Retinal Pigment Epithelial Adenoma: Initial Treatment Outcomes following Episcleral Brachytherapy.

Introduction: We aim to explore the safety and efficacy of episcleral brachytherapy as a primary management option for eyes with retinal pigment epithelial (RPE) adenoma. Methods: Retrospective chart review of the demographic, clinical, ancillary, and postoperative outcome data of patients with RPE adenoma in 2 tertiary referral centers. Tumor regression, final visual acuity, and complications were assessed. Results: Five patients (3 females and 2 males) were included. Four of the 5 eyes had peripheral and mid-peripheral lesions, while one tumor was juxtapapillary. Three eyes were treated with ruthenium-106 (100 Gray), and 2 received iodine-125 episcleral plaques (85 Gray). All eyes showed clinical and imaging-based evidence of regression. Four eyes had stable or improved visual acuity, while 1 eye exhibited one line loss of visual acuity due to radiation retinopathy. Local recurrence was not observed in any eye over a median follow-up of 24 (range 6-112) months. Conclusions: Episcleral brachytherapy is an effective management option for select cases of RPE adenoma that is capable of achieving tumor regression while maintaining favorable visual acuity. The initial safety profile of brachytherapy is good without significant vision-compromising complications.

MACULAR HOLE-RELATED RETINAL DETACHMENT COMPLICATING AUTOSOMAL RECESSIVE BESTROPHINOPATHY: CLINICAL FEATURES, MULTIMODAL IMAGING, AND SURGICAL OUTCOME.

PURPOSE: To report a case of full-thickness macular-hole related retinal detachment in a patient with autosomal recessive bestrophinopathy. METHODS: A 3-year-old boy presented for squint assessment. In the examination, there were typical features of autosomal recessive bestrophinopathy in the left eye and a macular hole-related retinal detachment in his right eye. Color fundus photography, autofluorescence, fundus fluorescence angiography, and spectral-domain optical coherence tomography were recorded. RESULTS: Optical coherence tomography of the right eye showed a full-thickness macular hole retinal detachment. The retina showed retinoschisis affecting the inner and outer nuclear layer at the fovea and parafoveal region. Also, hyperreflective dots were seen at the hole and on the inner retinal surface. The left eye showed subretinal fluid with stalactite-like extensions into the subretinal space, and hyperreflective material seen above the retinal pigment epithelium. Fundus autofluorescence showed hyperautofluorescence at the fovea of the right eye and punctate hyperautofluorescent spots in the mid-periphery of the left eye. After pars plana vitrectomy and temporal internal limiting membrane flap, the hole was closed and all the schitic cavities collapsed at the sixth-week follow-up visit. CONCLUSION: A full-thickness macular hole-related retinal detachment can develop in autosomal recessive bestrophinopathy in the pediatric age group. Pars plana vitrectomy with temporal internal limiting membrane flap may be helpful for successful surgical repair.

Safety and Efficacy of Black Tea Extract in the Treatment of Acute Bacterial Conjunctivitis: A Rabbit Model.

PURPOSE: To determine the safety and efficacy of black tea extract in the treatment of bacterial conjunctivitis in a rabbit model and compare it with that of gatifloxacin drops. METHODS: Black tea extract was tested in vitro on bacterial cultures of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. Forty-two rabbit eyes were cultured with either MRSA (n=21) or P. aeruginosa (n=21) and further divided into a control group (n=5), a tea group (n=8) treated with black tea extract, and a gatifloxacin group (n=8) treated with 0.3% gatifloxacin eye drops. Conjunctival swabs were collected on the third and fifth days. RESULTS: The tea extract successfully inhibited the growth of both organisms at a concentration of 400 mg/mL. Rabbits in the treatment groups showed a reduction in the clinical index on day 2 (P<0.01), unlike the control group (P=0.1), for both organisms. Resolution of conjunctivitis was achieved on days 4 and 5 in the tea and gatifloxacin groups, respectively. On days 3 and 5, while the control group still showed considerable bacterial growth, the tea and gatifloxacin groups showed its inhibition. CONCLUSION: Tea extract has antimicrobial effects similar to those of gatifloxacin in a rabbit model of conjunctivitis.

