Management of Vision-Threatening Complications of Vasoproliferative Tumors of the Retina.

AIMS: To report the management of vision-threatening complications of vasoproliferative tumors of the retina. METHODS: Clinical records of 31 eyes of 30 patients treated at our centers from 1998 through 2013 were reviewed. The main outcome measures included: type of treatment, tumor regression, tumor relapse and final visual acuity. RESULTS: Seventeen patients (57%) underwent vitrectomy for epimacular membranes (n = 10), rhegmatogenous retinal detachment (n = 2), vitreous hemorrhage (n = 2), tractional retinal detachment (n = 1), serous retinal detachment (n = 1) and subhyaloid hemorrhage (n = 1). After the initial treatment, 10 additional surgeries were performed for vitreoretinal complications. Tumor activity was treated in all eyes either with photocoagulation or cryotherapy. Control of tumor activity was achieved in all cases, after treatment of recurrences. There were no statistically significant differences between initial and final visual acuity (p = 0.437). Recurrence showed a statistically significant association with the presence of proliferative vitreoretinopathy (p = 0.024), tumor thickness (p = 0.026), basal diameter (p = 0.031), and use of photocoagulation alone as initial treatment (p = 0.006, logistic regression). CONCLUSION: In our series, more than half of vasoproliferative tumors of the retina required surgery as the initial treatment. Recurrence was associated with tumor size, presence of proliferative vitreoretinopathy, and use of photocoagulation alone as the initial treatment.

Clinical Outcomes and Cost Analysis of PreserFlo versus Trabeculectomy for Glaucoma Management in the United Kingdom.

PURPOSE: Clinical evaluation and cost analysis of mitomycin-C-augmented PreserFlo MicroShunt versus trabeculectomy. DESIGN: Retrospective cohort study across 3 teaching hospitals. PARTICIPANTS: A total of 134 consecutive eyes of 129 patients (70 undergoing MicroShunt, 64 trabeculectomy). METHODS: Primary and secondary glaucoma cases with uncontrolled intraocular pressure (IOP) were included. Neovascular glaucoma and surgery combined with cataract extraction were excluded. The cost analysis used results from the clinical study to estimate operative costs (equipment and staff costs) and postoperative costs (follow-up visits, nonglaucoma medications, and postoperative procedures) per eye for PreserFlo and trabeculectomy. MAIN OUTCOME MEASURES: The primary clinical outcome measure was surgical failure (defined as IOP > 21 mmHg or < 20% reduction from baseline, IOP ≤ 5 mmHg, reoperation, or loss of light perception) or qualified and complete success (with or without medication) at 18 months. Secondary measures were IOP, glaucoma medications, visual acuity, mean deviation, time to cessation of steroid drops, complications, surgical time, follow-up visits, postoperative interventions, and reoperations. The cost analysis evaluated costs of PreserFlo compared with trabeculectomy. RESULTS: Baseline characteristics were similar, except for more non-White patients in the trabeculectomy group (51% Black and Asian vs. 32% MicroShunt, P = 0.02) and more cases with prior ab externo glaucoma surgery in the MicroShunt group (19% vs. 3% in the trabeculectomy group, P = 0.004). Overall, 59% of eyes had primary open-angle glaucoma. Mean follow-up was 19.9 months for both groups. At 18 months, surgical failure was 25% for MicroShunt compared with 35% for trabeculectomy (P = 0.18). Failure in MicroShunt cases was due to inadequate IOP reduction (84%) or reoperation for glaucoma (16%). Failure in trabeculectomy cases was due to inadequate IOP reduction (58%), persistent hypotony (29%), or reoperation for glaucoma (13%). Combined blebitis and endophthalmitis rate was 1.4% for MicroShunt and 3.1% for trabeculectomy. Cost analysis showed a savings of £245 to £566 per eye in the MicroShunt group, driven mostly by reduced postoperative procedures and follow-up visits. This is in contrast to prior randomized controlled trial data reporting the incremental cost of $2058 of PreserFlo over trabeculectomy. CONCLUSIONS: Our experience of introducing PreserFlo MicroShunt surgery showed it was safer than trabeculectomy and is a cost-saving and effective option that offers potential to free up highly limited National Health Service resources. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Type 3 choroidal neovascularization associated with fundus flavimaculatus.

AIM: To describe a patient with type 3 choroidal neovascularization (CNV) associated with fundus flavimaculatus (FFM), who underwent treatment with intravitreal ranibizumab. METHODS: A 78-year-old woman diagnosed with FFM presented at our department complaining of decreased vision and metamorphopsia in her left eye. Upon a complete ophthalmologic examination, including best corrected visual acuity (BCVA), fundus autofluorescence, fluorescein angiography (FA), indocyanine green angiography (ICGA), and spectral domain optical coherence tomography (SD-OCT), the patient was diagnosed with type 3 CNV associated with FFM, and was submitted to intravitreal ranibizumab injections at monthly intervals. RESULTS: Six months after 3 monthly injections of ranibizumab, the patient's BCVA improved from 20/64 to 20/32. FA and ICGA revealed a type 3 CNV closure, and the SD-OCT scan showed a fibrous scar replacing the type 3 CNV, with resolution of serous retinal detachment. CONCLUSION: This case represents the first demonstration of type 3 CNV associated with FFM. Based on our findings, intravitreal ranibizumab may be considered as a therapeutic option for this rare association.

