decrement in axial length was 1.21 mm. The mean surgical time was 35 ± 15 minutes. Fundus angiography or indocyanine green revealed no alteration of the chorioretinal blood flow. Complications included conjunctiva erosion (15%), diplopia (7.7%), and pain (3.8%). Magnetic resonance imaging showed flattening of the posterior staphyloma. CONCLUSION: Considering the possible complications and technical difficulties of vitrectomy, we suggest that the macular buckle alone should be the first treatment of myopic traction maculopathy. Vitrectomy should be reserved only for cases of tangential tractions.

Inter-observer and intra-observer reliability of the myopic traction maculopathy staging system.

AIM: The aim of this study is to evaluate the inter-observer and intra-observer agreement of the myopic traction maculopathy (MTM) staging system (MSS). METHODS: The agreement test for MSS was based on the evaluation of 104 optical coherence tomography (OCT) scans from 104 myopic eyes. According to the MSS, six observers were asked to identify, in each image, one among four retinal patterns and one among three foveal patterns of MTM, the presence of an outer lamellar macular hole (OLMH) and an epiretinal membrane (ERM). Each observer repeated the agreement test after a 60 days interval. RESULTS: Inter-observer reliability: the agreement of the test for the retina pattern was substantial (0.724), for the fovea pattern was 0.821, for the OLMH was 0.656, and for the ERM was 0.463. When all the criteria are included in the validation test the agreement was 0.657. Regarding the weighted statistics (Gwet's AC2, 95% CI), the validation test was statistically significant both when the variables were considered one by one, with an excellent agreement, respectively for the retina pattern (0.955) and the fovea pattern (0.963) and when all the variables were included in the tests (0.930). Intra-observer repeatability: all observers rerun the test after 2 months with a statistically significant percentage of confirmation of the previous test. CONCLUSION: The MSS offers in one Table information on diagnosis, natural history, function, prognosis, and management of MTM. The MSS is user-friendly and highly reproducible.

The new Myopic Traction Maculopathy Staging System.

PURPOSE: To describe a comprehensive OCT-based classification of myopic traction maculopathy (MTM). METHODS: Two hundred eighty-one eyes with MTM (visited from 2006 to 2018), were retrospectively reviewed for age, best-corrected-visual-acuity (BCVA), axial length (AL), optical coherence tomography (OCT), and wide-field color fundus-photographs. The study was divided in two Phases. Phase 1: MTM types were categorized with OCT and correlated with age and BCVA. The type of staphyloma was described. Phase 2: the evolution of MTM was studied evaluating at least three OCT exams of each eye taken at different timings (interval between each exam: 1-10 years). RESULTS: Phase 1: We identified, four MTM retinal stages (1. Inner/Outer Maculoschisis; 2. Predominantly outer Maculoschisis; 3. Maculoschisis-Macular Detachment; 4. Macular Detachment) and three foveal stages (a. Normal fovea; b. Inner Lamellar-Macular-Hole; c. Full-Thickness-Macular-Hole). Outer-Lamellar-Macular-Holes and epiretinal abnormalities were associated findings. Stages 1 to 2 were younger than stages 3 to 4 (p < 0.05). BCVA in stages 1, 2 was similar, and higher than stages 3, 4 (p < 0.02). About 14% of eyes had no staphyloma, 73% of eyes had staphyloma type 1 or 2. MTM stages were not correlated with AL. Phase 2: The retina could change in time from stage 1 to 4, or the fovea could change from stage a to c. Mean evolution time from stage 1 to 2, stage 2 to 3, and 3 to 4 were 20, 12, 3 months, respectively. BCVA decreased over time as stages increased (p = 0.47). CONCLUSION: The MSS Table displays a new classification, the natural evolution, and practical insights for the management of MTM.

VISUAL RECOVERY AFTER AUTOLOGOUS RETINAL PIGMENT EPITHELIUM AND CHOROIDAL PATCH IN A PATIENT WITH CHOROIDAL NEOVASCULARIZATION SECONDARY TO ANGIOID STREAKS: LONG-TERM RESULTS.

PURPOSE: To describe a successfully treated case of autologous retinal pigment epithelium and choroidal patch in a patient with choroidal neovascularization secondary to angioid streaks. METHODS: A 53-year-old man with angioid streaks and a subfoveal choroidal neovascularization underwent autologous retinal pigment epithelium and choroid transplantation. Lensectomy, pars plana vitrectomy, 200° peripheral temporal retinotomy, isolation of the patch, endolaser, and silicone oil tamponade 1,000 cts were performed. Preoperative and postoperative ophthalmic examinations included best-corrected visual acuity, fluorescein angiography, indocyanine green angiography, autofluorescence, and optical coherence tomography. RESULTS: Two months after surgery, best-corrected visual acuity (Snellen equivalent) improved from 20/200 to 20/100. At 6 months, best-corrected visual acuity further increased to 20/40 and the reading ability, which was absent preoperatively, improved to J2. Visual results were maintained after 2.5 years and no recurrence of choroidal neovascularization was observed. CONCLUSION: Transplantation of a full-thickness patch of retinal pigment epithelium and choroid under the fovea may be considered to prevent retinal atrophy with significant visual improvement in the case of a low active choroidal neovascularization secondary to angioid streaks. Moreover, preoperative optical coherence tomography might guide in highlighting those patients in whom the outer retinal layers are still visible as the best candidate for surgery.