Management of presumed trematode-induced granulomatous intermediate uveitis.

PURPOSE: To describe the surgical management of presumed trematode-induced granulomatous intermediate uveitis (PTIGIU) not responding to medical treatment in controlling the inflammation. METHODS: A prospective, interventional, single-center study in which patients with a history of fresh canal water contact and PTIGIU were enrolled. All patients underwent lensectomy-pars plana vitrectomy (PPV) and post-operative control of inflammation, functional and anatomical outcomes were assessed. RESULTS: Fifteen eyes of 12 patients were included in the study with median age of 11.6 ± 4 yrs. Six months following lensectomy-PPV, inflammation was well controlled in all patients. The eyes were divided into two groups: Group A: 10 patients with an attached retina while Group B: 5 patients who were in the cicatricial stage with tractional retinal detachment. All patients in group A had CDVA of 20/40 or better, unlike patients in group B who failed to achieve a CDVA better than 20/70 throughout their follow-up. In group B, final anatomical success was achieved in only 40% with hypotony occurring in 20%. CONCLUSION: PTIGIU is associated with the presence of ciliary body granuloma which, if left untreated, can lead to drastic outcomes. Early lensectomy-PPV represents a viable management option in cases resistant to medical treatment, with a favorable outcome.

Corneal cross-linking guards against infectious keratitis: an experimental model.

BACKGROUND: PACK-CXL (photo-activated chromophore for keratitis-corneal cross-linking) is an alternative option in treatment of corneal infections. It inhibits corneal melting by increasing the stromal resistance, besides the microbicidal effect of photo-activated riboflavin. METHODS: Corneal infection with Pseudomonas aeruginosa and Staph aureus bacteria was induced in 20 eyes of 10 rabbits after 6 weeks of corneal cross-linking in half of the eyes, while the other acted as control group. Clinical and corneal histopathological examination was done to evaluate the extent of inflammation, ulceration, organism penetration, and depth of corneal stromal affection. RESULTS: The control eyes developed severe inflammation compared to the cross-linked eyes. Corneal melting occurred in 6 eyes in the control versus none in cross-linked group. Histopathological examination showed that the inflammation was confined to the superficial part of the stroma with localization of the inflammation in the cross-linked eyes in contrast to the control eyes that showed deep infiltration. CONCLUSION: PACK-CXL provides infection localization through increasing the corneal rigidity and resistance to enzymatic digestion, even in the absence of the riboflavin microbicidal role. So, early PACK-CXL is worth to be considered in the IK treatment algorithm.

CHANDELIER-ASSISTED VERSUS STANDARD SCLERAL BUCKLING FOR PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT: A Randomized Clinical Study.

PURPOSE: To compare anatomical outcomes, functional outcomes, and rate of complications of standard scleral buckling (SSB) versus chandelier-assisted scleral buckling (CSB) in phakic eyes with rhegmatogenous retinal detachment. METHODS: Patients were randomly assigned to either SSB or CSB. Surgical success/failure rate, corrected distance visual acuity, surgical operating time, and rate of intraoperative and postoperative complications including epiretinal membranes by spectral domain optical coherence tomography were compared between groups. RESULTS: A total of 50 eyes of 49 patients were included. At 6 months, there was no statistically significant difference between groups in primary success, or final anatomical success ( P > 0.9); mean corrected distance visual acuity at any visit ( P values >0.05); or mean surgical time: 120.3 ± 39.05 and 102.48 ± 43.76 minutes for the SSB and CSB, respectively ( P = 0.1). The CSB had a higher rate of postoperative complications (34.8%) compared with the SSB (3.8%) ( P < 0.05). On spectral domain optical coherence tomography, CSB had a statistically significant higher rate of epiretinal membranes compared with SSB (44% vs. 19% [ P < 0.05]) and showed vitreous entrapment in the chandelier sclerotomy site on the ultrasonic biomicroscopy. CONCLUSION: Chandelier-assisted scleral buckling surgery does not offer encouraging advantages over SSB. On the contrary, we detected a higher rate of complications with CSB especially epiretinal membranes development.

