Inverted internal limiting membrane flap for the management of optic disc pit maculopathy / Técnica do flap invertido da membrana limitante interna para o manejo da maculopatia causada pela fosseta do disco óptico

ABSTRACT Optic disc pit is a rare congenital anomaly that can cause serous macular detachment. It has no universally accepted single treatment. Recently, several investigators have performed new procedures to directly seal the pit. Herein, we report a case showing a promising method for optic pit maculopathy surgical treatment. We created an inverted internal limiting membrane flap and fold it over the pit to promote barrier in order to stop further fluid accumulation. Gradual absorption of subretinal fluid was observed over 12 months of follow-up. Optical coherence tomography can demonstrate internal limiting membrane folded over the pit and progressive subretinal fluid resolution. This technique resulted in a satisfactory anatomic outcome with good functional improvement in the best-corrected visual acuity.

RESUMO A fosseta do disco óptico é uma rara anomalia con gênita que pode causar descolamento de retina seroso na mácula. Não há um tratamento cirúrgico padrão universalmente aceito. Recentemente, cirurgiões têm realizado procedimentos novos que visam selar o buraco diretamente. Esse caso clínico mostra um método promissor para o tratamento cirúrgico da maculopatia causada pela fosseta do disco. Optamos por criar um flap invertido com a membrana limitante interna, dobrando-o sobre a fosseta para promover uma barreira, impedindo o acúmulo de fluido. A absorção gradual do líquido subretiniano foi observada ao longo de 12 meses de acompanhamento. Imagens de tomografia de coerência óptica podem demonstrar a membrana limitante interna dobrada sobre a fosseta e a resolução progressiva do fluido subretiniano. Esta técnica resultou em um resultado anatômico satisfatório com boa melhora funcional na acuidade visual.

Antagonistas de mineralocorticoides en coriorretinopatía central serosa crónica / Mineralocorticoid receptor antagonists in chronic central serous chorioretinopathy

INTRODUCCIÓN: La coriorretinopatía central serosa consiste en la filtración de fluido desde la coroides y su acumulación en el espacio subretinal. Su forma crónica se asocia a pérdida visual permanente. Los antagonistas de mineralocorticoides son una alternativa de tratamiento para esta patología, aunque no existe evidencia clara sobre su efectividad. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos tres revisiones sistemáticas que en conjunto incluyeron 22 estudios primarios, de los cuales, cuatro corresponden a ensayos aleatorizados. Concluimos que el uso de antagonistas de mineralocorticoides en coriorretinopatía central serosa crónica probablemente resulta en poca o nula diferencia en la agudeza visual corregida. No es posible establecer con claridad si su uso disminuye el grosor del fluido subretinal, debido a que la certeza de la evidencia ha sido evaluada como muy baja. Además, esta intervención podría resultar en poca o nula diferencia en la aparición de efectos adversos, pero la certeza de la evidencia es baja.

INTRODUCTION: Central serous chorioretinopathy consists of the leakage of fluid from the choroid and its accumulation into the subretinal space. Its chronic form is associated with permanent vision loss. Mineralocorticoid receptor antagonists are an alternative treatment for this condition, although there is no clear evidence about their effectiveness. METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified three systematic reviews including 22 studies overall and four of them are randomized trials. We concluded that in chronic central serous chorioretinopathy, mineralocorticoid receptor antagonists probably make little or no difference to best-corrected visual acuity. We are uncertain whether this intervention reduces subretinal fluid height because the certainty of the evidence is very low. Furthermore, this intervention may make little or no difference in terms of adverse effects, but the certainty of the evidence is low.

