Robotic-assisted patellofemoral arthroplasty provides excellent implant survivorship and high patient satisfaction at mid-term follow-up.

PURPOSE: Robotic adoption in knee surgery has yielded several benefits, but its application in patellofemoral arthroplasty (PFA) remains barely reported. The purpose of this study was to determine implant survival, patient satisfaction, and functional outcomes after robotic-assisted PFA at an intermediate follow-up. METHODS: This prospective analysis targeted 18 knees of 16 consecutive patients who underwent robot-aided PFA with three-year minimum follow-up (range, 3 to 6 years). Each patient was evaluated collecting pre-operative and post-operative medical record data, including range of motion, radiographic images, and multiple scores, such as VAS, APKS, and OKS. RESULTS: At surgery, the mean age was 55.4 years ± 14.4 (range, 32 to 78 years), and the mean BMI was 26.8 kg/m² ±5.2 (range, 20 to 36). Etiologies of patellofemoral osteoarthritis included idiopathic degeneration (28%), post-traumatic (33%), and dysplasia (39%). Pre-implantation scores were VAS 7.9 ± 1.4, AKPS 34.6 ± 23.3, and OKS 17.3 ± 10.3. One implant was revised with primary total knee arthroplasty for osteoarthritis progression. Clinical and radiographic follow-up showed no signs of loosening or infection. The maximum flexion reached an average of 131.1°±10.5° (range, 110° to 145°), accompanied by significantly improved score results (P-value < 0.01): VAS 1.1 ± 1.4, AKPS 90.2 ± 8.6, and OKS 46.3 ± 1.8. CONCLUSIONS: At 3 years after robotic assisted patellofemoral arthroplasty, excellent implant survival and patient satisfaction rates can be expected along with significantly improved functional and pain control outcomes. Although the limitations imposed by the restricted cohort, these findings indicate that robotic assistance in PFA is both safe and effective at intermediate follow-up.

Intraocular perfluorodecalin and silicone oil tamponade (double filling) in the management of complicated retinal detachment: functional and anatomical outcomes using small-gauge surgery.

PURPOSE: To describe the functional and anatomical results of complicated retinal detachment (RD) treated with small-gauge pars plana vitrectomy (PPV) and combined perfluorodecalin and polydimethylsiloxane tamponade (double filling, DF). METHODS: Retrospective analysis of consecutive patients with complex RD (severe proliferative vitreoretinopathy, inferior/posterior/giant retinal tears, and traumatic detachments) treated with small-gauge PPV, membrane peeling, and DF at the Department of Ophthalmology at San Gerardo Hospital, Monza, Italy. Main outcome measures included best-corrected visual acuity (BCVA), rates of retinal reattachment, and complications. RESULTS: This study included 15 patients with a median follow-up (FU) of 6 months (range 1-22). Three patients with early retinal redetachment under tamponade and FU shorter than 3 months were excluded from the final functional analysis, but they were considered anatomical failure. At the last examination, BCVA improved in 50% of patients and remained stable in 25% of patients and anatomical success was achieved in 73% of eyes, 64% of them without any endotamponade. Three eyes had retinal redetachment after perfluorodecalin/silicone oil exchange because of diffuse proliferative vitreoretinopathy (PVR) and required reoperation to achieve retinal attachment. In eyes with anatomical success, macular pucker was the most frequent long-term complication (27%). CONCLUSION: In the management of complex RD, small-gauge pars plana vitrectomy, and double filling endotamponade using wide-angle viewing systems was a well-tolerated and effective technique to preserve visual acuity and achieve anatomical success.

PREVALENCE AND RISK FACTORS OF ELLIPSOID ZONE DAMAGE AFTER PARS PLANA VITRECTOMY FOR IDIOPATHIC EPIRETINAL MEMBRANE.

