Punch and rescue technique for scleral fixation of dislocated single-piece intraocular lenses.

In-the-bag intraocular lens (IOL) dislocation is a well-known complication after cataract surgery. As the number of cataract surgeries performed annually continues to increase, so will the incidence of IOL dislocations requiring surgical correction. Described is a new technique for rescue and refixation of a single-piece acrylic IOL. In this method, a new instrument called the IOL punch is used to create a hole at the optic-haptic junction or along the border of the optic, which acts as an anchor point for centration and subsequent scleral fixation of a dislocated IOL. The IOL punch allows for precise intraocular manipulation of the IOL and is less invasive compared with popular scleral fixation methods. This innovative technique may decrease the risk for postoperative complications and allows patients to maintain or recover previous uncorrected visual acuity by circumventing the need for IOL explantation or exchange.

Ultra wide-field angiographic characteristics of branch retinal and hemicentral retinal vein occlusion.

PURPOSE: To study the peripheral angiographic features of branch retinal vein occlusions (BRVO) and hemicentral retinal vein occlusions (HRVO) and explore associations with macular edema and neovascularization. DESIGN: Retrospective observational case series. PARTICIPANTS: Seventy-eight outpatients. METHODS: An imaging database of angiograms performed at a single academic institution was searched for patients with a diagnosis of BRVO or HRVO. Images were graded for the presence of untreated nonperfusion (areas without evidence of laser photocoagulation), late peripheral vascular leakage (LPVL), neovascularization, macular edema, and prior laser treatment. Optical coherence tomography images were reviewed for all patients to confirm the presence of macular thickening and to exclude eyes with vitreomacular traction. MAIN OUTCOME MEASURES: Angiographic evidence of nonperfusion, neovascularization, macular edema, LPVL, and prior laser treatment. RESULTS: Angiograms from 80 eyes of 78 patients were analyzed with a diagnosis of BRVO (86%) or HRVO (14%). Angiographic macular edema (80%), untreated nonperfusion (82%), neovascularization (21%), and LPVL (58%) were observed. Untreated nonperfusion at any location was significantly associated with macular edema (P = 0.043). Untreated nonperfusion anterior to the globe equator was significantly associated with macular edema (P = 0.007). Untreated nonperfusion was significantly associated with the presence of neovascularization (P = 0.033). Late peripheral vascular leakage was not associated with other angiographic or clinical findings studied. CONCLUSIONS: Ultra wide-field angiography provides visualization of peripheral retinal pathology in BRVO and HRVO patients, which may be useful in their evaluation and treatment. Our findings support the hypothesis that areas of untreated retinal nonperfusion may be the source of production of biochemical mediators that promote neovascularization and macular edema. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Experimental model of intravitreal injection techniques.

PURPOSE: To evaluate the amount of drug reflux and vitreous leakage from the needle tract after various intravitreal (IVT) injection techniques in porcine cadaver eyes. METHODS: The reflux after IVT injection was quantified by methylene blue injection through the pars plana of fresh pig eyes (0.05 mL per eye, n = 150) and the vitreous incarceration measured after balanced salt solution (BSS) IVT injection (0.05 mL per eye, n = 150) into eyes with vitreous previously stained with methylene blue. Blue spots observed on the ocular surface after injection quantified both reflux and vitreous incarceration. We tested different needle sizes (27, 30, and 32 gauge) and different techniques (depth and speed of injection). We used an ocular endoscope to observe the flow and diffusion of injected methylene blue and the vitreous incarceration at the puncture site after IVT injection using the different techniques. RESULTS: Thirty-gauge needles showed less drug reflux than the 32-gauge or 27-gauge needles (P < 0.01). Thirty-two-gauge needles demonstrated less incarceration of vitreous at the tract site (P < 0.01), but with the endoscope, all needle tracts showed vitreous incarceration at their internal aspect. Deep IVT injection showed less reflux than superficial IVT injection, but vitreous incarceration did not differ. The delay between the scleral puncture and the injection did not modify the reflux or the vitreous incarceration. CONCLUSION: Thirty-gauge needles and deep placement of the needle tip into the vitreous before injection may reduce reflux and vitreous incarceration. This could maximize the therapeutic effect of IVT injection and may decrease the rates of severe complications such as retinal detachment and endophthalmitis.

Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis.

PURPOSE: To establish the necessity for an early follow-up examination after an initial funduscopic examination with negative results for patients with acute, symptomatic posterior vitreous detachment (PVD). DESIGN: Retrospective case-control study and meta-analysis. METHODS: Records were reviewed of patients seeking treatment over a 4.5-year period who were diagnosed with an acute, symptomatic PVD. A MEDLINE search to identify all published observational case studies reporting vitreoretinal pathologic features after acute, symptomatic PVD. RESULTS: The incidence of retinal tears in eyes with a symptomatic PVD was 8.2%. The overall rate of retinal break in the meta-analysis portion of the study was 21.7%. In total, 1.8% of patients had retinal tears that were not seen on initial examination. Of the 29 patients with delayed-onset retinal breaks, 24 (82.8%) had at least one of the following: vitreous hemorrhage at initial examination, hemorrhage in the peripheral retina at initial examination, or new symptoms. CONCLUSIONS: If the results of an initial examination of a patient with an acute, symptomatic PVD are negative for retinal tears, the necessity of early follow-up may be best determined by the presence of pigmented cells in the vitreous, vitreous hemorrhage, or retinal hemorrhage. Most patients with symptomatic PVD may not need an early follow-up examination.

Optical coherence tomography of idiopathic juxtafoveolar telangiectasia.

BACKGROUND AND OBJECTIVE: To document optical coherence tomography (OCT) findings in a series of eyes with group 2A idiopathic juxtafoveal telangiectasia. PATIENTS AND METHODS: This study is a retrospective review of patient charts, OCT, fundus photography, and fluorescein angiography involving 23 eyes (12 patients). Mean retinal thickness in 9 macular areas was calculated and compared to previously published measurements from normal eyes. RESULTS: OCT in 8 of 13 stage 3 eyes revealed foveal cysts without evidence of cystoid macular edema on fluorescein angiography or biomicroscopy, and 1 lamellar hole. In stage 3 eyes, mild retinal thickening was found in 7 of 9 macular areas (P < .05). CONCLUSIONS: OCT commonly reveals foveal cysts in stage 3 idiopathic juxtafoveal telangiectasia. Consistent findings of associated mild macular thickening and lack of late petaloid hyperfluorescence on fluorescein angiography suggest that these cysts differ in pathophysiology from cystoid macular

Indications and outcomes of resident-performed cataract surgery requiring return to the operating room.

PURPOSE: To identify the clinical and operative factors predicting reoperation within 30 days of resident-performed cataract surgery and correlate them with 1-year visual outcomes. SETTING: Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA. DESIGN: Retrospective cohort study. METHODS: The study assessed patients who had resident-performed cataract surgery between 2005 and 2013 and required return to the operating room for a second surgery on the same eye within 30 days. Preoperative and intraoperative risk factors were assessed. Outcome measures included corrected distance visual acuity (CDVA) at 1 year. RESULTS: A review of 6644 resident-performed cataract surgeries showed that 54 eyes (0.85%) of 54 patients required a return to the operating room within 30 days. The reoperation rate was higher in the first half of the academic year (1.18%) than in the second half (0.55%) (P = .004). The mean CDVA 1 year postoperatively was 20/40, with a loss of lines of vision in 4 eyes. The mean operative time was 59.23 minutes ± 35.05 (SD). A longer intraoperative time was predictive of a worse visual outcome (P < .01). CONCLUSIONS: Despite the need for reoperation within 30 days, most patients achieved improved visual acuity. The reoperation rate was significantly lower in the second half of the academic year. Increased operation times correlated with worse visual acuity independent of other variables.