Subretinal Fluid Drainage through Original Breaks without Perfluorocarbon Liquid for Rhegmatogenous Retinal Detachment

PURPOSE: To evaluate the efficiency of a surgical method using original breaks to drain subretinal fluid without using retinotomy and perfluorocarbon liquid for patients with rhegmatogenous retinal detachment (RRD). METHODS: A retrospective chart review comparing 41 eyes of 41 patients who received vitrectomy, and used original breaks to drain subretinal fluid without using perfluorocarbon liquid, and 40 eyes of 40 patients who received vitrectomy using perfluorocarbon liquid for simple RRD between February 2014 and December 2017 was conducted. All patients were followed for a minimum of 6 months after surgery. RESULTS: The primary anatomical success percentages were 97.6% and 97.5% for groups that did not and did use perfluorocarbon liquid, respectively. Retinal detachment recurred in one eye from both groups. The final success percentage was 100%. The preoperative mean logMAR best-corrected visual acuity (BCVA) of 0.87 ± 0.80 improved to 0.30 ± 0.30 at postoperative 6 months for the group that did not use perfluorocarbon liquid, while it improved from 0.86 ± 0.71 to 0.42 ± 0.52 for the group that did use perfluorocarbon liquid. Both groups showed significant BCVA improvement (p < 0.01). There was no significant difference in the incidence of complications caused by the use of perfluorocarbon liquid. CONCLUSIONS: Using original breaks to drain subretinal fluid without perfluorocarbon liquid in cases with RRD may be an effective and safe surgical technique for functional and anatomical recovery without serious complications.

Two Case Reports of a Purtscher-like Retinopathy Occurring after Retrobulbar Anesthesia

PURPOSE: Although there are significant risks, retrobulbar anesthesia is commonly used for eye surgery. We report two cases of Purtscher-like retinopathy, a rare complication. CASE SUMMARY: (Case 1) A 76-year-old female visited our hospital because of decreased vision. She underwent right cataract surgery with retrobulbar anesthesia. After 7 days, she had decreased visual acuity (VA) and a constricted visual field. Multiple white spots and cotton wool spots around the optic nerve and post pole, macular edema (ME), and subretinal fluid (SRF) were found using a fundus examination. A non-perfusion area and staining of the vascular wall were seen using fluorescence angiography. Although carotid arterial angiography, thrombolysis, and intravenous injection of high-dose steroids were performed, the ME and SRF persisted. After intravitreal aflibercept was injected twice (2-month interval), the ME and SRF decreased and remained stable. (Case 2) A 61-year-old male underwent left cataract surgery with retrobulbar anesthesia. After anesthesia, the VA of the left eye was 10 cm finger count. The fundus examination showed multiple hemorrhage blots and retinal hemorrhages, and hyperfluorescence around the optic nerve and post pole; vascular wall staining revealed a Purtscher-like retinopathy. Left carotid arterial angiography, thrombolysis, and intravenous injection of high-dose steroids were then performed. After treatment, the VA of the left eye, ME, and SRF were improved at the 4-month follow-up. CONCLUSIONS: We report rare complications of retrobulbar anesthesia, with active and timely treatment having a positive impact on the visual prognosis.

Choroidal Neovascularization in a Patient with Best Disease

PURPOSE: To report a case of choroidal neovascularization in a Best disease patient treated with intravitreal bevacizumab injection and followed up with optical coherence tomography angiography (OCTA). CASE SUMMARY: A 20-year-old female visited our clinic with decreased visual acuity of the left eye for 6 months. On optical coherence tomography (OCT), subretinal fluid and hyperreflective subretinal clumps were observed in the macula of the right eye. Subretinal hemorrhage and subretinal fluid were observed in the left eye. Choroidal neovascularization in the left eye was observed using OCTA, fluorescein angiography, and indocyanine green angiography. A full-field electroretinogram was normal in both eyes, but an electrooculogram revealed that the Arden ratio was 1.564 in the right eye and 1.081 in the left eye. Intravitreal bevacizumab injection was performed in the left eye. At 6 months after the intravitreal injection, the best-corrected visual acuity of the left eye had recovered to 20/20. OCT revealed that subretinal fluid reduced and choroidal neovascularization was stable. After 12 months, visual acuity of the left eye was maintained at 20/20, but OCTA revealed that choroidal neovascularization had increased. CONCLUSIONS: Choroidal neovascularization associated with Best disease can improve by intravitreal bevacizumab injection, and the changes in choroidal neovascularization can be followed using OCTA.

