Epithelial ingrowth in descemet membrane endothelial keratoplasty associated with vitreous loss.

BACKGROUND: Epithelial ingrowth is a rare but potentially sight-threatening complication caused by the invasion of corneal or conjunctival epithelial cells into the eye during ocular surgeries. DMEK is emerging as a widely used surgery for endothelial keratoplasty with its improved safety profile. We describe a case of epithelial ingrowth in the graft-host interface after uneventful DMEK associated with vitreous prolapse in the anterior chamber. CASE PRESENTATION: An 81-year-old female with Fuchs endothelial dystrophy underwent DMEK for corneal decompensation following cataract surgery. During the DMEK procedure, vitreous prolapse was observed around the intraocular lens (IOL). Her early postoperative course was unremarkable, but a dense paracentral interface opacity was observed during the 3-month follow-up. The area of epithelial ingrowth was imaged with optical coherence tomography (OCT) as a uniform nodule with a discrete increase in interface hyperreflectivity. A low-energy YAG laser was applied to remove the opacity. She maintained good vision and clear cornea without reoccurrence after treatment. CONCLUSIONS: We propose that, in addition to the introduction of epithelial cells during surgery, vitreous retention in the anterior chamber may be a risk factor by providing a scaffold that potentially aggravates epithelial ingrowth in DMEK. Our case demonstrated that early YAG intervention may disrupt interface epithelial cell growth, and the transmitted laser energy may fragment the scaffold vitreous noninvasively.

Decreased Ocular Perfusion Pressure Associated With Reverse Ophthalmic Artery Flow on Transcranial Doppler Ultrasonography.

Innovative applications of clinical ocular diagnostic tools are emerging to help identify systemic disorders that extend beyond ocular diseases. Ophthalmodynamometry (ODM) is a screening tool that non-invasively determines mean central retinal artery pressure (MCRAP) and ocular perfusion pressure (OPP). Decreased OPP and MCRAP on Falck Medical Multifunctional Device (FMD, Falck Medical, Inc., Mystic, CT), along with reverse ophthalmic artery flow (ROAF) on transcranial Doppler ultrasonography (TCD), indicate increased collateral brain perfusion and possible stenosis of the ophthalmic artery or internal carotid artery (ICA). In this case report, we describe the case of a 78-year-old female with ROAF, reduced MCRAP, and OPP in the right eye, confirmed by carotid duplex of 50-79% right ICA stenosis. Early application of ODM and TCD allowed for prompt diagnosis and management with a vascular specialist.

Urrets-Zavalia Syndrome of Unresolving Mydriasis Following Endocyclophotocoagulation Combined with Phacoemulsification.

Aim and background: Combined endocyclophotocoagulation and phacoemulsification (ECP/Phaco) are uncommonly associated with complications. We present the first case of a rare complication following ECP/Phaco. Case description: A 72-year-old patient with dense nuclear sclerotic cataracts and primary open-angle glaucoma (POAG) underwent bilateral surgery uneventfully. He experienced a brief episode of postoperative elevated intraocular pressure (IOP), but only one eye with a lower baseline IOP developed a dilated pupil. No pupillary response was observed after applying 4% pilocarpine. The fixed mydriasis persisted without reaction to light or near stimulus, and the best-corrected vision (BCVA) was 20/30 in the affected eye. Conclusion: This case reports a possible rare complication when undergoing ECP/Phaco therapy. The pathogenesis of Urrets-Zavalia syndrome is unknown, but we hypothesized that eyes with more pronounced increases in IOP from baseline may be more susceptible to ischemic injury to the pupillary sphincter, resulting in a chronically dilated pupil. Clinical significance: Even a modest transient rise in postoperative IOP in a glaucomatous eye with normal baseline IOP could result in a chronically dilated pupil. How to cite this article: Cheng AMS, Vedula GG, Kubal AA, et al. Urrets-Zavalia Syndrome of Unresolving Mydriasis Following Endocyclophotocoagulation Combined with Phacoemulsification. J Curr Glaucoma Pract 2024;18(1):28-30.

Antibacterial Potential of Gold Nanoparticles Synthesized From Leaf Extract of Syzygium cumini Against Multidrug-Resistant Urinary Tract Pathogens.