Long-term changes in ocular rigidity following scleral buckling for rhegmatogenous retinal detachment.

PURPOSE: To investigate the long-term effect of scleral buckling on corneal biomechanics and the effect of change of scleral properties on intraocular pressure (IOP) measurements. METHODS: This is a prospective case series, patients with rhegmatogenous retinal detachment prepared for scleral buckling were included. Goldmann applanation tonometry was used to measure IOP (GAT IOP). Ocular Response Analyzer (ORA) was used to measure corneal hysteresis (CH), corneal resistance factor (CRF), goldmann-corrected IOP (IOPg), and corneal-compensated IOP (IOPcc) preoperatively, and 1, 3, and 6 months postoperatively. RESULTS: Thirty-three eyes included in the final analysis, with an average age 38.4 ± 16.2 years. CH and CRF decreased significantly at first, third, sixth months post-scleral buckling; however, this effect decreased with time as follows; preoperative: 8.9 ± 1.5 and 8.5 ± 2.1, first month: 6.8 ± 1.6 and 7.1 ± 1.8 (P value = 0.00, 0.002), third month: 7.8 ± 1.5 and 7.6 ± 1.6 (P value = 0.001, 0.008), and sixth month: 7.7 ± 1.3 and 7.6 ± 1.7 (P value = 0.002, 0.055). IOP cc was 19.3 ± 3.6, 17.1 ± 4, and 17.6 ± 2.9 at 1, 3, and 6 months, and these readings were significantly higher than GAT (13.6 ± 7.6, 12.4 ± 5.1, and 12.1 ± 2.9, P values = 0.00) and IOPg (14.9 ± 3.6, 13.5 ± 4.1, and 13.9 ± 3.5, P values = 0.00). The change in CH at each visit is correlated with the difference between the IOPcc and GAT measurements. CONCLUSION: The conventional Goldmann applanation tonometry underestimates post buckle IOP measurements due corneal biomechanics changes. ORA might be an alternative and accurate method of measurement; however, further investigation is warranted.

Various modalities of cyclodestruction in non-refractory glaucoma: a comparative study.

PURPOSE: The aim of the study is to study the safety and efficacy of three cyclodestructive treatments; high-intensity focused ultrasound (HIFU) cyclocoagulation versus micropulse cyclophotocoagulation (MP-CPC) versus transscleral continuous-wave cyclophotocoagulation (CW-CPC) for treatment of non-refractory glaucoma. METHODS: This is a prospective comparative single-center study. Thirty non-refractory, medically uncontrolled, primary open-angle glaucoma patients with good vision were randomized to a single session of HIFU, MP-CPC or CW-CPC. Intraocular pressure (IOP) reduction, number of medications, success rate, visual acuity and complications were compared between the three groups. Success was defined as an IOP reduction of 30% and IOP between 6 and 21 mmHg with or without medications, in the absence of vision-threatening complications. RESULTS: Thirty patients were enrolled in our study: 10 patients received HIFU, 10 patients received MP-CPC and 10 patients received CW-CPC. At 6 months, IOP was reduced by 31.5%, 23.9% and 19.4% (P = 0.4) achieving a success rate of 50%, 60% and 50% (P = 0.8) for continuous, micropulse and HFU groups, respectively, with reduction in the number of drops and stop of oral acetazolamide. Although the difference in the rate of complications between groups was not significant, CW-CPC group had more complications. CONCLUSIONS: Cyclophotocoagulation could be an option in the treatment of non-refractory glaucoma even in patients with good visual acuity, with similar outcomes between the three types of cyclodestruction.

MONTHLY INTRAVITREAL INFLIXIMAB IN BEHÇET'S DISEASE ACTIVE POSTERIOR UVEITIS: A Long-Term Safety Study.