Utilizing a Previous Silicone Band Track in Recurred Retinal Detachment

PURPOSE: We report a case of utilizing a previous silicone band track in the reoperation of scleral encircling. CASE SUMMARY: An 8-year-old male presented with rhegmatogenous retinal detachment in the right eye. Five days after this diagnosis, he received scleral buckling surgery and cryopexy to seal the retinal tear. One month after surgery, a fundus examination showed subretinal fluid at the inferior site of the scleral buckle. He underwent scleral encircling surgery and a cryopexy procedure. The patient has had an uneventful postoperative course, and the retina has remained attached over a follow-up period of 9 months. However, exotropia and hypotropia developed in the right eye. Diagnosis of restrictive strabismus due to tissue adhesion around the silicone band was made. The encircling band was therefore removed and laser photocoagulation was performed 360° around the retina. Twenty-four hours after surgery, a fundus examination showed subretinal fluid. He received 360° scleral encircling surgery not using the 360° conjunctival peritomy. After confirming a previous encircling tract using #0-0 polydioxanone as a guide, #5-0 Nylon was tied to the end of the guide and inserted through the encircling tract with the end sutured with the silicone band. The silicone band was inserted into the encircling tract by pulling the #5-0 Nylon as a guide. Ophthalmoscopy revealed an attached retina with indentation of the scleral buckle at 360°. CONCLUSIONS: For reoperation in patients who previously underwent scleral encircling surgery, using the previous scleral encircling tract may be effective in cases with conjunctival and tissue adhesion.

Clinical Presentations of Focal Choroidal Excavation and Results of Long-term Follow-up

PURPOSE: To evaluate the clinical presentations of focal choroidal excavation and to report long-term outcomes of cases without retinal disorders at the initial presentation. METHODS: A retrospective review of medical records was performed for patients diagnosed with focal choroidal excavation. Concomitant retinal disorders at the initial presentation were identified. In cases without retinal disorders, the development of retinal disorders during follow-up was also evaluated. RESULTS: Forty-five eyes in 45 patients were examined in this study. Focal choroidal excavation was accompanied with retinal disorders in 16 eyes (35.6%). In the remaining 29 eyes, only focal choroidal excavation was noted without any accompanying retinal disorders. The accompanying retinal disorders included choroidal neovascularization (n = 8), central serous chorioretinopathy (n = 4), epiretinal membrane (n = 1), macular hole (n = 1), branch retinal vein occlusion (n = 1), and uveitis (n = 1). Of the 29 eyes without retinal disorders, 22 were followed up for a mean period of 33.5 ± 18.2 months. Consequently, choroidal neovascularization was found to have developed in one eye at 59 months, and subretinal fluid had developed in two eyes at 17 and 28 months, respectively. CONCLUSIONS: Focal choroidal excavation was accompanied by retinal disorders in 35.6% of the included patients. In patients without retinal disorders, the development of a retinal disorder was noted in some eyes, suggesting the need for long-term regular follow-up in patients diagnosed with focal choroidal excavation.

Central Serous Chorioretinopathy with Peripapillary Retinoschisis

PURPOSE: To report a case of central serous chorioretinopathy with peripapillary retinoschisis. CASE SUMMARY: A 64-year-old male presented with abnormal color vision of the left eye, which occurred 6 months prior to his visit. At the initial visit, a funduscopic examination revealed retinal elevation with suspected serous retinal detachment around the optic disc in the left eye. Spectral domain optical coherence tomography showed subretinal fluid on the nasal side of the optic disc and retinoschisis on the temporal side of the optic disc in the left eye. Fluorescein angiography revealed multiple leakages in the left eye. Indocyanine green angiography revealed choroidal vascular hyperpermeability in both eyes. Based on these results, the patient was diagnosed with chronic central serous chorioretinopathy and was treated with argon laser photocoagulation at the leakage points. After 8 weeks of laser therapy, optical coherence tomography indicated that there was no retinoschisis or subretinal fluid in the macula, nasal, or temporal sides of the optic disc. CONCLUSIONS: Peripapillary retinoschisis due to central serous chorioretinopathy improves with argon laser photocoagulation at leakage sites.