BACKGROUND: Urinary tract infection (UTI) is one of the most commonly encountered bacterial infections. Due to the misuse or excessive use of antibiotics, the upsurge of multidrug-resistance cases in UTIs has now become a global threat to public health. Exploring a newer or safer treatment using green synthesized nanoparticles (NPs) is another substitute for eliminating multidrug-resistant pathogens. METHODOLOGY: Leaf extract of Syzygium cumini was used for green synthesis of gold NPs. Synthesis of Syzygium cumini gold nanoparticles (ScAu-NPs) was achieved by optimizing various reaction parameters. These ScAu-NPs were characterized through UV-visible spectroscopy, transmission electron microscope, Fourier transform infrared spectroscopy (FTIR), and X-ray diffraction. ScAu-NPs were then processed for antibacterial activity against clinically isolated multidrug-resistant pathogens like Escherichia coli, Klebsiella pneumoniae, Proteus vulgaris, Acinetobacter baumannii, Staphylococcus aureus, and Enterococcus faecalis. RESULTS: Characterization of NPs revealed that biosynthesized NPs were spherical in shape. FTIR spectroscopy showed the presence of phenolics and aromatic compounds. Biosynthesized NPs exhibit good antibacterial activity with a significant bacterial reduction seen against all bacterial isolates compared to the controls. CONCLUSION: From the results of the present study, the formulation of biosynthesized ScAu-NPs can be utilized in drug development for eliminating infections caused by multidrug-resistant pathogens.

Pituitary Macroadenoma with Optic Cupping Masquerading as Normal Tension Glaucoma.

When non-glaucomatous disease with disc cupping mimics normal-tension glaucoma (NTG), diagnosis is challenging. The typical optic disc features of glaucomatous disease are often subjective, and often overlap with disc changes in compressive intracranial lesions. Ancillary diagnostic testing such as retinal nerve fiber layer (RNFL) analysis and visual field testing can elevate the index of suspicion of an underlying non-glaucomatous process. We present a case of a nonfunctional macroadenoma coexisting with NTG, although it is unclear if the concurrent brain lesion aggravated or caused it. This case highlights the diagnostic challenge of recognizing optic cupping and non-matching abnormalities in the visual field from a coexisting intracranial lesion, even in the absence of other neurological signs.

Recent Advances in Imaging Macular Atrophy for Late-Stage Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) is a leading cause of blindness worldwide. In late-stage AMD, geographic atrophy (GA) of dry AMD or choroidal neovascularization (CNV) of neovascular AMD eventually results in macular atrophy (MA), leading to significant visual loss. Despite the development of innovative therapies, there are currently no established effective treatments for MA. As a result, early detection of MA is critical in identifying later central macular involvement throughout time. Accurate and early diagnosis is achieved through a combination of clinical examination and imaging techniques. Our review of the literature depicts advances in retinal imaging to identify biomarkers of progression and risk factors for late AMD. Imaging methods like fundus photography; dye-based angiography; fundus autofluorescence (FAF); near-infrared reflectance (NIR); optical coherence tomography (OCT); and optical coherence tomography angiography (OCTA) can be used to detect and monitor the progression of retinal atrophy. These evolving diverse imaging modalities optimize detection of pathologic anatomy and measurement of visual function; they may also contribute to the understanding of underlying mechanistic pathways, particularly the underlying MA changes in late AMD.

Factors associated with visual acuity outcomes after vitrectomy for diabetic macular edema: diabetic retinopathy clinical research network.

PURPOSE: To evaluate factors ¶associated with favorable outcomes after vitrectomy for diabetic macular edema. METHODS: Data were collected prospectively on 241 eyes undergoing vitrectomy for diabetic macular edema. Multivariate models were used to evaluate associations of 20 preoperative and intraoperative factors with 6-month outcomes of visual acuity and retinal thickness. RESULTS: Median central subfield thickness decreased from 412 µm to 278 µm at 6 months, but median visual acuity remained unchanged (20/80, Snellen equivalent). Greater visual acuity improvement occurred in eyes with worse baseline acuity (P < 0.001) and in eyes in which an epiretinal membrane was removed (P = 0.006). Greater reduction in central subfield thickness occurred with worse baseline visual acuity (P < 0.001), greater preoperative retinal thickness (P = 0.001), removal of internal limiting membrane (P = 0.003), and optical coherence tomography evidence of vitreoretinal abnormalities (P = 0.006). No associations with clinician's preoperative assessments of the posterior vitreous were identified. CONCLUSION: These results suggest that the removal of epiretinal membranes may favorably affect visual outcome after vitrectomy. Preoperative presence of vitreoretinal abnormalities appeared to be associated with somewhat greater reductions in retinal thickness but not with visual acuity outcome. These results may be useful for future studies evaluating vitrectomy for diabetic macular edema.