PURPOSE: To assess factors associated with external limiting membrane (ELM)/ellipsoid zone (EZ) damage after pars plana vitrectomy (PPV) for epiretinal membrane and evaluate ELM/EZ damage impact on functional and anatomical outcomes. METHODS: Patients who underwent PPV with epiretinal membrane ± inner limiting membrane peeling were retrospectively analyzed. Best-corrected visual acuity and central macular thickness were longitudinally collected based on the available follow-up. Demographic data, clinical data, and surgical details were included in logistic regression models having ELM/EZ damage as a binary outcome. RESULTS: Overall, 179 eyes (171 patients) were included; 93 had a 12-month follow-up. Thirty-four eyes (19%) had ELM/EZ damage after surgery; in nine eyes (5%), ELM/EZ damage persisted at 12 months. Phacoemulsification during PPV (odds ratio = 6.97; P = 0.007) and ELM/EZ damage before PPV (odds ratio = 6.91; P = 0.007) were risk factors for postoperative ELM/EZ disruption. Thicker outer nuclear layer (P = 0.002), thicker ectopic inner foveal layer (P < 0.001), and higher endoillumination power (P = 0.03) were associated with slower visual recovery. Inner limiting membrane peeling (P = 0.04) was associated with slower anatomical recovery. CONCLUSION: Cataract extraction and outer retinal damage before PPV are associated with higher risk of photoreceptor damage postoperatively. The rate of visual improvement varies as a function of retinal layers' distortion before surgery; additional retinal manipulation slows restoration of the macular anatomy.

ASSOCIATED FACTORS AND SURGICAL OUTCOMES OF MICROCYSTOID MACULAR EDEMA AND CONE BOUQUET ABNORMALITIES IN EYES WITH EPIRETINAL MEMBRANE.

PURPOSE: To investigate the associated features and the surgical outcomes in eyes with microcystoid macular edema (MME) and cone bouquet abnormalities (CBA) undergoing epiretinal membrane peeling. METHODS: Retrospective study including patients who underwent pars plana vitrectomy for idiopathic epiretinal membrane. Factors associated with MME and CBA at baseline and their regression were identified with logistic regression models. Postoperative visual acuity was evaluated with linear mixed models from baseline to 12 months. Risk factors for new or worsened macular edema were explored with a Cox regression model. RESULTS: One hundred and eighty-seven eyes are included in this study; 30 eyes (16%) had MME and 53 eyes (28%) had CBA preoperatively. Microcystoid macular edema was associated with severe epiretinal membrane stage (odds ratio [95% confidence interval] = 3.6 [1.3-12.7], P = 0.02); CBA was inversely associated with ectopic inner foveal layer thickness (odds ratio [95% confidence interval] = 0.97 [0.97-0.99] for each 1- µ m EIFL increase, P = 0.006). Eyes with MME had worse visual acuity after epiretinal membrane peeling ( P = 0.01) and were at risk of macular edema worsening (hazard ratio [95% confidence interval] = 2.22 [1.01-5.16], P = 0.04). Older age was associated with MME persistence (odds ratio [95% confidence interval] = 2.46 [1.06-6.82] for each 10-year increase, P = 0.04). No significant associations were found for CBA. CONCLUSION: Although CBA had no prognostic consequences, MME was associated with suboptimal visual recovery and less efficient control of inflammation after surgery. Degeneration of Müller cells may have an alleged role, and further imaging and functional tests are warranted.

The visual outcomes of idiopathic epiretinal membrane removal in eyes with ectopic inner foveal layers and preserved macular segmentation.

PURPOSE: To analyze the functional impact of ectopic inner foveal layers (EIFL), along with other clinical and optical coherence tomography biomarkers, on patients with epiretinal membrane (ERM) and preserved foveal layers' segmentation undergoing ERM removal. METHODS: Retrospective review of consecutive patients with ERM who underwent pars plana vitrectomy with ERM peeling from December 2018 to December 2019. Baseline factors including age, gender, lens status, phacoemulsification at the time of surgery, tamponade agent, dye used for ERM and internal limiting membrane (ILM) enhancement, ILM peeling, best-corrected visual acuity (BCVA) and central macular thickness (CMT), presence and thickness of EIFL, thickness of outer nuclear layer (ONL), presence of a cotton ball, subfoveal state of photoreceptors, and presence of cystoid macular edema were included in a multivariable model having the BCVA at 12 months as the main outcome. The changes in EIFL and ONL thickness over time were also analyzed. RESULTS: Fifty-one patients (58 eyes, 23 eyes in the no EIFL group, and 35 eyes in the EIFL group) were enrolled. The BCVA significantly improved over 12 months after surgery, regardless of the presence of EIFL (p < 0.001). Eyes with no EIFL had better BCVA at month 3 (p = 0.04), but this difference was no longer detectable at 6 and 12 months. The presence of EIFL was not associated with the final BCVA (p = 0.9), while the CMT at 12 months correlated with EIFL thickness (r = 0.8, p = 0.008). CONCLUSION: Patients with EIFL could reach optimal visual acuity in the absence of disorganization of the inner retinal layers but should be warned of potentially longer healing times. None of the morphologic signs included in this study precluded good visual recovery on long-term follow-up.