Adjunct Intravitreous Triamcinolone Acetonide in the Treatment of Diabetic Macular Edema with Anti-VEGF Agents.

Aims. To compare visual and anatomic outcomes of adjunct intravitreous (IVT) triamcinolone acetonide to antivascular endothelial growth factor (VEGF) injections to IVT anti-VEGF injections alone for center-involving diabetic macular edema (DME) in treatment-naïve eyes. Methods. Retrospective study of treatment-naïve eyes with center-involving DME. The primary outcome was the change in best corrected visual acuity (BCVA) in eyes receiving only IVT anti-VEGF (group 1) and eyes receiving IVT anti-VEGF and adjunct IVT-TA (group 2). Results. Included were 192 eyes. The mean change in BCVA was +3.5 letters in group 1 compared to -3.5 letters in group 2 (p = 0.048). Final macular thickness improved by -94 µm in group 1 versus -68 µm in group 2 (p = 0.26). In group 1, 5/150 eyes compared to 9/42 eyes in group 2 (3.3% versus 21%, p = 0.0005) had a IOP >10 mmHg increase. Six of 126 phakic eyes in group 1 versus 12/33 phakic eyes in group 2 underwent cataract surgery (4.7% versus 36.3%, p = 0.00009). Conclusions. IVT-TA results in no additional benefit in eyes treated with anti-VEGF agents for DME.

Evaluation of Automated Teleretinal Screening Program for Diabetic Retinopathy.

IMPORTANCE: Diabetic retinopathy is a leading cause of blindness, but its detrimental effects are preventable with early detection and treatment. Screening for diabetic retinopathy has the potential to increase the number of cases treated early, especially in populations with limited access to care. OBJECTIVE: To determine the efficacy of an automated algorithm in interpreting screening ophthalmoscopic photographs from patients with diabetes compared with a reading center interpretation. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort analysis of 15,015 patients with type 1 or 2 diabetes in the Harris Health System in Harris County, Texas, who had undergone a retinal screening examination and nonmydriatic fundus photography via the Intelligent Retinal Imaging System (IRIS) from June 2013 to April 2014 were included. The IRIS-based interpretations were compared with manual interpretation. The IRIS algorithm population statistics were calculated. MAIN OUTCOMES AND MEASURES: Sensitivity and false-negative rate of the IRIS computer-based algorithm compared with reading center interpretation of the same images. RESULTS: A total of 15 015 consecutive patients (aged 18-98 years); mean 54.3 years with known type 1 or 2 diabetes underwent nonmydriatic fundus photography for a diabetic retinopathy screening examination. The sensitivity of the IRIS algorithm in detecting sight-threatening diabetic eye disease compared with the reading center interpretation was 66.4% (95% CI, 62.8%-69.9%) with a false-negative rate of 2%. The specificity was 72.8% (95% CI, 72.0%-73.5%). In a population where 15.8% of people with diabetes have sight-threatening diabetic eye disease, the IRIS algorithm positive predictive value was 10.8% (95% CI, 9.6%-11.9%) and the negative predictive value was 97.8% (95% CI, 96.8%-98.6%). CONCLUSIONS AND RELEVANCE: In this large urban setting, the IRIS computer algorithm-based screening program had a high sensitivity and a low false-negative rate, suggesting that it may be an effective alternative to conventional reading center image interpretation. The IRIS algorithm shows promise as a screening program, but algorithm refinement is needed to achieve better performance. Further studies of patient safety, cost-effectiveness, and widespread applications of this type of algorithm should be pursued to better understand the role of teleretinal imaging and automated analysis in the global health care system.

Arterial compression of the retro-olivary sulcus of the medulla in essential hypertension: a multivariate analysis.