RITONAVIR-ASSOCIATED TOXICITY MIMICKING RETINITIS PIGMENTOSA IN AN HIV-INFECTED PATIENT ON HIGHLY ACTIVE ANTIRETROVIRAL THERAPY.

PURPOSE: To report ritonavir-associated retinal pigment epithelium toxicity in a patient infected with the HIV on highly active antiretroviral therapy including ritonavir. METHODS: Retrospective single case report. The authors describe a case of gradual onset of blurry vision in both eyes in an HIV-positive male. Visual acuity, clinical examination findings, and functional testing (electroretinogram and Goldmann perimetry) were reviewed. Diagnostic imaging, including fundus photography, spectral domain optical coherence tomography, fluorescein angiography, and fundus autofluorescence were assessed. RESULTS: 59-year-old HIV-infected male, treated with ritonavir for eight years, presented with a history of decreased night vision and peripheral field loss. Ophthalmologic examination confirmed the diagnosis of retinal toxicity. Goldmann perimetry showed areas of central and para-central scotomas. Electroretinograms demonstrated mild to moderate photoreceptor dysfunction. Fundus examination revealed a diffuse pattern of retinal pigment epithelium mottling in both eyes. Spectral domain optical coherence tomography confirmed the presence of choroidal thinning, whereas fundus autofluorescence showed mottled hypoautofluorescence. CONCLUSION: Although ritonavir-associated retinal toxicity is clinically uncommon, the clinical features of our findings support this diagnosis. Consideration of highly active antiretroviral therapy-associated retinal toxicity should be given to the differential diagnosis in HIV-positive patients with retinopathy of unclear etiology. This report also highlights the need for constant monitoring of patients using the ritonavir for early detection of possible retinal toxicity.

Scleral buckling in phakic uncomplicated primary rhegmatogenous retinal detachment: long-term outcomes.

PURPOSE: Scleral buckling (SB) is a surgical technique that has been used successfully to treat retinal detachments for the last 6 decades. The aim of this study was to report the long-term anatomical and functional outcomes of SB surgery in phakic patients with uncomplicated primary rhegmatogenous retinal detachment (PRRD). This article also outlines the benefits of SB compared to pars plana vitrectomy, such as reducing the risk of developing cataract, high intraocular pressure, and glaucoma, in addition to reducing surgical cost. METHODS: We retrospectively reviewed the clinical notes of 90 phakic eyes with PRRD treated with SB surgery that had a minimum of 5 years follow-up. Preoperative and postoperative characteristics were recorded. Main outcome measures were reattachment rate, best-corrected visual acuity (BCVA) improvement, and complications. RESULTS: A total of 90 eyes (88 patients) with phakic PRRD repaired through SB surgery were included. Mean age was 49.2 ± 14.6 years (range 20-80). Primary and final anatomic success was 96.7% and 100%, respectively. Mean preoperative BCVA was 0.3 ± 0.31 logMAR (6/12) and mean postoperative BCVA 0.1 ± 0.2 logMAR (p<0.001) (6/7.5). There were no cataract or primary open-angle glaucoma cases after 1 year of follow-up. Mean follow-up was 8.5 ± 2.6 years (range 5-13). CONCLUSIONS: We report a high single operation success rate over time in phakic PRRD, repaired through SB surgery. Functional and anatomical success was maintained throughout the follow-up without complications. Therefore, the authors recommend the use of this technique in selected cases in order to reduce morbidity and the incidence of reoperations.

Variations in Treatment Delivery for Patients with Neovascular AMD in the UK: Results from an Ophthalmology Trainee Clinical Research Network Study.

INTRODUCTION: The aim of this study was to determine treatment delivery patterns for patients with neovascular age-related macular degeneration (nAMD) across the UK through an ophthalmology trainee research network delivered observational study. METHODS: Data were collected via an online tool by potential research collaborators identified by the Ophthalmology Trainee Clinical Trial Network (OCTN). Collaborators were asked to comment on periprocedural practices of treatment of nAMD in their eye unit including treatment location and injectors, clinical assessment and routine observation in patients undergoing intravitreal treatment. RESULTS: Data were available from 26 units around the United Kingdom. Survey methodology refinement was approximately 3 months, and the average response time was 4.9 ± 2.4 days. The majority of responders confirmed that treatment was undertaken as a "one-stop" service (n = 15, 58%), delivered in a clean room (n = 23, 88%). In the majority of units, doctors administered injections (n = 24, 92%), but significant treatment was also given by nurse injectors (n = 21, 81%). All collaborators reported that patients underwent visual acuity testing and optical coherence tomography imaging at all visits, but other imaging including fundus fluorescein angiography (FFA) did not take place in all cases (n = 17, 65%) and only at baseline visit. CONCLUSIONS: These results demonstrate the feasibility of conducting ophthalmology trainee led and delivered observational studies. Our results show that FFA is not routinely used in the diagnosis of nAMD in the units sampled; most injections are carried out in a clean room, and ophthalmic nurses delivering injections is a highly prevalent model of care in the UK.