PURPOSE: To study the safety of extended monthly intravitreal infliximab injections in patients with active posterior uveitis in Behcet's disease. METHODS: This is a prospective, interventional, noncomparative, open-label, pilot study of 9 monthly intravitreal infliximab injections (1 mg/0.05 mL) for 22 eyes of 16 patients with active posterior uveitis in Behcet's disease. Control of inflammation and visual outcomes were assessed, and ocular complications were monitored during the study period. RESULTS: Successful treatment was achieved in 7 eyes (35%), and failure was encountered in 13 eyes (65%). Only seven eyes of six patients (35%) had completed the study and achieved complete resolution of inflammation with improved best-corrected visual acuity and no complications. Failure was either because of inability to control the inflammation in nine eyes (45%) or development of exacerbation of inflammation in four eyes (20%). Four eyes developed severe immunological reaction from the drug after first (n = 1), second (n = 2), and third (n = 1) injections and had to discontinue the injections. Kaplan-Meier survival analysis showed that the mean estimated time to failure was 3.3 ± 0.2 months, and all failed eyes required revision of their systemic immunotherapy to control the ocular inflammation. CONCLUSION: Intravitreal infliximab for active posterior uveitis in Behcet's disease was associated with a high complication rate and failure to control inflammation in most eyes. It should not be considered a substitute to systemic therapy.

Endodiathermy assisted vitreous base and anterior hyaloid visualization during vitrectomy for rhegmatogenous retinal detachment.

PURPOSE: To describe a novel technique to visualize vitreous base and the anterior hyaloid during vitrectomy for Rhegmatogenous Retinal Detachment (RRD). METHODS: Retrospective, single-center study enrolling all patients who underwent vitrectomy for RRD between June 2015 and June 2018. After core vitrectomy and the necessary additional procedures, endodiathermy was activated near the edge of the peripheral vitreous. This created a heat-induced bubble stream and the bubbles were entangled in the vitreous base and anterior hyaloid. As a result, the vitreous base and anterior hyaloid were visualized and removed. RESULTS: Between June 2015 and June 2018, a total of 210 cases of rhegmatogenous retinal detachment were treated with vitrectomy. Endodiathermy assisted vitreous base shaving and anterior hyaloid removal was used in those cases with a very low incidence of iatrogenic peripheral retinal breaks during vitreous base shaving (2%), and with no case of lens injury related to the technique. We achieved a final anatomical success of 95.2% in the study period after mean number of operations of 1.3 ± 0.2. Endodiathermy near the peripheral vitreous was not associated with any intraoperative or postoperative complications. CONCLUSION: Endodiathermy assisted vitreous base and anterior hyaloid visualization is a safe adjuvant method that could help in achieving complete and rapid vitreous base shaving and anterior hyaloid removal.

Extended Internal Limiting Membrane Peeling in Complex Pediatric Rhegmatogenous Retinal Detachment.

PURPOSE: To assess the feasibility and investigate the anatomical and functional outcomes of extended internal limiting membrane (ILM) peeling with pars plana vitrectomy (PPV) for complex pediatric rhegmatogenous retinal detachment (RRD). METHODS: This was a retrospective interventional case series where children (≤18 years) with RRD and severe PVR (grade C) were included. All eyes underwent PPV with ILM peeling up to 2-disk diameter beyond the vascular arcades. The main outcome measures were assessment of feasibility of ILM peeling in the pediatric RRD and evaluation of the rate of complete retinal reattachment and corrected-distance visual acuity (CDVA) at the final follow-up. RESULTS: A total of 29 eyes (25 patients) were enrolled in this study. ILM peeling performed on these children was not more difficult than in adult eyes. After a mean follow-up of 18 months, the patients achieved final CDVA better than 20/200 in 37.9%. The initial retinal reattachment was 55.2% while the final anatomical success was 86.2%. CONCLUSION: Vitrectomy with ILM peeling is technically feasible in pediatric RRD, limiting epiretinal proliferation and achieving favorable anatomical outcomes in cases of complex pediatric RRD. The long-term effects of ILM peeling need further investigation.

Change in Ophthalmology Practice during COVID-19 Pandemic: Egyptian Perspective.