OBJECTIVE: Pulsatile arterial compression (AC) of the ventrolateral medulla (VLM) has been postulated to cause neurogenically mediated essential hypertension (EHTN). We aimed to establish whether the association between AC of specifically the retro-olivary sulcus (ROS) of the VLM and EHTN was significant, while controlling for other risks associated with EHTN. DESIGN: Case-control study. METHODS: Posterior fossa magnetic resonance imaging scans of 131 subjects, including 58 subjects with EHTN and 73 normotensives, were reviewed to determine the presence of AC in the ROS. The history of other risk factors for EHTN was obtained by reviewing medical records. RESULTS: Multivariate logistic regression analysis of these data shows a significant association between AC in the ROS (right and/or left) and EHTN [odds ratio (OR) = 3.03, 95% confidence interval (CI) = 1.30, 7.06]. This analysis was done controlling for other known EHTN risk factors such as age, race, sex, diabetes, and obesity. A secondary analysis also controlling for these variables shows that AC of both the right and left ROS are independently associated with EHTN (right AC: OR = 5.04, 95% CI = 1.33, 19.17; left AC: OR = 3.39, 95% CI = 1.20, 9.60). CONCLUSIONS: In this retrospective study of subjects with EHTN and normotensive controls that had undergone magnetic resonance imaging of the posterior fossa, AC of the ROS on either side of the medulla is a significant independent risk factor in EHTN. Further studies are required to determine whether this is true for the general population of patients with neurogenically mediated EHTN.

Bilateral diffuse uveal melanocytic proliferation as a precursor to multiple systemic malignancies.

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a rare, intraocular paraneoplastic syndrome characterized by multiple, elevated, pigmented uveal lesions, diffuse thickening of the uveal tract, and rapidly progressive cataracts. We report a 70-year-old Caucasian male with an inferotemporal conjunctival-scleral pigmented lesion of the right eye. Funduscopy and ultrasonography revealed multiple elevated pigmented choroidal lesions in both eyes. Genome-wide single nucleotide polymorphism (SNP) analysis of intraoperative transscleral fine-needle aspiration biopsies from both eyes revealed a whole gain on chromosome 5. BDUMP was diagnosed, and the patient underwent a thorough systemic investigation, which was negative for an underlying malignancy; however, by maintaining a high index of suspicion, multiple malignancies were uncovered and appropriately treated over the ensuing years. This report presents the clinical, cytologic, and cytogenetic features of BDUMP, and is the first to demonstrate a novel finding of a whole gain in chromosome 5 by SNP analysis of the choroidal lesions. Additionally, this is the first case to potentially associate BDUMP and both transitional cell carcinoma of the bladder as well as renal clear cell carcinoma.

Outcomes of anterior chamber intraocular lenses placed by surgeons in training.

PURPOSE: To evaluate risk factors and outcomes of unplanned, primary anterior chamber intraocular lenses (AC IOLs) placed by surgeons in training. SETTING: Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA. DESIGN: Retrospective case series. METHODS: Cataract surgeries performed primarily by a resident surgeon that resulted in an unplanned AC IOL were included. Cases that had concomitant retinal surgery were excluded. Preoperative data gathered included corrected distance visual acuity (CDVA), intraocular pressure (IOP), and ocular comorbid conditions. Operative times and complications requiring an AC IOL were assessed. Postoperative CDVA, IOP, corneal edema, persistent intraocular inflammation, macular edema, and need for additional surgery were analyzed for the first postoperative year. RESULTS: Twenty-two eyes were included. The mean preoperative CDVA was 1.24 logMAR ± 0.92 SD and the mean preoperative IOP was 17.55 ± 3.88 mm Hg. The mean operative time was 103 ± 30 minutes. The most common operative complications necessitating an AC IOL were 7 (32%) capsule tears with vitreous prolapse requiring anterior vitrectomy and 7 (32%) capsule tears, zonular dehiscence, and vitreous prolapse requiring anterior vitrectomy. By the first postoperative year, the mean visual acuity was 0.40 ± 0.58 logMAR and the IOP was 15.05 ± 6.01 mm Hg. The most common complications 1 year postoperatively included persistent macular edema (23%) and need for additional surgery (18%). CONCLUSION: This group of patients who received unplanned primary AC IOLs by surgeons in training had improved visual acuity and well-controlled IOP 1 year postoperatively. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Ultra wide-field imaging of choroidal metastasis secondary to primary breast cancer.