Effect of Serous Retinal Detachment on the Measurement of Axial Length in Central Serous Chorioretinopathy

PURPOSE: To evaluate the changes of axial length (AXL) in eyes with unilateral idiopathic central serous chorioretinopathy (CSC) after resolution of serous retinal detachment. METHODS: A total of 31 patients diagnosed with idiopathic unilateral CSC were included in this study. The changes of AXL according to serous retinal detachment were examined. The keratometric value and AXL were measured using partial coherence interferometry. Serous retinal detachment and central macular thickness (CMT) were measured by spectral domain optical coherence tomography. RESULTS: The mean age of the 31 CSC patients, including 19 males, was 42.7 years. The AXL was significantly increased from 23.41 to 23.58 mm after resolution of serous retinal detachment (p < 0.001). The CMT was significantly decreased from 413.4 to 226.8 µm after resolution of serous retinal detachment (p < 0.001). The differences in AXL correlated with CMT differences and subretinal fluid height (r = −0.616, p < 0.001 and r = −0.637, p < 0.001, respectively), and the best-corrected visual acuity was significantly different after resolution of serous retinal detachment (p < 0.001). CONCLUSIONS: In unilateral idiopathic CSC with serous retinal detachment, a shortened AXL in the acute phase was restored after resolution of serous retinal detachment.

Outcomes of Anti-vascular Endothelial Growth Factor Treatment for Foveal Serous Retinal Detachment Associated with Inferior Staphyloma

PURPOSE: To evaluate the efficacy of anti-vascular endothelial growth factor (VEGF) treatment of eyes with foveal serous retinal detachment (SRD) associated with inferior staphyloma and to investigate choroidal thickness changes following anti-VEGF therapy. METHODS: In this observational case series, eyes with inferior staphyloma accompanied by foveal SRD were treated with a single intravitreal anti-VEGF injection, followed by further injections as needed. Changes in height and width of subretinal fluid (SRF) and visual acuity after treatment were assessed. Choroidal thickness was measured at the subfovea, 1.5 mm superior and inferior to the fovea using enhanced depth imaging optical coherence tomography at baseline and 1 month after initial anti-VEGF therapy. RESULTS: Six eyes from six patients were included. One month after the initial injection, the mean SRF height and width had decreased significantly from 112.5 ± 40.1 to 44.5 ± 48.7 µm (p = 0.046) and from 1,401.8 ± 627.3 to 690.7 ± 634.7 µm (p = 0.028), respectively. Mean choroidal thickness at the superior point decreased from 218.7 ± 59.3 to 200.5 ± 61.0 µm (p = 0.046). SRF resolved completely in three of the six eyes (50%) with a mean of 6.8 ± 5.9 injections (range, 1 to 15). All eyes experienced at least one recurrence of exudation, at a mean interval of 4.8 months. Mean visual acuity improvement was 0.17 logarithm of the minimum angle of resolution units at a mean of 28.7 months follow-up. CONCLUSIONS: Anti-VEGF therapy resulted in an SRF decrease and modest visual improvement in eyes with foveal SRD associated with inferior staphyloma. Reduction in superior choroidal thickness appeared to contribute to the clinical improvements that were observed.

Effect of Acetazolamide on Choroidal Morphology in Central Serous Chorioretinopathy

PURPOSE: We sought to elucidate the influence of acetazolamide on choroidal structure changes during the treatment of central serous chorioretinopathy (CSC).METHODS: This was a retrospective study of 45 eyes from 45 patients with acute CSC who were divided into an acetazolamide group (group 1, n = 20) and an observation group (group 2, n = 25). The main outcome measures were the changes in best-corrected visual acuity, subretinal fluid (SRF) height, subfoveal choroidal thickness (SFCT), and choroidal vascularity index (CVI) at one week, one month, two months, and three months, respectively.RESULTS: Although statistical significance was not reached, best-corrected visual acuity improved in both groups at month 3 (from 0.06 ± 0.07 to 0.01 ± 0.03 in group 1 and 0.17 ± 0.24 to 0.09 ± 0.18 in group 2; p = 0.083 and 0.183, respectively). Separately, SRF height and CVI showed a significant decrease at three months in both groups (all p < 0.05), while a significant SRF height decrease was also noted in group 1 at one month (p = 0.038). In group 1, a significant decrease in the SFCT and CVI started at one week and one month (p = 0.021 and 0.008), respectively. However, in group 2, a significant decrease in the SFCT and CVI started at one month and two months (p = 0.005 and 0.015), respectively.CONCLUSIONS: Acetazolamide has no effect on final functional or anatomical status at three months in eyes with CSC but does shorten the time for SRF absorption and accompanying choroidal structural changes.

