Surgical Management of Full-Thickness Macular Holes in Macular Telangiectasia Type 2: A Global Multicenter Study.

PURPOSE: To report on macular hole repair in macular telangiectasia type 2 (MacTel2). DESIGN: Global, multicenter, retrospective case series. PARTICIPANTS: Patients undergoing surgery for MacTel2-associated full-thickness macular hole (MTMH). METHODS: Standardized data collection sheet distributed to all surgeons. MAIN OUTCOME MEASURES: Anatomic closure and visual outcomes of MTMH. RESULTS: Sixty-three surgeries in 47 patients with MTMH were included from 30 surgeons. Mean age was 68.1 years, with 62% female, 72% White, 21% East or South Asian, 2% African American, and 2% Hispanic or Latino. Procedures included 34 internal limiting membrane (ILM) peeling alone, 22 ILM flaps, 5 autologous retinal transplantations (ARTs), 1 retinotomy, and 1 subretinal bleb. For ILM peeling, preoperative visual acuity (VA) was 0.667 ± 0.423 logarithm of the minimum angle of resolution (logMAR). Minimum hole diameter (MHD) was 305.5 ± 159.4 µm (range, 34-573 µm). Sixteen of 34 ILM peels (47%) resulted in MTMH closure. At postoperative month 6, VA was stable at 0.602 ± 0.516 logMAR (P = 0.65). VA improved by at least 2 lines in 43% and at least 4 lines in 24%. For ILM flaps, preoperative VA was 0.878 ± 0.552 logMAR. MHD was 440.8 ± 175.5 µm (range, 97-697 µm), which was significantly larger than for ILM peels (P < 0.01). Twenty of 22 ILM flaps (90%) resulted in MTMH closure, which was significantly higher than for ILM peels (P < 0.01). At postoperative month 6, VA improved to 0.555 ± 0.405 logMAR (P < 0.05). VA improved by at least 2 lines in 56% and at least 4 lines in 28%. For ARTs, preoperative VA was 1.460 ± 0.391 logMAR. MHD was 390.2 ± 203.7 µm (range, 132-687 µm). All 5 ARTs (100%) resulted in MTMH closure. At postoperative month 6, VA was stable at 1.000 ± 0.246 logMAR (P = 0.08). Visual acuity improved at least 2 lines in 25%. CONCLUSIONS: Surgical closure of macular holes improved VA in 57% of MTMHs. Internal limiting membrane flaps achieved better anatomic and functional outcomes than ILM peeling alone. Autologous retinal transplantation may be an option for refractory MTMHs. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

LONG-TERM USE OF ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

PURPOSE: Although pivotal trials have demonstrated efficacy of anti-vascular endothelial growth factor therapy in neovascular age-related macular degeneration, there is a paucity of clinical data about the long-term (>5 years) treatment. METHODS: Retrospective analysis of all patients with neovascular age-related macular degeneration who were actively treated, had received >40 anti-vascular endothelial growth factor injections, and were followed for ≥5 years. Snellen-corrected visual acuity, initial drug choice, and times elapsed between treatments were collected. Rates of endophthalmitis and outcomes of submacular hemorrhage were also evaluated. RESULTS: A total of 88 patients (162 eyes) met the inclusion criteria: the average patient age was 86.3 years with an average follow-up period of 7.6 years. The average total number of injections per eye was 69 (18.0 SD); a total of 11,208 injections were given throughout the study period, and 6 cases (0.05%) of endophthalmitis were observed. Overall, there was a clinical and statistical difference in average Snellen-corrected visual acuity at Injections #2,#3, #4, #5, #6, #10, and #20, as compared with baseline ( P = 0.03, P < 0.01, P = 0.02, P < 0.01, P = 0.01, P = 0.01, P < 0.01, respectively). Patients in the Snellen-corrected visual acuity subgroup 20/20 to 20/40 maintained vision until injection #30. Seven eyes experienced a visually significant submacular hemorrhage. CONCLUSION: This neovascular age-related macular degeneration cohort received on average eight anti-vascular endothelial growth factor injections per year for approximately 8 years; eyes with good (≥20/40) initial baseline vision maintained their visual acuity, whereas those with worse Snellen-corrected visual acuity (≤20/50) had a robust initial improvement that diminished with time. Most patients were maintained on the same initial drug of choice and the rate of endophthalmitis was low.