Foveal structure defined by spectral domain optical coherence tomography correlates with visual function after macular hole surgery.

PURPOSE: To study the correlation between final visual acuity after successful anatomic macular hole repair and features on spectral domain optical coherence tomography (SD-OCT). METHODS: Retrospective review of charts of patients who underwent macular hole surgery. Data collection included pre- and postoperative best-corrected visual acuity (BCVA), central subfield foveal thickness (CSFT), and presence or absence of inner segment-outer segment (IS-OS) line changes on SD-OCT. Data collected from SD-OCT were correlated with Snellen BCVA, which was converted to logMAR score. Subjects were divided into 2 groups: group I had improvement in BCVA of 2 lines or more and group II improved less than 2 lines or had worsening of BCVA. RESULTS: A total of 35 eyes of 32 patients had successful anatomic closure, which was documented both clinically and on SD-OCT. Mean age of the patients was 74.1 years and 71.2% (23/32) of patients were female. Overall, the mean BCVA changed from 1.01+/-0.38 preoperatively to 0.89+/-0.48 postoperatively (p=0.33). Based on the postoperative visual outcome, 16 eyes belonged to group I and 19 eyes belonged to group II. On the SD-OCT, the mean CSFT was 252.7+/-69.1 microm. No correlation was found between the mean CSFT and BCVA in either group. All the 16 patients in group I had a continuous IS-OS line on SD-OCT at the fovea in contrast to 26.3 % (5/19) of patients in group II (p=0.03). CONCLUSIONS: Establishment of continuity of IS-OS line is an important indicator of visual recovery in eyes with successful anatomic closure of macular hole.

Central Retinal Artery Occlusion After Nasosinal Surgery - an Insight.

OBJECTIVE: To describe a case of central retinal artery occlusion (CRAO) after nasosinal surgery and subject's subsequent response to hyperbaric oxygen therapy (HBOT). DESIGN: Observational case report. RESULTS: We describe a subject with diagnosed CRAO after septoplasty, bilateral inferior turbinate reduction and balloon sinuplasty, who was given hyperbaric oxygen treatment after four days of onset of CRAO with an improvement in visual acuity and visual field. CONCLUSION: Even though CRAO has been rarely reported after ENT procedures and HBOT has been previously described for the treatment, this is the case report where hyperbaric oxygen was given after four days of onset, with a possible improvement.

Comparative efficacy of topical tetraVisc versus lidocaine gel in cataract surgery.

BACKGROUND: To compare the clinical efficacy of lidocaine 2% with tetracaine 0.5% for cataract surgery. METHODS: In a randomized, multi-surgeon, controlled clinical trial,122 consecutive cataract cases eligible for topical anesthesia, were randomly assigned to receive lidocaine 2% gel (1 ml) or tetracaine solution 0.5% (TetraVisc, 0.5 ml) before clear corneal phacoemulsification. Main outcome measure was visual analog scale (0 to 10), which was used to measure intra-operative pain. Secondary outcome measures included patients' discomfort due to tissue manipulation and surgeon graded patients' cooperation. Duration of surgery and intra-operative complications were also recorded. RESULTS: The mean age in TetraVisc (TV) group was 70.4 years and in the lidocaine gel group (LG) it was 70.6 years (p = 0.89). Patient reported mean intra-operative pain scores by visual analog scale were 0.70 +/- 0.31 in TV group and 1.8 +/- 0.4 in LG group (P < 0.001). Mean patient cooperation was also marginally better in the TV group (8.3 +/- 0.3) compared to LG group (8.4 +/- 0.6) (P = 0.25). 96% of patients in TV group showed intra-operative corneal clarity compared to 91% in LG group. TV group had less (1 out of 61 patients, 1.6%) intra-operative complications than LG group (3 out of 61 patients, 4.8%). No anesthesia related complications were noted in either group CONCLUSION: Topical TetraVisc solution was superior to lidocaine 2% gel for pain control in patients undergoing clear corneal phacoemulsification. Lidocaine 2% gel is similar to TetraVisc in patient comfort and surgeon satisfaction. TRIAL REGISTRATION: Clinical trials number: ISRCTN78374774.

Illuminated curved 25-gauge vitrectomy probe for removal of subsclerotomy vitreous in vitreoretinal surgery.