PURPOSE: To demonstrate the ability of ultra wide-field fundus imaging to document the response to treatment of a choroidal metastatic lesion from primary breast carcinoma. DESIGN: Observational case report. METHODS: A 45 year old female with a history of metastatic breast cancer and progressive vision loss in the right eye was noted to have an elevated, minimally pigmented choroidal lesion in the superior fundus periphery associated with a serous retinal detachment involving the macula. Ultra wide-field imaging allowed for comparison of the lesion size and secondary serous retinal detachment in response to systemic chemotherapy. RESULTS: Over a 3 month follow up period of observation while the patient received systemic chemotherapy the lesion demonstrated increased growth and increased subretinal fluid. CONCLUSION: Ultra wide-field fundus photography allowed for accurate documentation of growth of a peripheral choroidal metastatic lesion and associated serous retinal detachment.

Optos Panoramic 200MA ultrawide-field imaging of peripheral RPE adenoma.

PURPOSE: To illustrate the utility of ultrawide-angle fundus imaging in documenting a suspicous lesion in the far retinal periphery. DESIGN: Observational case report. METHOD: A 48 year-old female with new onset floaters in the left eye was noted to have an elevated and heavily pigmented lesion in the far retinal periphery. Optos Panoramic200MA ultrawide-field photography and fluorescein angiography allowed for accurate serial documentaton of the lesion which was determined to be a retinal pigment epithelial adenoma. RESULT: Over a four year period of observation, Optos ultrawide-field photography of the retinal pigment epithelial adenoma demonstrated stability of the lesion size and mild lesion depigmentation with overlying vitreous pigmentation. CONCLUSION: The Optos ultra-widefield system demonstrates the ability to rapidly and reproducibily obtain images to monitor a peripheral retinal pigment epithelial adenoma for objective and comparitive detection of change.

Extensively necrotic retinoblastoma is associated with high-risk prognostic factors.

CONTEXT: Retinoblastoma is the most common malignant intraocular tumor in children. It has been shown that adjuvant therapy following enucleation in patients with high-risk histopathologic features significantly decreases the mortality. We describe the association of extensive necrosis of tumor and intraocular structures with 2 of the major risk factors: optic nerve invasion and choroidal invasion. This may alert the pathologist who makes the observation of extensive necrosis to carefully search for histologic features associated with adverse outcome. OBJECTIVE: To determine whether extensively necrotic retinoblastoma is associated with high-risk histologic prognostic factors for metastatic disease and patient survival. DESIGN: Retrospective case series. Forty-three eyes of 43 patients with retinoblastoma who underwent enucleation between 1990 and 2001 were evaluated. Medical records, histopathology specimens, pathology reports, and clinical photographs were reviewed. Tumors were designated as exhibiting extensive necrosis if more than 95% of tumor cells and intraocular tissues were necrotic. The main outcome measure was the association of extensive tumor necrosis with 3 high-risk histopathologic features: extraocular extension, optic nerve invasion, or choroidal invasion. Metastatic disease, patient survival, and associations with pathologic findings were also analyzed. RESULTS: Optic nerve head invasion (P < .001), post-lamina-cribrosal invasion (P < .001), and choroidal invasion by tumor (P = .004) were observed more frequently in eyes with extensive necrosis compared with eyes without extensive necrosis. Two of the 11 patients with extensively necrotic intraocular retinoblastoma died from metastatic disease (P = .06). None of the 32 patients without extensive necrosis developed metastatic disease or died. CONCLUSIONS: Extensive ocular tissue and tumor necrosis is associated with histologic high-risk prognostic factors for tumor metastasis and mortality.