LONG-TERM VISUAL OUTCOMES AND THE TIMING OF SURGICAL REPAIR OF FOVEA-SPLITTING RHEGMATOGENOUS RETINAL DETACHMENTS.

PURPOSE: To evaluate the visual outcomes and the affect of timing of surgical repair of fovea-splitting rhegmatogenous retinal detachments. METHOD: A retrospective, consecutive cohort from multiple surgeons at a single center. Fovea status (fovea-on, fovea-splitting, or fovea-off) was classified by preoperative optical coherence tomography. The primary outcome measure was the visual acuity at the last follow-up that was further correlated with the timing of surgical repair. RESULTS: One hundred and ninety-five eyes were included with 62 fovea-on, 65 fovea-splitting, and 68 fovea-off detachments. The mean preoperative logarithm of the minimum angle of resolution visual acuity for fovea-on, fovea-splitting, and fovea-off groups was 0.16 ± 0.21, 0.70 ± 0.56, and 1.67 ± 0.87, respectively (P = <0.001). Mean postoperative logarithm of the minimum angle of resolution visual acuity for fovea-on, fovea-splitting, and fovea-off groups were 0.07 ± 0.13, 0.10 ± 0.15, and 0.20 ± 0.22, respectively (P = <0.001). A statistically significant difference in mean postoperative logMAR visual acuity was found between fovea-off and fovea-on groups (P = 0.003) and between fovea-off and fovea-splitting groups (P = 0.013), however not between fovea-on and fovea-splitting groups (P = 0.827). Visual acuity improved when repair was performed earlier after presentation for fovea-on (R = 0.378, P = 0.002) and fovea-off groups (R = 0.277, P = 0.022), but not for the fovea-splitting group (R = 0.089, P = 0.481). CONCLUSION: We described the favorable visual outcomes of surgery for fovea-splitting rhegmatogenous retinal detachment and correlated these with the timing of surgical repair, which may help guide the management of this urgent, vision-threatening condition.

PERIPHERAL RETINAL ANGIOGRAPHIC FINDINGS IN MACULAR TELANGIECTASIS TYPE 2.

PURPOSE: To evaluate the retinal periphery in patients with idiopathic juxtafoveal telangiectasis or macular telangiectasis Type 2 (MacTel2), using widefield fluorescein angiography. METHODS: Single-center, retrospective, observational case series of 50 eyes of 50 patients with MacTel2 and 50 eyes of 50 age-matched controls. RESULTS: Thirty-seven eyes in the MacTel2 group (74%) showed peripheral capillary nonperfusion or dropout, compared with 37 eyes in the control group (74%, P = 1.0). Morphologically, the MacTel2 group trended toward having a higher proportion of pruning-type capillary dropout (44%) compared with controls (28%), but this was not statistically significant (P = 0.12). Patients with MacTel2 had a higher incidence of microaneurysms compared with controls (MacTel2 56%; controls 42%; P = 0.048), independent of age or systemic risk factors. There was no difference in the incidence of venous-venous shunts (MacTel2 10%; controls 10%; P = 1.0), arteriovenous shunts (MacTel2 14%; controls 18%; P = 0.60), venous tortuosity (MacTel2 60%; controls 66%; P = 0.58), or arterial tortuosity (MacTel2 54%; controls 68%; P = 0.20), which was mild in most cases. CONCLUSION: We note a high incidence of peripheral vascular and retinal findings in both patients with MacTel2 and age-matched controls, using widefield fluorescein angiography. Patients with MacTel2 had significantly more microaneurysms, independent of age or other systemic risk factors.

CLINICAL OUTCOMES AND TREATMENT COURSE OF EYES WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION FOLLOWING THE DEVELOPMENT OF ENDOPHTHALMITIS.

