Longitudinal analysis of the structural pattern of pseudophakic cystoid macular edema using multimodal imaging.

PURPOSE: To describe the relationship between pseudophakic cystoid macular edema (CME) progression and retinal structural changes observed by spectral-domain optical coherence tomography (SD-OCT) and fluorescein angiography. METHODS: Retrospective, consecutive, longitudinal imaging analysis of patients with acute pseudophakic cystoid macular edema. Two observers at two study centers evaluated all images and categorized the macular structural features based on the retinal layer involved with cystic changes and/or subretinal fluid. A time series of the structural pattern and visual acuity was constructed for 1-month intervals over a 6-month study period. RESULTS: Thirty nine patients presented with CME. The mean time since cataract extraction was 48 ±38 days (range 5-71). CME included inner nuclear layer (INL) cystic changes, outer plexiform layer (OPL) cystic changes, and subretinal fluid. Isolated INL changes were observed in four phakic fellow eyes. Isolated OPL morphology was not observed, and additional inner layers remained uninvolved. Resolution occurred rapidly following administration of periocular glucocorticoids, and typically demonstrated a reverse structural pattern or delayed subretinal fluid resolution. Isolated subretinal fluid or a combined INL and subretinal fluid structure indicated CME resolution. CONCLUSION: Acute and recurrent pseudophakic CME involves a directional progression of the retinal layer involved with cystic changes and a clinical course. CME begins with INL cystic changes, progresses to combined INL and OPL morphology, and may continue to involve subretinal fluid. The inner nuclear layer is the most frequently involved layer, and isolated INL cysts may occur in phakic fellow eyes. A three-layer structure, the presence of OPL morphology, or isolated INL early in the postoperative period indicates disease activity.

25-gauge pars plana vitrectomy with medium-term postoperative perfluoro-n-octane for the repair of giant retinal tears.

PURPOSE: The purpose of this study was to describe the treatment of giant retinal tears (GRTs) with 25-gauge pars plana vitrectomy (PPV) and medium-term postoperative perfluoro-n-octane (MT-PFO). METHODS: The study was a retrospective interventional case series of consecutive patients with GRTs treated with 25-gauge PPV and postoperative MT-PFO for a period of 2-3 weeks. A second, staged procedure was performed in all patients for PFO removal. RESULTS: Twenty-three eyes of 22 patients were studied, with a mean follow-up of 33.04 ± 19.74 months. Successful reattachment was achieved in 91.3 % of eyes (21/23) after MT-PFO. Retinal re-detachment occurred in five eyes, which was caused by proliferative vitreoretinopathy. Additional complications included cataract progression (n = 10), foreign body response (30.4 %, 7/23), and transient intraocular pressure (IOP) elevation (8/23, 34.8 %). Transient IOP elevation was associated with worse visual outcome (p = 0.01). CONCLUSIONS: MT-PFO was found to be an effective and safe technique for operative management of GRTs. In the majority of patients, retinas remained attached without further surgical intervention. Cataract progression, intraocular inflammation, and associated increased intraocular pressure are potential complications of MT-PFO.

Retinal angiomatous proliferation with chorioretinal anastomosis in childhood Coats disease: a reappraisal of macular fibrosis using multimodal imaging.

PURPOSE: To describe the structural characteristics of retinal angiomatous proliferation and chorioretinal anastomosis in childhood Coats disease and redefine the previously described macular fibrosis. METHODS: Prospective observational case series of consecutive patients with Coats disease examined over a 1-year study period. Multimodal imaging, including color fundus photography, wide-field fluorescein angiography, and spectral domain optical coherence tomography, was used to identify the features of macular retinal angiomatous proliferation and chorioretinal anastomosis. RESULTS: Retinal angiomatous proliferation and chorioretinal anastomosis were present in 5 of 21 patients with Coats disease (24%). The lesions appeared as well demarcated, nodular retinal pigment epithelial detachments surrounded by exudate, with retinal vessels continuous with the underlying choroidal neovascularization. CONCLUSION: Retinal angiomatous proliferation and chorioretinal anastomoses are features observed in a number of children (24% in the present series) with Coats disease and macular involvement. This lesion represents a distinct macular variant of Coats disease that underlies at least a proportion (all in the present series) of the previously described "macular fibrosis" and "subretinal mounds."