PURPOSE: To assess the impact of the COVID-19 pandemic on ophthalmology practice in the Cairo metropolitan area. METHODS: This is a cross-sectional observational analytic study among ophthalmologists practicing in different hospitals in the Cairo metropolitan area. The data were collected through a self-administered questionnaire covering general measures taken during practice. RESULTS: The questionnaire was sent to 250 ophthalmologists, with an 82% response rate. Most of the participants were concerned about the economic impact of the pandemic, as there is a 60-80% reduction in the flow of patients with a consequent 80-100% reduction in surgical cases. Most of the participants have access to personal protective equipment, and the safety protocols are followed, especially by the older ophthalmologists. Thus, the surgeons are willing to perform elective surgeries, adhering to strict safety protocols (70.8, 42.6, and 18.8% of the refractive surgeons, corneal surgeons, and retinal surgeons, respectively; p = 0.00). Furthermore, 63.9% of the participants, especially the young ophthalmologists, are willing to see COVID-19 patients and operate on them if needed. CONCLUSIONS: The COVID-19 pandemic could go on for months or even years with a significant impact on ophthalmology practice. Trying to keep a balance between safety and economic burden, the majority of ophthalmologists are willing to see elective patients and urgently operate on a COVID-19 patient, under adherence to the safety protocols.

Pars plana Ex-Press mini shunt for management of persistent glaucoma in vitrectomized eyes: A novel technique.

PURPOSE: To evaluate the safety and efficacy of a novel approach to implant Ex-Press mini shunt via the pars plana under a scleral flap in pseudophakic or aphakic, vitrectomized patients with secondary refractory glaucoma. METHODS: A prospective interventional case series of three patients with secondary glaucoma after pars plana vitrectomy. Intraocular pressure was not controlled by silicone oil removal, if the patient was siliconized, nor the maximum medical treatment. Ex-Press mini shunt via the pars plana was implanted. We evaluated the control of intraocular pressure and the development of intraoperative and postoperative complications. RESULTS: During 1-year follow-up, control of intraocular pressure was achieved; 14, 15, and 15 mmHg at the 3 months, and 15, 15, and 16 mmHg at the 6 months in our three cases without antiglaucoma treatment and 16, 16, and 18 with single antiglaucoma medication at 1 year. Blebs were posterior and diffuse. No complications were encountered intraoperatively or postoperatively. Ultrasound biomicroscopy showed suprachoroidal posterior lake of fluid as an additional filtration route without any choroidal or retinal complication. CONCLUSION: Implantation of Ex-Press mini shunt via the pars plana in aphakic or pseudophakic, vitrectomized eyes is a promising, safe, and effective technique in patients with secondary glaucoma.

The value of prednisolone acetate provocative test before intravitreal triamcinolone acetonide injections.

PURPOSE: The aim of this study was to investigate the diagnostic value of a topical prednisolone acetate 1% provocative test for steroid-induced ocular hypertension before intravitreal triamcinolone acetonide injection. METHODS: This is a prospective, single-center, randomized controlled study at Kasr El Aini Hospital, Cairo University. Patients scheduled for intravitreal triamcinolone acetonide were enrolled and randomly allocated in a ratio 2:1 to either Group A: received prednisolone acetate provocative test and those who did not develop SIOH proceeded with intravitreal triamcinolone acetonide or Group B: did not receive prednisolone acetate provocative test and proceeded directly to intravitreal triamcinolone acetonide. Intraocular pressures were measured weekly for 4 weeks following intravitreal triamcinolone acetonide. Steroid-induced ocular hypertension is defined as intraocular pressure increase of 5 mmHg or more from baseline after prednisolone acetate provocative test or intravitreal triamcinolone acetonide. RESULTS: A total of 66 eyes (66 patients) were included. Of which, 10 eyes (23.8%) showed prednisolone acetate provocative test steroid-induced ocular hypertension during the 4-week period. Intravitreal triamcinolone acetonide steroid-induced ocular hypertension was less likely to develop in Group A (prednisolone acetate provocative test non-steroid-induced ocular hypertension, n = 32, 31.25%) than in group B (n = 24, 54.2%) (p = 0.006, odds ratio: 0.178, 95% CI: 0.53-0.596). Our test achieved a negative predictive value of 68.75%. CONCLUSION: The topical prednisolone acetate provocative test may be a useful method to predict a steroid-induced ocular hypertension following intravitreal triamcinolone acetonide.