Endoresection of a high equatorial choroidal melanoma.

PURPOSE: To describe previously unreported endoresection of a high equatorial choroidal melanoma. METHODS: Surgical case report imaged with wide-angle retinography and angiography, ecography, optical coherence tomography, and a short video of surgical procedure. RESULTS: The authors describe a 9.68-mm thick mushroom-shaped equatorial melanoma, which was successfully treated by endoresection. A wide-field lens and scleral indentation allowed complete tumor removal by the vitrectomy probe. Liquid perfluorocarbon stabilized the retina, therefore laser endophotocoagulation was applied to tumor margins and the scleral bed. Silicone oil was left as a tamponade, and a ruthenium-106 plaque for radiation therapy was sutured to the episclera. Eleven months after endoresection surgery, there were no signs of systemic or local recurrences. CONCLUSION: Endoresection of an equatorial choroidal melanoma was shown to be a safe technique in this patient, allowing the preservation of anatomy and function of the eye. It should be considered as an option for the treatment of large equatorial choroidal melanomas.

Swept-source optical coherence tomography of retinal cavernous hemangioma: a new imaging modality.

The authors report a new, non-invasive diagnostic method in the diagnosis of retinal cavernous hemangioma (RCH). A 6-year-old girl was referred for a non-clearing retinal hemorrhage of 6 months' duration. Fourier-domain optical coherence tomography (FD-OCT) showed an intraretinal lesion with cystic-like internal appearance. Optical shadowing was present, preventing establishment of any subretinal component to the lesion. Swept-source OCT (SS-OCT) showed an intraretinal lesion consisting of a group of clearly defined grape-like caverns with overlying preretinal tissue. Wide-field fundus fluorescein angiography (WF-FFA) confirmed the diagnosis of RCH. SS-OCT was superior to FD-OCT in showing the internal anatomy of the RCH and allowing for the measurement of its structures, confirming the intraretinal location of the lesion and the presence of an associated preretinal tissue. SS-OCT may assist in cases in which hemorrhage prevents an accurate diagnosis by ophthalmoscopy or angiography, thus becoming an alternative imaging method to confirm the diagnosis of RCH while avoiding the risks of fluorescein angiography in children.

In-Vivo Visualization of Retinal Crystals in Bietti's Crystalline Dystrophy by Spectral Domain Optical Coherence Tomography.

In this study, an attempt is made to assess in-vivo, the location of retinal crystals in a 39-year-old woman with Bietti's crystalline dystrophy using spectral domain optical coherence tomography (Spectralis SD-OCT). In this patient, it was possible to show the exact correspondence between the retinal crystals, as visualized by infrared frame, and the tiny hyper-reflective SD-OCT lesions that appeared localized in all retinal layers, from the RPE to the retinal nerve fibre layer.

High-definition optical coherence tomography features in vitelliform macular dystrophy.

PURPOSE: To correlate high-definition optical coherence tomography (HD OCT) and fundus examination findings at different phases of vitelliform macular dystrophy and to determine the anatomic location of vitelliform material. DESIGN: Prospective, noncomparative, observational case series. METHODS: A complete ophthalmologic examination, including fundus biomicroscopy and HD OCT, was performed in 11 consecutive patients with a diagnosis of vitelliform macular dystrophy. RESULTS: Using HD OCT, we were able to demonstrate for the first time the presence of previtelliform lesions, characterized by a thicker layer between the retinal pigment epithelium (RPE) and the inner segment and outer segment (IS/OS) interface. At this stage, a normal-appearing RPE and IS/OS interface were found in two of four eyes. In all progressive stages from the vitelliform to the vitelliruptive, the vitelliform material was visualized by HD OCT as an highly reflective lesion located between the hyporeflective outer nuclear layer and the hyperreflective RPE layer, associated or not to an optically empty lesion. At these stages, a disrupted IS/OS interface and an almost normal appearance of all major intraretinal layers was detected. At the vitelliruptive and atrophic stages, on some parts, the HD OCT scan revealed hyperreflective mottling on the RPE layer, probably representing areas of focal RPE hypertrophy. The atrophic stage and the fibrotic stage were characterized by thinning of all the retinal layers and diffuse loss of the IS/OS interface. In our series, mean best-corrected visual acuity impairment showed a statistically significant correlation to the presence of focal disruption or diffuse loss of the IS/OS interface (P = .002), as well as to a more advanced stage of the disease (P = .01). A more advanced stage of the disease showed a strong statistically significant correlation to the presence of diffuse loss of the IS/OS interface (P < .001). CONCLUSIONS: Based on the HD OCT findings, we hypothesize that early changes in vitelliform macular dystrophy involve the layer between the RPE and the IS/OS interface, first with accumulation of material beneath the sensory retina, and then with disruption and attenuation of IS and OS; late changes seem to affect the RPE, which undergoes hypertrophy, disruption, and attenuation.