PURPOSE: To evaluate the clinical course of patients with neovascular age-related macular degeneration (nAMD) after developing endophthalmitis during their treatment with intravitreal injections. METHODS: Multicenter, retrospective series. RESULTS: From April 2013 to October 2018, 196,598 intravitreal anti-vascular endothelial growth factor (VEGF) injections were performed, with 75 cases of endophthalmitis (incidence 0.0381%). There was no association between intravitreal anti-VEGF drug (P = 0.29), anesthetic method (P = 0.26), povidone concentration (P = 0.22), or any intraprocedure variable and endophthalmitis incidence. Seventy-two patients (96%) were treated with intravitreal tap and inject , while 3 underwent immediate pars plana vitrectomy. After endophthalmitis resolution, 17 patients (22.7%) were not re-treated for nAMD (in 10 cases due to inactive disease; follow-up, 115 ± 8.4 weeks). Patients required less frequent anti-VEGF injections after infection (7.4 ± 0.61 weeks vs. 11.5 ± 1.8 weeks; P = 0.004). Preinfection logarithm of the minimum angle of resolution visual acuity was 0.585 ± 0.053 (∼20/77). It worsened with endophthalmitis (1.67 ± 0.08, ∼20/935; P < 0.001) and again on postendophthalmitis treatment day 1 (1.94 ± 0.064; count fingers; P < 0.001), but improved after reinitiating nAMD therapy (1.02 ± 0.11; ∼20/209; P < 0.001). Better visual acuity on postendophthalmitis week 1 (P = 0.002) and reinitiation of nAMD treatment (P = 0.008) were associated with better final visual acuity, and streptococcal culture with worse visual acuity (P = 0.028). The postendophthalmitis treatment interval was associated with the anti-VEGF drug used (aflibercept = ranibizumab > bevacizumab; P < 0.001). CONCLUSION: Patients with nAMD required fewer injections after endophthalmitis, suggesting a biological change in disease activity. Neovascular age-related macular degeneration became quiescent in 13.3% of eyes. Most achieved better outcomes with anti-VEGF reinitiation.

Preventing Iatrogenic Retinal Breaks in Cutter-Associated Traction from Chronic Vitreous Hemorrhage (CATCH).

BACKGROUND AND OBJECTIVE: To describe an under-recognized complication in the surgical management of dense, nonclearing vitreous hemorrhage, specifically, the development of iatrogenic retinal breaks as a result of cutter-associated traction. STUDY DESIGN/PATIENTS AND METHODS: Review of surgical cases with cutter-associated traction from chronic vitreous hemorrhage (CATCH). RESULTS: Cutter-associated traction from chronic vitreous hemorrhage is a commonly encountered surgical entity that may result in complications such as iatrogenic retinal breaks, including giant retinal tears. These complications can be minimized or potentially avoided through the use of open sclerotomies or potentially mixed-gauge vitrectomy. CONCLUSION: Careful surgical planning in cases of dense or chronic vitreous hemorrhage is required to prevent cutter-associated tractional retinal breaks. [Ophthalmic Surg Lasers Imaging Retina 2022;53:584-585.].

Bilateral Exudative Retinal Detachments, Chemosis, and Impaired Ocular Motility in the Setting of Preeclampsia and HELLP Syndrome.

Purpose: We present a complication of preeclampsia and hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome including bilateral exudative retinal detachments, bullous chemosis, and impaired ocular motility. Methods: The patient was followed in the inpatient and outpatient setting with clinical examinations, optical coherence tomography, widefield fundus photography, neuroimaging including magnetic resonance imaging of the brain/orbits, as well as carotid artery ultrasonography. Results: Our patient was admitted with bilateral vision changes in the setting of preeclampsia and HELLP syndrome and was found to have bilateral exudative detachments, retinal exudation, severe bullous chemosis, and impaired motility. She was started on intravenous dexamethasone followed by an extended prednisone taper with resolution of her ocular findings and return of her vision to baseline. Conclusions: There is evidence that HELLP syndrome and preeclampsia are proinflammatory syndromes. Aggressive blood pressure control, corticosteroids, and a multidisciplinary approach might accelerate visual and systemic recovery in these complex cases.

Endogenous methicillin-resistant Staphylococcus aureus endophthalmitis.