Comparison of Focal and Conventional Verteporfin Photodynamic Therapy for Chronic Central Serous Chorioretinopathy

PURPOSE: To evaluate the efficacy of focal verteporfin photodynamic therapy (PDT) in patients diagnosed with chronic central serous chorioretinopathy (CSC).METHODS: This study enrolled 52 eyes of 52 patients with chronic CSC who had received verteporfin PDT. The laser spot size of 26 eyes covering only the localized hyperfluorescent area in indocyanine green angiography was classified as focal PDT. The PDT spot size of the other 26 eyes covered the total area of retinal pigment epithelial detachment including the leaking point and was defined as conventional PDT. The central subfield thickness and subfoveal choroidal thickness were measured using Heidelberg Spectralis optical coherence tomography before PDT and at months 1, 3, 6, and 12 after PDT.RESULTS: The mean spot size of the PDT was 1,995 µm in the focal group and 2,995 µm in the conventional group. Central subfield thickness steadily decreased in both groups. The mean baseline subfoveal choroidal thickness for the two groups was 334.95 and 348.35 µm, respectively, with no significant difference (p = 0.602). Subfoveal choroidal thickness decreased significantly to 304.20 µm at 1 month, 284.85 µm at 3 months, 271.60 µm at 6 months, and 265.95 µm at 12 months in the focal group (p < 0.001, p < 0.001, p < 0.001, and p < 0.001, respectively, compared with baseline). In the conventional group, subfoveal choroidal thickness decreased significantly to 318.75, 300, 284, and 272 µm at 1, 3, 6, and 12 months, respectively (p < 0.001, p < 0.001, p < 0.001 and p < 0.001 compared with baseline). There were no significant differences between the two groups in subfoveal choroidal thickness based on PDT spot size at 1, 3, 6, and 12 months (p = 0.633, p = 0.625, p = 0.676, and p =0.755, respectively).CONCLUSIONS: Focal verteporfin PDT for CSC significantly decreased the subretinal fluid and sufoveal choroidal thickness to the same extent as conventional PDT.

Clinical Manifestations of Steroid-associated Central Serous Chorioretinopathy

PURPOSE: To evaluate the clinical differences between patients with central serous chorioretinopathy (CSC) developed after steroid use and CSC patients without a history of steroid use for short-term periods. METHODS: We retrospectively analyzed the medical records of 47 patients (55 eyes) diagnosed with CSC from January 2011 to August 2017 by categorizing Group 1 (32 patients, 36 eyes) without a history of steroid use and Group 2 (15 patients, 19 eyes) with a history of steroid use within 6 months. We evaluated the differences in best-corrected visual acuity (BCVA), subretinal fluid (SRF) height, subfoveal choroidal thickness (SFCT), and Haller's layer thickness in the two groups. We also analyzed the changes in the BCVA, SRF height, SFCT, and Haller’s layer thickness in each group for 1 month and compared them depending on the treatment. RESULTS: There were no significant differences between the two groups with regard to age, sex, BCVA, bilaterality, number of leakage points, and Haller's layer thickness. Group 2 showed significantly increased SRF height and SFCT than Group 1 (p = 0.002, p = 0.005, respectively). In Group 1, the level of SRF and SFCT were significantly more decreased after 1 month (p = 0.001, 0.015, respectively) in patients with treatment than in those without treatment. In Group 2, the height of the SRF and SFCT were significantly more decreased after 1 month (p = 0.005, 0.002, respectively) in untreated patients compared to treated patients. CONCLUSIONS: CSC patients with a prior history of steroid use have higher serous detachment and a thicker SFCT than those without prior history of steroid use. Therefore, termination of steroid treatment may reduce the SFCT and SRF in steroid-treated CSC patients.