Pearls and pitfalls in diagnosis and management of coats disease.

PURPOSE: To review current literature on Coats disease and provide a structured framework for differentiating challenging clinical features in Coats disease patients. METHODS: We critically reappraise historical and current literature and present clinical methods for developing a thorough differential diagnosis and management strategy for Coats disease. RESULTS: Coats disease is a sporadic, usually unilateral condition typically occurring in young males. When untreated, this disorder can lead to total exudative retinal detachment and secondary glaucoma. CONCLUSIONS: Anti-VEGF agents are currently a treatment option in combination with ablative therapy of telangiectatic vessels. Anti-VEGF agents appear particularly useful for patients with extensive areas of exudative retinal detachment, and are an effective treatment option for total retinal detachment.

Comparison of morphologic features of macular proliferative vitreoretinopathy and idiopathic epimacular membrane.

BACKGROUND: To compare the spectral-domain optical coherence tomography morphologic features and visual characteristics of a series of patients with epimacular membrane with and without a history of retinal breaks. METHODS: Prospective, comparative case series of patients with epimacular membrane. All patients were evaluated with spectral-domain optical coherence tomography and detailed peripheral retinal examination. Symptomatic patients were treated with pars plana vitrectomy and epimacular membrane removal based on standard visual criteria. RESULTS: Macular proliferative vitreoretinopathy was present in 21 of 50 patients (42%). Approximately 18 of 21 patients had a previous retinal break, 5 of which were untreated before the initial examination. No retinal breaks were observed in the idiopathic group. Macular proliferative vitreoretinopathy was highly associated with a history of retinal breaks (P < 0.001). Presenting visual acuity was significantly worse (mean, 0.86 ± 0.44) for macular proliferative vitreoretinopathy than for the idiopathic group (mean, 0.44 ± 0.36). CONCLUSION: Epimacular membrane occurring in the context of previous retinal breaks or macular proliferative vitreoretinopathy has a characteristic morphologic feature in spectral-domain optical coherence tomography. Surgical removal typically results in significant visual improvement.

Foreign body response within postoperative perfluoro-N-octane for retinal detachment repair: clinical features, grading system, and histopathology.

PURPOSE: To describe the clinical and histopathologic characteristics of inflammatory deposits occurring within intermediate duration postoperative perfluoro-n-octane (PFO) for inferior retinal detachment repair. METHODS: Prospective interventional case series of consecutive patients with inferior retinal detachment treated with intermediate duration postoperative vitreous cavity PFO endotamponade were analyzed by ophthalmoscopy for the presence of inflammation and white deposits. Ten consecutive samples developing white deposits were analyzed microscopically. Clinical variables were analyzed. RESULTS: One hundred and eighty-one eyes of 181 patients were included (mean age = 52.4 ± 14 years; mean follow-up = 29.7 ± 14 months). Fifty of 181 patients (28%) developed a characteristic foreign body response with abundant white deposits within indwelling PFO. Ten consecutive samples analyzed histologically contained abundant macrophages, the absence of additional inflammatory cells, and intracytoplasmic optically lucent inclusions. Foreign body response was associated with longer duration of PFO (P = 0.003). Perfluoro-n-octane foreign body response was not associated with age (P = 0.136), ethnicity (P = 0.101), visual outcome (P = 0.157), or persistent intraocular pressure elevation (P = 0.381). CONCLUSION: A stereotypical foreign body response occurs in ∼ 30% of patients with postoperative vitreous cavity PFO and becomes clinically apparent at 7 days to 10 days after initial placement for rhegmatogenous retinal detachment repair. The response consists almost exclusively of macrophages and does not seem to be related to either long-term intraocular pressure elevation or visual outcome. The response may be related to the duration of indwelling PFO and may limit visualization of the retina during PFO removal.

Anatomical and visual outcomes after two-port pars plana vitrectomy reoperation under silicone oil for epimacular membrane or recurrent retinal detachment.