Incarceration of vitreous in sclerotomy sites during pars plana vitrectomy can lead to wound-related complications similar to vitreous incarceration in cataract surgery. We describe an illuminated curved 25-gauge vitrectomy probe for removing vitreous from sclerotomy sites. Polyester tubing is used to secure a fiber optic endoilluminator (0.5 mm) with the curved 25-gauge vitrector (0.5 mm). The resultant illuminated curved vitrector (20 G) has a diameter of 1.0 mm. It facilitates complete removal of vitreous around the internal sclerotomies under direct visualization in both phakic and pseudophakic eyes. The same was confirmed with ultrasound biomicroscopy of the sclerotomy sites. Curved vitrector reduces postoperative complications related to incarcerated vitreous in phakic and pseudophakic eyes and other sclerotomy-related wound complications.

Lightweight autoclavable wide-angle contact lens for vitreous surgery.

The authors describe an autoclavable, self-stabilizing, lightweight wide-angle contact lens for vitrectomy. The lens has two optical pieces with perforated plastic casing to sustain a high temperature (150 degrees C) for autoclaving. The lens has a 106 degrees static and 127 degrees dynamic field of view. The footplates and reduced weight (2.4 grams) due to the plastic casing allow self-stabilization of the lens. The open lens design.with high temperature resistant plastic prevents fogging during autoclaving and surgery. The autoclavable, self-stabilizing, lightweight wide-angle contact lens allows visualization of the peripheral retina during surgery and faster sterilization by autoclaving between surgeries without the disadvantage of lens fogging.

Illuminated curved vitrectomy probe for vitreoretinal surgery.

A new self-illuminated and curved vitrectomy probe was designed for better accessibility of the peripheral retina, particularly in phakic patients. This probe has a 20-gauge pneumatic cutter. The curvature at the shaft has a 19.4-mm radius and is 25 mm long. A 2.5-cm piece of polyethylene terephthalate tubing (heat-shrink tubing) is threaded over both the probe and the 0.5-mm diameter fiberoptic light source to assemble the illuminated probe. Use of this instrument avoids inadvertent trauma to the clear lens in phakic eyes and allows the surgeon to illuminate the anterior vitreous with one hand while the other hand can be used to depress the sclera. This instrument complements wide-angle viewing for safe and quick surgical treatment of peripheral retinal pathology in phakic patients.

Recovery of retinal sensitivity after transient branch retinal artery occlusion.

A 66-year-old man with hypertension and branch retinal artery occlusion in the right eye with a visual acuity of 20/20 underwent sequential investigation with fluorescein angiography, optical coherence tomography, and microperimetry to evaluate the retinal sensitivity overlying an area of branch retinal artery occlusion. On follow-up, clinical resolution of retinal whitening and thickening was noted in the affected area. Optical coherence tomography revealed retinal thinning and inner retinal atrophy and microperimetry showed improvement in retinal sensitivity (11 db) overlying the area of branch retinal artery occlusion following resolution of retinal edema.

Rapid establishment of the European Bank for induced Pluripotent Stem Cells (EBiSC) - the Hot Start experience.

A fast track "Hot Start" process was implemented to launch the European Bank for Induced Pluripotent Stem Cells (EBiSC) to provide early release of a range of established control and disease linked human induced pluripotent stem cell (hiPSC) lines. Established practice amongst consortium members was surveyed to arrive at harmonised and publically accessible Standard Operations Procedures (SOPs) for tissue procurement, bio-sample tracking, iPSC expansion, cryopreservation, qualification and distribution to the research community. These were implemented to create a quality managed foundational collection of lines and associated data made available for distribution. Here we report on the successful outcome of this experience and work flow for banking and facilitating access to an otherwise disparate European resource, with lessons to benefit the international research community. ETOC: The report focuses on the EBiSC experience of rapidly establishing an operational capacity to procure, bank and distribute a foundational collection of established hiPSC lines. It validates the feasibility and defines the challenges of harnessing and integrating the capability and productivity of centres across Europe using commonly available resources currently in the field.

Five-Year Outcomes of Ranibizumab With Prompt or Deferred Laser Versus Laser or Triamcinolone Plus Deferred Ranibizumab for Diabetic Macular Edema.