A Case of Central Serous Chorioretinopathy after Tadalafil Treatment

PURPOSE: To describe a patient who presented with central serous chorioretinopathy after 2 months of tadalafil administration without any other underlying disease or medication. CASE SUMMARY: A 49-year-old male patient was transferred from a local clinic with metamorphopsia and decreased visual acuity in the right eye. His visual acuity was 6/20 in the right eye and 18/20 in the left eye. The fundus examination showed a large serous detachment between the superior and inferior blood vessel arcades in the right retina. In his medical history, he used tadalafil three times a week for 2 months. His medication was then stopped, and a follow-up examination was scheduled. After 2 months, a fundus examination showed resolution of the subretinal fluid, and his corrected visual acuity recovered to 20/20. CONCLUSIONS: Tadalafil (Cialis®) is a phosphodiesterase (PDE)-5 inhibitor and predominantly prescribed for the treatment of erectile dysfunction. PDE–5 inhibitors may be potent vasodilators in the retina and choroid, and may induce choroidal vessel engorgement leading to leakage across the retinal pigment epithelium and accumulation of subretinal fluid in selected patients. When making a diagnosis as central serous chorioretinopathy, the physician should confirm the causative drugs that are easy to miss, by performing a thorough review of the patient's medical history and promptly terminating the causative drugs.

Prognostic Factors for Functional and Anatomic Outcomes in Patients with Diabetic Macular Edema Treated with Dexamethasone Implant

PURPOSE: To investigate the prognostic factors of visual and anatomic outcomes in patients with diabetic macular edema (DME) treated with intravitreal injection of dexamethasone implant. METHODS: We retrospectively studied 32 eyes of 31 patients with DME for best-corrected visual acuity (BCVA), central macular thickness, and height and width of both intraretinal fluid (IRF) and subretinal fluid. Logistic regression analysis was used to examine correlations between the baseline characteristics and outcomes at 3 and 6 months. RESULTS: Baseline predictor of BCVA ≥20 / 40 at month 3 was short height of baseline IRF (p = 0.02), while good baseline BCVA was a predictor for month 6 (p = 0.01). Predictors of improvement in logarithm of minimum angle of resolution BCVA 0.2 at month 3 were the absence of baseline IRF and poor baseline BCVA (p = 0.02 and p = 0.009, respectively), while poor baseline BCVA was the sole predictor at month 6 (p = 0.01). Predictor of central macular thickness ≤300 µm at month 3 was younger age (p = 0.03), while the absence of IRF was the predictor for BCVA improvement at month 6 (p = 0.02). BCVA ≤20 / 100 at month 3 was predicted by poor baseline BCVA (p = 0.01), and increased width of total IRF was the predictor at month 6 (p = 0.02). Predictor of loss of logarithm of minimum angle of resolution BCVA 0.2 at month 6 was increased width of total IRF at baseline (p = 0.04). Additional injection within 6 months was negatively associated with the presence of baseline DME (p = 0.03). CONCLUSIONS: The visual and anatomical outcome of DME treatment with dexamethasone implant can be predicted by baseline visual acuity and IRF morphology.

Scleral Buckling under a Slit-lamp Illumination System with a Contact Wide-angle Viewing Lens Compared with an Indirect Ophthalmoscope