PURPOSE: To report on the presentation, treatment, and outcomes of the largest series to date for patients with endogenous methicillin-resistant Staphylococcus aureus endophthalmitis at a single institution and compare the results from previously published reports of this disease entity. METHODS: Retrospective, noncomparative, consecutive case series of patients who were treated for endogenous methicillin-resistant S. aureus endophthalmitis from a single tertiary referral institution were reviewed. RESULTS: Eight eyes of seven consecutive patients, with a mean age of 58.1 years, were diagnosed with culture-proven endogenous methicillin-resistant S. aureus endophthalmitis. Five patients were male, and six patients had a unilateral presentation. Five of eight eyes were treated with initial vitreous tap and injection of antibiotics, and six eyes showed a retinal detachment during the course of treatment. Final visual acuity ranged from 20/40 to no light perception, and 5 of 8 eyes showed improvement in visual acuity from initial presentation. Only one eye became blind and painful and required enucleation. CONCLUSION: This series represents the largest single-institution report on endogenous methicillin-resistant S. aureus endophthalmitis and associated outcomes. Although previously reported cases cited poor visual outcomes and high enucleation rates, the authors' current series shows that retinal detachments are common and enucleation rates are low.

Study of intraocular pressure after 23-gauge and 25-gauge pars plana vitrectomy randomized to fluid versus air fill.

PURPOSE: To determine if a difference in intraocular pressure (IOP) exists after small-gauge pars plana vitrectomy randomized to fluid versus 80% sterile air fill. METHODS: Ninety-two eyes undergoing 23-gauge and 25-gauge transconjunctival pars plana vitrectomy were randomized to fluid versus air fill, and IOP was measured at 5 different time points. RESULTS: There is no difference in the mean IOP for eyes undergoing small-gauge pars plana vitrectomy randomized to fluid versus air fill after vitrectomy. Using 23-gauge instrumentation, the mean immediate and 2-hour postoperative IOPs were statistically lower than the mean preoperative IOP. The mean Postoperative Day 1 and Week 1 IOPs were statistically higher than the mean immediate postoperative IOP. Using 25-gauge instrumentation, the mean IOP was not statistically different at any time points in the 2 groups. When comparing 23-gauge with 25-gauge instrumentation, the immediate postoperative IOP was statistically lower and the rate of suture closure for sclerotomies was higher for 23-gauge vitrectomy. CONCLUSION: When performing 23-gauge or 25-gauge pars plana vitrectomy, there was no difference in mean IOP for fluid- versus air-filled eyes. However, the mean IOP in the immediate postoperative period was statistically lower, and there was a higher rate of suture closure for 23-gauge compared with 25-gauge instrumentation.

Predictors of Endophthalmitis after Intravitreal Injection: A Multivariable Analysis Based on Injection Protocol and Povidone Iodine Strength.

PURPOSE: To determine the incidence of endophthalmitis after anti-vascular endothelial growth factor (VEGF) therapy at our institution and to identify potential risk factors for endophthalmitis occurring after injection. DESIGN: Retrospective, single-center cohort study. PARTICIPANTS: All patients who received an intravitreal injection of an anti-VEGF medication between January 1, 2014, and March 31, 2017. METHODS: Current Procedural Terminology and International Classification of Diseases billing codes were used to identify instances of anti-VEGF administration and cases of endophthalmitis. Medical records and injection technique were reviewed carefully in each case. Multivariable logistic regression analysis was performed in a stepwise fashion to determine independent predictors of endophthalmitis based on injection protocol. MAIN OUTCOME MEASURES: Incidence of endophthalmitis after injection and odds of endophthalmitis by injection technique with 95% confidence intervals (CIs). RESULTS: A total of 154 198 anti-VEGF injections were performed during the period of interest, resulting in 58 cases of endophthalmitis (0.038% [1:2659]). After adjustment for confounders, both 2% lidocaine jelly (odds ratio [OR], 11.28; 95% CI, 3.39-37.46; P < 0.001) and 0.5% Tetravisc (Ocusoft, Richmond, TX; OR, 3.95; 95% CI, 1.15-13.50; P = 0.03) use were independent risk factors for endophthalmitis after injection. Lid speculum use, povidone iodine strength (5% vs. 10%), injection location (superior or inferior), conjunctival displacement, use of provider gloves, use of a strict no-talking policy, use of subconjunctival lidocaine, and topical antibiotic use were not statistically significant predictors of endophthalmitis after injection. There was no difference in endophthalmitis rate among the anti-VEGF agents (bevacizumab, ranibizumab 0.3 mg, ranibizumab 0.5 mg, and aflibercept). CONCLUSIONS: The incidence of endophthalmitis after anti-VEGF injections is low. Use of lidocaine jelly or Tetravisc may increase the risk of endophthalmitis after injection.