Simultaneous intravitreal dexamethasone and aflibercept for refractory macular edema secondary to retinal vein occlusion.

PURPOSE: To assess the functional and anatomical outcomes of concurrent administration of aflibercept injection and dexamethasone (DEX) implant in patients with macular edema (ME) secondary to retinal vein occlusion (RVO), refractory to each of the two drugs previously administered as monotherapy. Secondary outcomes included the number of retreatments required in a 12-month follow-up and safety. METHODS: This is a prospective, interventional case series of consecutive patients with refractory ME secondary to RVO, followed over a year. One injection of aflibercept was followed by a DEX implant on the same day; retreatment was driven by the persistence of ME on SD-OCT at least 4 months after the previous combined therapy. Central retinal thickness (CRT), best-corrected visual acuity (BCVA), and intraocular pressure (IOP) were collected at 1 month and then every 2 months until the end of follow-up. RESULTS: Thirty eyes of 30 Caucasian patients were enrolled; mean duration of RVO before the first combined treatment was 25 ± 5 months (range 11 ± 30). Baseline BCVA was 0.73 ± 0.5 LogMAR, with no significant changes at 12 months (0.77 ± 0.51 µm, p = 0.2). Baseline CRT was 578.3 ± 161 µm, reducing to 352.5 ± 81 µm at 12 months (p = 0.003). Thirteen eyes (43.3%) required a second treatment. Twenty eyes (66.6%) showed no ME at the end of follow-up. One patient (3.3%) required topical IOP-lowering therapy during the study. CONCLUSION: In eyes with ME secondary to RVO unresponsive to either aflibercept or DEX administered singularly, a combination therapy with simultaneous administration of aflibercept and DEX was effective in resolving ME, despite the absence of visual improvement. Earlier combined treatment in the course of the disease might lead to better functional outcomes.

Comparison of two popular nuclear disassembly techniques for cataract surgeons in training: divide and conquer versus stop and chop.

PURPOSE: To compare two common phacoemulsification techniques in the learning curve phase, and their effect on ultrasound energy dissipation. METHODS: One hundred and ten consecutive patients scheduled for cataract surgery with the same surgeon in training were prospectively enrolled. Study was divided in two parts. In the first one, 60 patients were stratified for cataract grade [nuclear opalescence (NO) grade 2-4] and divided in two groups receiving surgery with the divide-and-conquer technique (Group-1) and with the stop-and-chop technique (Group-2). In the second part, 50 patients were stratified according to cataract grade (NO2-6), and the surgeon had to choose one of the two techniques according to personal preference. The primary outcome was the cumulative dissipated energy (CDE). RESULTS: Significant differences of CDE were observed between the NO3 and NO4 cataracts in Group-1. In Group-2, this difference was not significant, suggesting that with more advanced cataracts, the stop-and-chop technique allows less ultrasound use. In the second part of the study, the stop and chop was most frequently used for more advanced cataracts. When considering harder cataracts (NO5-NO6), patients receiving surgery with the divide-and-conquer technique had higher CDE values compared to stop and chop. CONCLUSIONS: Both divide-and-conquer and stop-and-chop techniques are efficient in the learning curve. Stop and chop dissipates less energy in harder nuclei. Once surgeons reach sufficient experience with both techniques, they should switch to a stop-and-chop technique, allowing lower levels of ultrasound energy.

Importance of Light Filters in Modern Vitreoretinal Surgery: An Update of the Literature.

PURPOSE: Direct endobulbar illumination during vitreoretinal surgery causes light-induced retinal damage known as phototoxicity. Spectral filters have been proposed to eliminate hazardous wavelengths from the emission spectrum before entering the eye. The purpose of our paper is to review advances in vitreoretinal surgery, focusing on intraoperative light filters. METHODS: A PubMed and Medline database search was carried out using the terms "spectral filters" associated with "vitreoretinal surgery," "phototoxicity," and "vitrectomy." Original articles, reviews, and book chapters up to March 2017 were reviewed; a few select articles published before 2000 are included for historical purposes. Material from recent meeting presentations was also added. The preferred language for the reviewed literature was English. RESULTS: Spectral filters significantly reduce the risk of phototoxicity associated with endoillumination in vitreoretinal surgery, allowing higher exposure times than with optic light fibers alone. Spectral filters may affect intraoperative luminance, but do not alter color contrast. Amber filters showed superiority over green and yellow filters. CONCLUSION: The choice of light sources coupled to spectral filters is strongly suggested, especially in dye-assisted chromovitrectomy. Histological donor eye studies and large multicenter trials are needed to validate the amount of photoprotection provided by spectral filters before a general recommendation can be made.