PURPOSE: To compare long-term vision and anatomic effects of ranibizumab with prompt or deferred laser vs laser or triamcinolone + laser with very deferred ranibizumab in diabetic macular edema (DME). DESIGN: Randomized clinical trial. METHODS: Eight hundred and twenty-eight study eyes (558 [67%] completed the 5-year visit), at 52 sites, with visual acuity 20/32 to 20/320 and DME involving the central macula were randomly assigned to intravitreous ranibizumab (0.5 mg) with either (1) prompt or (2) deferred laser; (3) sham injection + prompt laser; or (4) intravitreous triamcinolone (4 mg) + prompt laser. The latter 2 groups could initiate ranibizumab as early as 74 weeks from baseline, for persistent DME with vision impairment. The main outcome measures were visual acuity, optical coherence central subfield thickness, and number of injections through 5 years. RESULTS: At 5 years mean (± standard deviation) change in Early Treatment Diabetic Retinopathy Study visual acuity letter scores from baseline in the ranibizumab + deferred laser (N = 111), ranibizumab + prompt laser (N = 124), laser/very deferred ranibizumab (N = 198), and triamcinolone + laser/very deferred ranibizumab (N = 125) groups were 10 ± 13, 8 ± 13, 5 ± 14, and 7 ± 14, respectively. The difference (95% confidence interval) in mean change between ranibizumab + deferred laser and laser/very deferred ranibizumab and triamcinolone + laser/very deferred ranibizumab was 4.4 (1.2-7.6, P = .001) and 2.8 (-0.9 to 6.5, P = .067), respectively, at 5 years. CONCLUSIONS: Recognizing limitations of follow-up available at 5 years, eyes receiving initial ranibizumab therapy for center-involving DME likely have better long-term vision improvements than eyes managed with laser or triamcinolone + laser followed by very deferred ranibizumab for persistent thickening and vision impairment.

Sutureless limited vitrectomy for positive vitreous pressure in cataract surgery.

A sutureless transconjunctival pars plana vitrectomy with the 25-gauge transconjunctival vitrectomy system is used to facilitate phacoemulsification in eyes with positive posterior vitreous pressure and shallow anterior chamber. Peribulbar local anesthesia is administered. In eyes with shallow anterior chamber, if an injection of a viscoelastic substance through anterior chamber paracentesis fails to deepen the anterior chamber, a limited pars plana vitrectomy is performed to remove a small amount of retro-lental vitreous (approximately 0.2 to 0.3 cc) with a 25-gauge high-speed cutter. Phacoemulsification is subsequently performed. The limited pars plana vitrectomy reduces the chances of intraoperative vitreous loss and suprachoroidal hemorrhage. It also increases the anterior chamber depth, facilitates intraoperative steps such as pupil stretching and capsulorhexis, and results in a phacoemulsification procedure that is less complex and safer.

Concurrent removal of intravitreal lens fragments after phacoemulsification with pars plana vitrectomy prevents development of retinal detachment.

AIM: To evaluate the outcomes of "concurrent vitrectomy" to retrieve dislocated lens fragment during phacoemulsification. METHODS: In a retrospective, observational case series, data of patients who underwent "concurrent" pars plana vitrectomy (PPV) for dislocated lens fragments between the period 2000 and 2008 were reviewed. Data collected included patient demographics, pre-operative visual acuity, intra-operative occurrence of retinal breaks, duration of follow up, post-operative intraocular pressure, final best-corrected visual acuity (BCVA), presence of cystoid macular edema (CME) and occurrence of rhegmatogenous retinal detachment (RRD). RESULTS: A total of 58 eyes of 58 patients were included in the study. At 12mo the mean postoperative BCVA was logMAR 0.17 (20/30) with a range of logMAR 0 to 0.69 (20/20 to 20/100), with 96.6% (56/58) of patients showing post-operative improvement in visual acuity (P=0.005). None of the patients developed postoperative retinal detachment, endophthalmitis or non-resolving uveitis at 12mo. CONCLUSION: Our study results suggest concurrent PPV for retained lens fragments after cataract surgery is beneficial and may decrease the risk of glaucoma and prevent development of RRD.

Small-gauge, sutureless pars plana vitrectomy to manage vitreous loss during phacoemulsification.

This technique manages vitreous prolapse associated with posterior capsule rupture during phacoemulsification by performing small-gauge pars plana vitrectomy with a sutureless, self-sealing incision performed in a closed chamber, maintaining normal intraocular pressure. A high-speed cutter exerts minimal traction on the vitreous. Accessibility to the vitreous through the pars plana is better, ensuring more complete removal of the vitreous and restoration of normal anatomy.