Characterization of Epiretinal Proliferation in Full-Thickness Macular Holes and Effects on Surgical Outcomes.

PURPOSE: Epiretinal proliferation is a distinct clinical entity from epiretinal membrane that classically is associated with lamellar macular holes, but its prevalence and association with full-thickness macular holes (FTMH) have not been well described. We characterized macular hole-associated epiretinal proliferation (MHEP) and its effects on long-term surgical outcomes. DESIGN: Multicenter, interventional, retrospective case-control study. PARTICIPANTS: Consecutive eyes that underwent surgery for FTMH with a minimum of 12 months follow-up. METHODS: All eyes underwent pars plana vitrectomy, removal of any epiretinal membranes, and gas tamponade, with or without internal limiting membrane (ILM) peeling. Spectral-domain OCT imaging was obtained before and after surgery. MAIN OUTCOME MEASURES: Improvement in visual acuity and single-surgery hole closure rates in eyes with, versus without, MHEP at 12 months. RESULTS: Seven hundred twenty-five charts were analyzed, and 113 patients met inclusion criteria. Of 113 eyes with FTMH, 30 (26.5%) showed MHEP. Patients with FTMH and MHEP were older (P < 0.002) and more often men (P = 0.001), and showed more advanced macular hole stages than those without MHEP (P = 0.010). A full posterior vitreous detachment was more common in eyes with MHEP (P < 0.004). Twelve months after surgery, FTMH with MHEP patients showed significantly less improvement in visual acuity (P = 0.019) with higher rates of ellipsoid and external limiting membrane defects (P < 0.05) and with a higher rate of failure to close with 1 surgery compared to FTMH without MHEP (26.7% vs. 4.8%; P = 0.002]). Peeling the ILM was associated with improved rates of hole closure in FTMH with MHEP (P < 0.001). Multivariate testing confirmed that the presence of MHEP was an independent risk factor for less visual improvement (P = 0.031) and for single-surgery nonclosure (P = 0.009) and that ILM peeling improved single-surgery closure rates (P = 0.026). CONCLUSIONS: We found that FTMH with MHEP showed poorer anatomic and visual outcomes after vitrectomy compared with FTMH without MHEP. Internal limiting membrane peeling was associated with improved closure rates and should be considered when MHEP is detected before surgery.

Vitrectomy for a symptomatic lamellar macular hole.

PURPOSE: To investigate the surgical findings and outcomes after vitrectomy for a lamellar macular hole (LMH). DESIGN: Retrospective, consecutive, interventional case series. PARTICIPANTS: Twenty-seven patients (27 eyes) with a lamellar macular hole and central vision loss. INTERVENTION: All patients underwent 3-port vitrectomy with internal limiting membrane (ILM) stripping by one of the authors. Best-corrected visual acuity (BCVA) and appearance by optical coherence tomography (OCT) were obtained preoperatively and postoperatively. MAIN OUTCOME MEASURES: Preoperative and postoperative BCVA and OCT imaging. RESULTS: Visual acuity improved postoperatively in 25 of 27 eyes (93%), with a mean improvement of 3.2 Snellen lines. Preoperative and postoperative OCT images were obtained in 24 of 27 eyes (89%) and were judged to have improved or normalized in 22 of 24 (92%) of these patients. CONCLUSION: In patients with central visual loss from a lamellar macular hole, vitrectomy with ILM stripping appears to be a beneficial treatment.

Retinal neovascularization after internal carotid artery occlusion.