PURPOSE: To describe the anatomical and visual outcomes in a series of patients undergoing two-port pars plana vitrectomy reoperation under silicone oil for recurrent retinal detachment (RD) due to proliferative vitreoretinopathy or epimacular membrane (EMM) after RD repair. METHODS: This study is a prospective, consecutive, interventional case series of patients presenting with recurrent RD or EMM under silicone oil. Two-port 25-gauge pars plana vitrectomy reoperation without an infusion port was performed in all cases. RESULTS: Thirty-nine patients were included. Reoperation pathology included recurrent RD with proliferative vitreoretinopathy (n = 33) and EMM alone (n = 6). The mean number of previous retinal surgeries was 2.4 ± 1.1 (range, 1-5). The mean overall follow-up was 24 ± 3.7 months. The mean visual acuity change from baseline at final follow-up was an improvement of 0.74 ± 0.63. Macular reattachment was achieved in 29 of 33 patients with RD, and EMMs were successfully removed in all patients. CONCLUSION: Two-port pars plana vitrectomy reoperation is an efficacious method for repair of consecutive RD due to proliferative vitreoretinopathy or EMM in patients with previous RD repair with silicone oil. Significant visual improvement with a low complication rate may be achieved in patients with advanced proliferative vitreoretinopathy or EMM under silicone oil.

Delayed onset inner nuclear layer cystic changes following internal limiting membrane removal for epimacular membrane.

PURPOSE: To report the rare occurrence of new inner nuclear layer cystic spaces occurring in eyes treated with pars plana vitrectomy (PPV) and internal limiting membrane (ILM) removal for idiopathic epimacular membrane (EMM). MATERIALS AND METHODS: Consecutive patients with EMM without preoperative retinal cystic changes undergoing PPV with ILM peeling were retrospectively evaluated. Patients developing a characteristic inner nuclear layer cystic change were analyzed. RESULTS: Inner nuclear layer cystic changes appeared in eight of 768 (1.04 %) eyes at a mean postoperative time period of 3.2 ± 0.89 months. No leakage or pooling was demonstrated on postoperative fluorescein angiography. Morphologic characteristics included vertically elongated hyporeflectant spaces within the inner nuclear layer on spectral domain optical coherence tomography (SD-OCT). CONCLUSIONS: A minority of patients undergoing PPV with ILM peeling develop new, delayed onset, postoperative inner nuclear layer cystic spaces with a characteristic SD-OCT appearance and no evidence of angiographic leakage.

Comparison of observation, intravitreal bevacizumab, or pars plana vitrectomy for non-proliferative type 2 idiopathic macular telangiectasia.

PURPOSE: To compare visual and anatomic outcomes in eyes with type 2 idiopathic macular telangiectasia (Mactel) treated with either intravitreal bevacizumab (IVB), observation, or pars plana vitrectomy (PPV) with internal limiting membrane removal. METHODS: Retrospective, consecutive, interventional case series of phakic patients with Mactel. Best-corrected Snellen visual acuity (BCVA) and complete ophthalmic exam was obtained prior to treatment and at subsequent 3-month intervals for a minimum of 6 months. Fluorescein angiographic and spectral-domain optical coherence tomography features were examined, and compared to BCVA at treatment initiation and follow-up. RESULTS: Fifty-six eyes of 28 patients were evaluated. Mean age was 65 ± 12 years, and mean follow-up was 24 ± 13 months. Patients were treated with either observation (n = 33), IVB (n = 15), or PPV (n = 8). Mean number of treatments for the IVB group was 2.5 ± 3.5 intravitreal injections. No significant differences in BCVA change were observed between treatment groups via one-way ANOVA (p = 0.49). Presence of inner retinal cysts was not correlated to BCVA (p > 0.05). Discontinuous outer nuclear layer was significantly related to worse initial and final vision, but not to BCVA change. CONCLUSION: IVB and PPV with ILM removal appear ineffective in improving visual outcome in eyes with non-proliferative Mactel. SD-OCT evidence of disrupted foveal outer nuclear layer is related to decreased BCVA, but not related to BCVA change following treatment.

Incidence, morphology, and classification of epimacular membrane rip.