Real-world experience with fluocinolone acetonide intravitreal implant in patients with diabetic macular edema.

OBJECTIVES: to evaluate long-term effectiveness and safety of fluocinolone acetonide (FAc) implant used as second-line treatment in patients with persistent diabetic macular edema (DME). METHODS: retrospective data chart review of 241 pseudophakic eyes of 178 patients treated with FAc from July 2017 to December 2021 in 10 medical retinal units in Italy. The primary endpoint was the change of best-corrected visual acuity (BCVA) and central macular thickness (CMT) at 2 years. A Student's paired t-test was used. Additional therapies for DME and intraocular pressure (IOP)-related events were also evaluated. RESULTS: efficacy of FAc was assessed in a subset of 111 eyes with at least 24 months of follow-up. Mean BCVA increased at 2 years by 5.1 ETDRS letters (95%CI = 2.6-7.5; p < 0.001) while mean CMT decreased by 189 µm (95% CI 151-227; p < 0.001). Thirty-eight of these eyes (34.2%) needed additional intravitreal treatments, mainly anti-VEGF. Safety was evaluated on the entire cohort of 241 eyes treated with FAc. Overall, 66 eyes (27.4%) required emergent IOP-lowering medications (typically within the first-year post FAc) while 14 eyes (5.8%) underwent trabeculectomy, mostly during the second year of follow-up. CONCLUSION: FAc implant provides a substantial long-term functional and anatomical benefit when used as second-line treatment in eyes with DME. IOP rise can be adequately managed with topical agents although some eyes may require IOP-lowering surgery.

Resurrecting seasonal dynamics in waterbirds after wetland restoration: before-after monitoring highlights the role of a single dominant species.

We compared a set of uni-varied diversity metrics of a guild of water-related birds (hereafter 'waterbirds') before and after a wetland restoration carried out on uncultivated (reclaimed) lands. Over a period of five years, we observed a restart of seasonal waterbirds dynamics after wetland restoration by flooding of abandoned croplands, with a significant increase in all metrics of diversity, more evident in autumn-winter periods. Seasonal thresholds were evident before (2017-2018) and after (2018-2019) the flooding. These dynamics appeared irregular, probably for a different inter-annual suitability of the flooded meadows due to local ecological factors (e.g., change in meteorological regime and in rush-bed vegetation cover). Rarefaction curves, both for richness and diversity, showed how the waterbird community moved towards a greater complexity. Flooded meadow restoration, particularly favoured wintering species in Mediterranean sites, which explained the strong fluctuations in total abundance. At the species level, Northern Lapwing (Vanellus vanellus), absent before restoration, was the most abundant species after flooding, using flooded meadows with its gregarious behaviour. This 'crowding' may be explained also for a lack of similar habitats in the surrounding. Other dominant species (Anas platyrhynchos, Ardea cinerea, Egretta garzetta) showed a significant increase after restoration. Standardized before-after monitoring on medium term time periods seem suitable to evidence inter-annual season dynamics in diversity metrics of waterbird assemblages.

Recurrences and Macular Complications after Perfluorocarbon-Liquid-Free Vitrectomy for Primary Rhegmatogenous Retinal Detachment.

INTRODUCTION: This study investigates factors associated with recurrent rhegmatogenous retinal detachment (RRD), macular complications, and visual outcomes after pars plana vitrectomy (PPV) without perfluorocarbon liquids (PFCLs) for primary RRD. METHODS: A longitudinal cohort study included consecutive patients with RRD who underwent PFCL-free PPV. Postoperative visual acuity and spectral-domain optical coherence tomography findings [cystoid macular edema (CME), epiretinal membrane (ERM), ellipsoid zone/interdigitation zone (EZ/IZ) damage] were collected. Logistic regression and linear mixed models analyzed rates and risk factors for RRD recurrence, CME, ERM, EZ/IZ damage, and visual acuity at 12 months. RESULTS: 346 eyes with RRD were studied. Single-operation success rates were 96% and 93% for uncomplicated (n = 274 eyes) and complicated (n = 72 eyes) RRD, respectively. Factors associated with RRD recurrence were posterior retinal breaks [odds ratio (OR) = 10.7 compared to peripheral retinal breaks, p = 0.008], silicone oil tamponade (OR = 5.66 compared to gas, p = 0.01), and sectorial laser retinopexy (OR = 4.34 compared to 360° laser retinopexy, p = 0.007). The prevalence of CME, ERM, and EZ/IZ damage at 12 months was 10%, 9%, and 6%, respectively. Eyes with EZ/IZ defects had worse postoperative visual acuity in both uncomplicated and complicated RRD. Proliferative vitreoretinopathy (OR = 2.95, p = 0.03) and silicone oil tamponade (OR = 3.70 compared to gas, p = 0.05) were associated with EZ/IZ damage. CONCLUSIONS: PFCL-free PPV demonstrated satisfactory single-operation success rates for uncomplicated and complicated RRD, with a low prevalence of macular complications. Analyzing factors associated with RRD recurrence can provide provisional recommendations for PFCL-free approaches in the absence of randomized trials.