PURPOSE: To report a case of retinal neovascularization after surgical ligation of the internal carotid artery for treatment of direct carotid-cavernous fistula. METHODS: Case report. RESULT: A 44-year-old Asian woman presented with unilateral retinal neovascularization and vitreous hemorrhage. Surgical ligation of the ipsilateral internal carotid artery had been performed 14 years earlier as a treatment for carotid-cavernous fistula after failed attempts at fistula embolization. Vitrectomy was performed for removal of nonclearing vitreous hemorrhage, with intraoperative peripheral retinal ablation and cryotherapy of the lesion. CONCLUSION: We report a case of retinal neovascularization associated with total occlusion of the ipsilateral internal carotid artery 14 years earlier.

Repair of primary rhegmatogenous retinal detachment using 25-gauge transconjunctival sutureless vitrectomy.

PURPOSE: : To evaluate the anatomical and visual outcomes of primary rhegmatogenous retinal detachment repairs performed using 25-gauge transconjunctival sutureless vitrectomy. METHODS: : A retrospective, noncomparative interventional case series including 53 consecutive eyes of 52 patients who underwent 25-gauge transconjunctival sutureless vitrectomy to repair primary rhegmatogenous retinal detachment was performed. Variables collected for the study were patient demographics, lens status, preoperative visual acuity, and macular status. Outcome measures included single-operation anatomical success rate, final anatomical success rate, postoperative visual acuity, and surgical complications. RESULTS: : The retina was reattached with a single operation in 39 (74%) of 53 eyes. The final anatomical success rate was 100%. The mean time to redetachment was 72 days (range, 13-334 days). Proliferative vitreoretinopathy (64%) and development of new retinal breaks (43%) were the most common reasons associated with redetachment. Mean visual acuity improved from 20/100 to 20/60 (P = 0.001); 55% of eyes had final vision of 20/40 or better. Three eyes (6%) developed postoperative choroidal hemorrhage. Three eyes (6%) developed visually significant macular pucker that required surgery. No postoperative hypotony or endophthalmitis was observed. CONCLUSIONS: : Repair of primary rhegmatogenous retinal detachments using 25-gauge transconjunctival sutureless vitrectomy resulted in excellent final anatomical success rate and postoperative visual outcomes. However, redetachments due to new tears and/or proliferative vitreoretinopathy resulted in a lower single-operation success rate than those reported with 20-gauge systems.

The effect of duration of macular detachment on results after the scleral buckle repair of primary, macula-off retinal detachments.

PURPOSE: To present a current series that determined the effect of duration of macular detachment (DMD) and patient age on postscleral buckle (SB) visual acuity (VA) and anatomic results. DESIGN: Retrospective, noncomparative, observational case series. PARTICIPANTS: Ninety-four consecutive patients (94 eyes) with primary, uncomplicated, macula-off retinal detachments, a preoperative VA of 20/200 or worse, and a precise history of when macular function was lost. INTERVENTION: Standard explant scleral buckle technique performed by multiple surgeons. MAIN OUTCOME MEASURES: Visual acuity, anatomic reattachment, and proliferative vitreoretinopathy. RESULTS: Visual acuity after SB of 20/40 or better was seen in 71% of eyes with a DMD of 10 days or fewer, 27% of eyes with a DMD of 11 days to 6 weeks, and 14% of eyes with a DMD of more than 6 weeks. Eyes achieved a mean VA after SB of 20/41 after a DMD of 10 days or fewer, 20/121 after a DMD of 11 days to 6 weeks, and 20/178 after a DMD of more than 6 weeks. No decrease in VA was seen within the 1- to 10-day period or the 11 days to 6 week period of DMD. Patients 60 years of age or less achieved a mean VA after SB of 20/47 compared with 20/81 for patients between 61 to 75 years of age and 20 of 96 in patients more than 76 years of age. Duration of macular detachment and patient age had no statistically significant effect on final anatomic reattachment after SB, reoperation rate, or proliferative vitreoretinopathy. CONCLUSIONS: Eyes with primary, uncomplicated, macula-off retinal detachment repaired with SB achieve excellent postoperative VA if repaired within the first 10 days of macular detachment. These results are better than the VA in eyes repaired after 11 days to 6 weeks and more than 6 weeks of macular detachment. Patients 60 years of age and younger obtained better postoperative VA than older patients. Duration of macular detachment and patient age did not significantly effect anatomic outcomes.