Intravitreal decorin preventing proliferative vitreoretinopathy in perforating injuries: a pilot study.

PURPOSE: To determine the short-term safety of human recombinant decorin protein in preventing proliferative vitreoretinopathy (PVR) in perforating injuries. METHODS: This is a prospective, single-center, open-label, interventional case series. Single intravitreal injection of decorin 200 µg (n = 4) or 400 µg (n = 8) was given 48 h after injury. At the tenth day, pars plana vitrectomy was done whenever indicated. Flash electroretinogram (ERG) was done before and 3 months post-injection. We assessed ocular inflammation, ERG changes, and retinal layer integrity by optical coherence tomography (OCT). Systemic and vitreous pharmacokinetics were also evaluated. RESULTS: Twelve patients (12 eyes) with perforating globe injuries (zone III) were included and followed for a median of 6 months. Intravitreal decorin injection was well tolerated with no ocular or systemic safety adverse events. Decorin retinal safety was demonstrated anatomically by intact retinal layer by OCT, and functionally by flash ERG which did not show any significant worsening during the study and the final mean logMAR best-corrected visual acuity (BCVA) which was 1.15 (20/280) and 0.7 (20/100) for groups A and B, respectively, and ≥ 20/200 in 75% of all eyes. Decorin serum and vitreous levels were elevated following trauma, with higher and extended levels following intravitreal injection. CONCLUSIONS: No short-term safety concerns were detected after a single intravitreal injection of decorin in patients with perforating injuries. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02865031.

Vitrectomy with scleral buckling versus with inferior retinectomy in treating primary rhegmatogenous retinal detachment with PVR and inferior breaks.

PURPOSE: To evaluate anatomic and functional outcomes of patients treated with pars plana vitrectomy (PPV) with scleral buckling versus PPV with inferior retinectomy for treatment of cases of primary rhegmatogenous retinal detachment (RRD) associated with proliferative vitreoretinopathy (PVR) and inferior retinal breaks. METHODS: Retrospective, comparative, interventional, single-center study. Fifty-one eyes of fifty-one patients with primary RRD associated with inferior breaks and PVR grade C1 or more were reviewed over 3 years. Twenty-one eyes underwent PPV with encircling band 360° and thirty eyes underwent PPV with primary inferior retinectomy. The primary outcome was final anatomic success. Secondary outcomes included change in visual acuity, primary anatomical success, the mean number of operations, and incidence of postoperative complications. RESULTS: Primary anatomical success of 85.7% was achieved in buckle group compared to 83.3% in retinectomy group (p = 0.82). Mean duration of follow-up and mean number of operations was 9.8 ± 2.26 and 9.97 ± 2.44 months; 1.24 ± 0.62 and 1.3 ± 0.75 in buckle group and retinectomy group, respectively, achieving final anatomical success of 95.2% for the buckle group and 90% for the retinectomy group with no statistical significant difference (p = 0.49). Although visual acuity (logMAR) was better in the buckle group in the 1st month, it became nearly equal thereafter during the follow-up period (p = 0.5). CONCLUSION: Similar anatomical and functional outcomes were achieved by combining PPV with scleral buckle or inferior retinectomy for treatment of primary RRD with PVR and inferior breaks.

Why Poor Vision Despite an Attached Retina following Primary Vitrectomy in Egyptian Patients?

OBJECTIVE: To correlate findings on spectral domain optical coherence tomography (SD-OCT) and best-corrected visual acuity (BCVA) following primary vitrectomy for rhegmatogenous retinal detachment (RRD). METHODS: In this prospective, interventional, non-randomized case series, 71 eyes with RRD of intermediate severity underwent primary vitrectomy followed by SD-OCT one month later. Main outcome measures were inner segment/outer segment (IS/OS) junction line and external limiting membrane (ELM) disruption. RESULTS: All patients achieved reattachment with mean BCVA of 0.77 ± 0.36 logMAR. There was statistically significant correlation between each length of IS/OS and ELM defect on the one hand, and BCVA on the other hand. CONCLUSION: The extent of IS/OS and ELM disruption explains the poor visual outcome in successful RD surgery with an otherwise normal foveal contour.