Safety Profile of Lutein- Versus Triamcinolone Acetonide-Based Vitreous Staining.

Purpose: To assess the safety profile of a new lutein-based vitreous dye (LB-VD) formulation compared with various triamcinolone acetonide (TA) formulations with and without subsequent exposure to perfluorodecalin (PFD) in vitro. Methods: Human adult retinal pigment epithelial cells (ARPE-19) were treated with the following formulations: undiluted preserved TA (TA-BA), diluted preserved TA (D-TA-BA), preservative-free TA (TA-PF), and LB-VD. First, cell tolerability was evaluated with MTT, LDH, and ATPlite assays after 1, 5, and 30 minutes of exposure to each tested formulation. Then, cells were sequentially exposed to formulations and PFD. After 24 hours of exposure to PFD, cell tolerability was evaluated through MTT and ATPlite assays. Results: Among the formulations tested, LB-VD showed the highest levels of cell viability, cell metabolism, and cell proliferation and induced the lowest release of LDH, whereas the TA-based formulations demonstrated a cytotoxic effect on ARPE-19 cells in vitro. After subsequent 24-hour exposure to PFD, a greater reduction of cell viability was noted for all the formulations; however, this reduction was not significant only for the combination LB-VD-PFD, which was the best tolerated condition. Conclusions: LB-VD showed a better safety profile compared with all TA-based formulations, even when used in combination with PFD. Translational Relevance: In surgical practice, LB-VD may be preferred to TA-based formulations for vitreous staining in the light of its more favorable safety profile.

Isolated Vitreous Metastasis in a Patient with an ALK Positive Lung Cancer Treated with Lorlatinib.

PURPOSE: To describe the ocular clinical and imaging findings of a patient with isolated vitreous metastasis, confirmed by vitreous biopsy, from an anaplastic lymphoma kinase (ALK) positive metastatic lung cancer. METHODS: case report. RESULTS: A 47-year-old female with a history of metastatic ALK positive lung cancer was referred by her oncologist due to unilateral blurred vision over 4 weeks. The fundus examination showed vitreous opacities with clumps of non-pigmented cells, without vasculitis or retinitis while optical coherence tomography (OCT) showed hyper-reflective deposits on the inner retinal surface with no retinal involvement. Diagnostic vitrectomy revealed neoplastic cells with ALK mutation. CONCLUSION: This is the first report that documents a case of isolated vitreous metastasis from ALK positive lung carcer in a patient under targeted therapy to treat metastatic lung cancer. We emphasize the importance of multimodal imaging, diagnostic vitrectomy, and a pathologist's cooperation to provide essential information about diagnosis and effective treatment.

Atypical unilateral exudative retinal detachment in a child affected by tuberous sclerosis.

INTRODUCTION: Tuberous sclerosis complex (TSC) is a rare hereditary phakomatosis. The clinical features can include benign growths in the central nervous system, tumors of various visceral organs, and retinal or optic disc astrocytic hamartomas in the nerve fiber layer. Here we present the case of a child with known TSC developing Coats-like manifestations. CASE DESCRIPTION: A 22-month-old girl with known TSC and retinal hamartoma followed since birth presented for the development of exotropia and leukocoria in the left eye. Fundus examination of the left eye showed blurred optic disc, macular star, and yellow retinal exudation in the temporal area. In addition, the left eye showed marked retinal vascular tortuosity and telangiectasias. The patient underwent brain and orbit magnetic resonance imaging, revealing heterotopic gray matter nodulations along ependyma of both lateral ventricles, with partial calcification, and a posterior flattening of the left eye. CONCLUSION: This report shows a rare case of Coats-like disease in a child with tuberous sclerosis. In case of presence of Coats' manifestations associated with atypical retinal or systemic findings, genetic diseases should be considered in the differential diagnosis.