PURPOSE: To describe the incidence, associated factors, morphology, and visual characteristics of a series of patients with tears within an epimacular membrane (EMM). METHODS: Consecutive, prospective, observational case series of patients with EMM rip. Patients were evaluated with spectral domain optical coherence tomography, infrared photography, and fundus autofluorescence. Symptomatic patients were treated with pars plana vitrectomy and EMM removal. Follow-up imaging evaluation was performed at 3-month intervals. RESULTS: A total of 761 patients presented with EMM. Thirty-four eyes of 34 patients (4.5%) developed EMM rip. Frequent associated features included history of cataract extraction, diabetes mellitus, and retinal tear treated with photocoagulation. Morphologic characteristics included a scrolled torn edge of internal limiting membrane/EMM. Rip patterns include horseshoe shapes and patchy confluent striae and appeared as dark lines on infrared or fundus autofluorescence imaging. The EMM rips were classified as Type 1 if the rip occurred within 500 µm of the foveola on spectral domain optical coherence tomography and Type 2 if extrafoveal. Foveal involvement was associated with worse presenting vision (P = 0.002) and visual outcome after EMM removal (P = 0.012). Previous retinal tear was associated with worse visual outcome. CONCLUSION: The EMM rip occurs in a small but significant minority of patients with EMM. Foveal involvement leads to increased visual deficit and may indicate a worse visual outcome at presentation and after intervention. Fundus autofluorescence and infrared imaging are useful in identifying EMM rip patterns.

Pars plana vitrectomy with medium-term postoperative perfluoro-N-octane for recurrent inferior retinal detachment complicated by advanced proliferative vitreoretinopathy.

PURPOSE: To describe a series of patients with recurrent inferior retinal detachment complicated by proliferative vitreoretinopathy (PVR) treated with pars plana vitrectomy and postoperative perfluoro-n-octane (PFO). METHODS: Consecutive patients with recurrent inferior retinal detachment and Grade C PVR were prospectively treated with 25-gauge pars plana vitrectomy and postoperative "medium-term" PFO for 2- to 3-week duration. All patients had subsequent PFO removal in a planned staged procedure. RESULTS: Forty-four eyes of 44 patients were included. Mean follow-up time was 30.71 ± 12.92 months. Successful reattachment was achieved in 86% of eyes (38/44). Reattachment rates were statistically equivalent between eyes with and without previous scleral buckle. Reasons for redetachment were recurrent inferior PVR (four of six) and new superior break without PVR (two of six). Additional complications observed were cataract progression requiring surgery (42%), persistent intraocular pressure elevation (36%), and transient inflammation (32%). Macula-off status (P = 0.02) and persistent intraocular pressure elevation (P = 0.02) were factors associated with worse visual outcome. CONCLUSION: Medium-term PFO was found to be an efficacious technique for operative management of recurrent inferior retinal detachments complicated by Grade C PVR. The method of primary repair (scleral buckle vs. pars plana vitrectomy) did not affect reattachment rates. Transient inflammation and intraocular pressure elevation are potential complications associated with this technique. Persistent intraocular pressure elevation was associated with worse visual outcome.

Clinicopathologic correlation of disc and peripapillary region using SD-OCT.

PURPOSE: To describe a technique for evaluating peripapillary and optic nerve head (ONH) anatomy using spectral domain optical coherence tomography (SD-OCT) raster scanning in humans and compare quantifiable parameters between diagnosis categories. METHODS: Ninety-five eyes of 51 consecutive patients were evaluated in this retrospective cross-sectional pilot study. Cirrus 5-line raster SD-OCTs with a resolution of 5 to 15 µm obtained through the ONH were included. A single observer manually measured neural canal opening (NCO), prelaminar canal depth (PLCD), peripapillary choroidal thickness (PPCT), and canal nerve fiber layer (CNFL) in normals, ocular hypertension, primary open-angle glaucoma (POAG), low-pressure glaucoma (LPG), secondary glaucoma, and early atrophic age-related macular degeneration. Clinical information, including central corneal thickness (CCT), was obtained via medical record review. Mean anatomical values within diagnosis categories were compared using one-way analysis of variance and multivariate analysis. Bivariate analysis was used to investigate relationships between continuous variables, and significant (p < 0.05) relationships were incorporated into the final statistical model. RESULTS: Horizontal NCO was significantly greater in eyes with LPG than that in normals (p = 0.021). The PPCT was thinner in age-related macular degeneration (p = 0.001) and glaucoma (p = 0.004) compared with that in controls (normals). Mean CNFL was thinner in POAG (p < 0.001) and LPG (p = 0.053) compared with that in normals. Vertical NCO was inversely correlated to CCT (p = 0.013). Multivariate analysis indicated a positive correlation between PLCD and PPCT (p = 0.008) and an inverse correlation between CNFL and PLCD (p < 0.001). Controlling for PPCT, PLCD and CCT were inversely correlated (p < 0.001). CONCLUSIONS: The SD-OCT raster scanning may be used to quantify ONH anatomy in humans. The NCO differences between POAG and LPG may indicate a distinct structural vulnerability in LPG. In addition, CNFL, PPCT, and PLCD may be important parameters to consider in glaucoma. The PLCD correlates with PPCT and should be considered in new models of glaucoma pathogenesis.