PURPOSE: To investigate the outcomes of scleral buckling surgery performed under a slit-lamp illumination system (Visulux) with a contact wide-angle viewing lens (Mini Quad) in patients with rhegmatogenous retinal detachment (RRD) and to compare these outcomes with those of surgery performed under an indirect ophthalmoscope. METHODS: By retrospective review of electronic medical records, patients with RRD who had undergone scleral buckling surgery were identified. Scleral buckling surgeries were performed with two illumination instruments, a slit-lamp (SL group) and an indirect ophthalmoscope (IO group). Subretinal fluid drainage, cryopexy, and intravitreal gas injection were performed optionally. At 6 months after surgery, anatomical and functional outcomes were evaluated and compared between the two groups. Operation time was also compared between the two groups. RESULTS: Of the 45 total patients (45 eyes), 28 were included in the SL group, and 17 were included in the IO group. In the SL and IO groups, the primary anatomical success rate was 89.3% and 88.2%, respectively (p = 0.92). The logarithm of the minimal angle of resolution change, which reflects improvement in best-corrected visual acuity after surgery, was −0.19 ± 0.38 in the SL group and −0.21 ± 0.63 in the IO group; this difference was not statistically significant (p = 0.91). The mean operation time was significantly shorter in the SL group (78.9 ± 11.8 minutes) than in the IO group (100.0 ± 13.9 minutes, p < 0.001), especially for patients who underwent additional procedures such as subretinal fluid drainage and cryopexy (81.4 ± 12.9 and 103.5 ± 12.3 minutes, respectively, p < 0.001). CONCLUSIONS: Scleral buckling surgery performed under a slit-lamp illumination system yielded a similar anatomical success rate and similar functional improvement in RRD compared with surgery performed under an indirect ophthalmoscope. The slit-lamp system could save time, especially in bullous RRD, which requires additional subretinal fluid drainage.

Effectiveness of Intravitreal Ranibizumab for Diabetic Macular Edema with Serous Retinal Detachment

PURPOSE: To evaluate the effectiveness of intravitreal injection of ranibizumab (IVR) in treating diabetic macular edema (DME) with serous retinal detachment (SRD) based on spectral domain optical coherence tomography (SD-OCT) patterns. METHODS: One hundred thirty-four eyes of 134 patients with DME who underwent SD-OCT evaluation were included in this study. We retrospectively analyzed the medical records of patients who received IVR for the treatment of DME. Their eyes were classified into three groups according to the following SD-OCT features: SRD, diffuse retinal thickness and cystoid macular edema. The three groups were compared regarding changes in best-corrected visual acuity and central foveal thickness (CFT) after IVR. RESULTS: The mean age was 61.4 ± 9.2 years (range, 44 to 81 years). The average length of the follow-up period was 9.4 ± 3.4 months (range, 6 to 24 months). The mean CFT value was significantly reduced in all groups (p < 0.001) after treatment. Increases in best-corrected visual acuity were statistically significant for the diffuse retinal thickness and cystoid macular edema groups (p < 0.001 and p < 0.001, respectively). However, there was no significant improvement after IVR injection in the SRD group (p = 0.252). In the SRD group, patients with ellipsoid zone disruption and external limiting membrane disruption demonstrated poorer visual gains at the last follow-up visit (p < 0.005 and p = 0.002, respectively). CONCLUSIONS: A significant reduction in CFT with required IVR injections in DME with SRD was achieved but was accompanied by a worse functional outcome in the SRD group. The presence of subretinal fluid on SD-OCT in study eyes may be a poor prognostic factor for visual acuity.

Anatomical Characteristics of End-stage Exudative Age-related Macular Degeneration Refractory to Intravitreal Anti-vascular Endothelial Growth Factor Injection

PURPOSE: To analyze the anatomical characteristics on spectral-domain optical coherence tomography (SD-OCT) of patients who are legally blind (less than 20/1,000) due to end-stage exudative age-related macular degeneration (AMD) that does not require intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection. METHODS: After anti-VEGF injections (active group), 120 eyes of 103 exudative AMD patients experienced visual acuity improved by at least 2 lines or improvement on SD-OCT. In addition, 55 eyes of 54 end-stage exudative AMD patients who did not respond to treatment or who were legally blind due to foveal scar at the first visit (end-stage group) were evaluated retrospectively. Changes in retinal structures of the 2 groups were analyzed by SD-OCT at the last visit. RESULTS: The mean age of the end-stage group was about 5 years older than the active group. During the follow-up period, subretinal hemorrhage, intraretinal hemorrhage and retinal pigment epithelium tear occurred more frequently in the end-stage group than in the active group (p < 0.05). Intra-retinal fluids and subretinal fluids were more frequently administered in the active group than in the end-stage group, and thick subretinal hyper-reflective materials (SRHRM), fibrovascular pigment epithelial detachment (PED) and extensive inner segment/outer segment (IS/OS) line disruption were observed in all eyes of the end-stage group. The size and thickness of PED, foveal thickness and SRHRM thickness were significantly larger in the end-stage group than in the active group (p < 0.05). Disciform retinal scars were eventually formed in most of the end-stage group. CONCLUSIONS: In end-stage exudative AMD, the presence of retinal hemorrhage and retinal pigment epithelium tear during follow-up, or the findings of thick SRHRM, fibrovascular PED, and extensive IS/OS line disruption on SD-OCT suggest weak expected effect of intravitreal anti-VEGF injection, which can act as a reference for determining the timing of treatment termination.