Inner Nuclear Layer Cystic Changes in Phakic Fellow Eyes of Patients With Acute Pseudophakic Cystoid Macular Edema.

Improvements in retinal imaging have recently elucidated structural patterns in the development of macular edema, particularly involving the inner nuclear layer. Here, the authors describe two cases of isolated inner nuclear layer cystic changes in the phakic fellow eye of patients with pseudophakic cystoid macular edema. Both cases improved with treatment of their fellow eye and resolution of contralateral macular edema. The authors hypothesize potential pathomechanisms for this likely common but under-recognized phenomenon. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:522-524.].

Focal Choroidal Elevations: Localized Pigment Epithelial Contour Alterations due to Isolated Choroidal Vessels.

PURPOSE: The objective of this case series was to describe the clinical and imaging features of focal choroidal elevations (FCE), which are chorioretinal contour changes induced by individual choroidal vessels within an overall thin-appearing choroid. METHODS: A total of 787 enhanced depth imaging (EDI) spectral domain optical coherence tomography (SD-OCT) patient images were initially screened for the presence of FCE. Prospective imaging analysis of 38 patients with FCE was done. Mean central macular choroidal thickness (CMCT), FCE location, FCE vessel lumen diameter, patient demographics, cycloplegic autorefraction, ophthalmoscopic findings, and presence of choroidal neovascularization (CNV) in the fellow eye were recorded. RESULTS: FCE were observed in 25 patients with age-related macular degeneration (ARMD), in 5 patients with high myopia, and in 8 patients with age-related choroidal atrophy (ARCA). Mean patient age was 80 ± 9.4 years. Mean CMCT was 86 ± 40 µm. Mean lumen diameter of the vessels inducing FCE was 131 ± 33 µm. CONCLUSIONS: FCE are relatively frequently encountered morphologic features of elderly patients with ARMD, high myopia, and ARCA, and have a distinct clinical and imaging morphology which differs from classically described chorioretinal folds. The lesions may commonly be mistaken for pigment epithelial detachments on ophthalmoscopy, may be associated with CNV in fellow eyes, and have a characteristic SD-OCT appearance.

Morphology of Peripheral Vitreoretinal Interface Abnormalities Imaged with Spectral Domain Optical Coherence Tomography.

The objective of this study is to describe the clinical utility and morphologic characteristics of peripheral vitreoretinal interface abnormalities with spectral domain optical coherence tomography (SD-OCT). A prospective imaging analysis of 43 patients with peripheral vitreoretinal interface abnormalities seen on binocular indirect examination with scleral indentation was done. SD-OCT was evaluated for image quality and structural findings. Laser retinopexy was performed to surround all retinal breaks containing a full-thickness component via SD-OCT. Acceptable image quality for inclusion was obtained in 39/43 (91%) patients. Mean age was 41 ± 22 years, and mean follow-up was 14 ± 1.6 months. Decision to treat was altered following SD-OCT in 5% of the patients. Two cases of previously diagnosed operculated holes were found on SD-OCT to be partial-thickness operculated breaks or focal operculated schisis. Peripheral SD-OCT is a reliable and useful technique to examine the structural features of vitreoretinal interface abnormalities in vivo. This imaging modality is useful in the clinical management of suspected retinal breaks identified with indirect ophthalmoscopy.