Anatomical Characteristics of End-stage Exudative Age-related Macular Degeneration Refractory to Intravitreal Anti-vascular Endothelial Growth Factor Injection

PURPOSE: To analyze the anatomical characteristics on spectral-domain optical coherence tomography (SD-OCT) of patients who are legally blind (less than 20/1,000) due to end-stage exudative age-related macular degeneration (AMD) that does not require intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection. METHODS: After anti-VEGF injections (active group), 120 eyes of 103 exudative AMD patients experienced visual acuity improved by at least 2 lines or improvement on SD-OCT. In addition, 55 eyes of 54 end-stage exudative AMD patients who did not respond to treatment or who were legally blind due to foveal scar at the first visit (end-stage group) were evaluated retrospectively. Changes in retinal structures of the 2 groups were analyzed by SD-OCT at the last visit. RESULTS: The mean age of the end-stage group was about 5 years older than the active group. During the follow-up period, subretinal hemorrhage, intraretinal hemorrhage and retinal pigment epithelium tear occurred more frequently in the end-stage group than in the active group (p < 0.05). Intra-retinal fluids and subretinal fluids were more frequently administered in the active group than in the end-stage group, and thick subretinal hyper-reflective materials (SRHRM), fibrovascular pigment epithelial detachment (PED) and extensive inner segment/outer segment (IS/OS) line disruption were observed in all eyes of the end-stage group. The size and thickness of PED, foveal thickness and SRHRM thickness were significantly larger in the end-stage group than in the active group (p < 0.05). Disciform retinal scars were eventually formed in most of the end-stage group. CONCLUSIONS: In end-stage exudative AMD, the presence of retinal hemorrhage and retinal pigment epithelium tear during follow-up, or the findings of thick SRHRM, fibrovascular PED, and extensive IS/OS line disruption on SD-OCT suggest weak expected effect of intravitreal anti-VEGF injection, which can act as a reference for determining the timing of treatment termination.

Ruptured Retinal Arterial Macroaneurysm after Panretinal Photocoagulation for Diabetic Retinopathy

PURPOSE: To report a case of deterioration of a retinal arterial macroaneurysm after panretinal photocoagulation (PRP) for diabetic retinopathy. CASE SUMMARY: A 70-year-old woman visited our clinic for evaluation of diabetic retinopathy. Fundus examination and fluorescein angiography showed severe non-proliferative diabetic retinopathy and PRP was planned for the patient. In addition, the patient was found to have a retinal arterial macroaneurysm on the superotemporal area of the retina on her right eye. However, the lesion was small and was located far from the macula, causing no symptoms; thus we decided to observe the patient over a period of time. Two months after PRP, the patient revisited the clinic complaining of acute visual loss. Fundus examination showed vitreous and retinal hemorrhage and optical coherence tomography revealed subretinal fluid in the corresponding area. This was considered to be due to aggravation of the pre-existing macroaneurysm. Intravitreal Bevacizumab injection, C₃F₈ gas injection, and pars plana vitrectomy were performed. After absorption of the hemorrhage, barrier photocoagulation was performed around the retinal macroanerysm. The visual acuity improved and the retina remained stable through the most recent follow-up. CONCLUSIONS: We experienced the rupture of a preexisting retinal arterial macroaneurysm in an asymptomatic patient after panretinal photocoagulation. PRP in diabetic patients could aggravate retinal arterial macroaneurysms. Therefore, it is necessary to carefully examine the patient for retinal macroaneurysms when planning a PRP for diabetic retinopathy.