Effect of Extended Release Steroid Implants on the Contralateral Eye.

PURPOSE: To investigate the contralateral effect of extended release steroid implants on cystoid macular edema (CME). METHODS: Retrospective study of patients with bilateral CME receiving intravitreal injections of long-acting intravitreal corticosteroid implants in one eye. Changes in CME and central subfield thickness (CST) in the contralateral eye on optical coherence tomography (OCT) were compared to an untreated control group. The main outcome measures were the change in central subfield thickness (CST) and the change in the macular volume. RESULTS: Thirteen study patients and 14 controls were included in the study. There was no difference in the baseline LogMAR visual acuity (0.32 ± 0.35 vs 0.43 ± 0.26, p = 0.37) or the baseline central subfield thickness (341.4 ± 76.6 vs 296.5 ± 65.0 µm, p = 0.12) between groups. In the treatment group CST remained stable in 92.3% of the patients. Of the controls, CST worsened in 21.4% and remained stable in 78.6%. The mean change in CST (6.3 ± 30.3 vs. 27.5 ± 66.1 µm, p = 0.2) and the mean change in macular volume (0.08 ± 0.34 vs. -0.05 ± 0.21 mm3, P = 0.8) were not statistically different between the treatment group and control group. In the post-hoc analysis restricting the treatment group to patients who had not received intravitreal injections in the study eye within 6 months, CST decrement was not statistically significant (p = 0.11). CONCLUSION: In this study there was no statistically significant effect on CME of contralateral intravitreal corticosteroid implants.

Long-Term Follow-Up of Outer Retinal Layers in Patients with Epiretinal Membranes.

PURPOSE: This study aimed to investigate the long-term effect of observed epiretinal membranes on the outer retinal layers and visual acuity. METHODS: It is a retrospective observational study. Subjects with an epiretinal membrane and consecutive optical coherence tomography scans were followed for changes in visual acuity, central macular thickness, ellipsoid zone loss, and outer foveal thickness (OFT). RESULTS: The study consisted of 24 eyes of 22 patients, with a mean follow-up of 5 ± 1.6 years. The mean visual acuity was slightly worse at the last follow-up (0.22 ± 0.36 LogMAR [20/33] vs. 0.27 ± 0.36 LogMAR [20/36], p = 0.05). Ellipsoid zone loss was found in 37.5% of eyes. Vision loss was associated with initial size of ellipsoid disruption (p = 0.048) and age (p = 0.027). A decrease in OFT was associated with an initially larger zone of ellipsoid disruption (p = 0.006) and an initially thicker OFT (p = 0.011). An epiretinal membrane associated with vitreomacular adhesion within 1,000 µm of the foveal center at baseline was associated with ellipsoid zone loss (p = 0.012) but not with a change in visual acuity. CONCLUSIONS: Ellipsoid zone changes were common in this study and tended to enlarge over time. Epiretinal membranes associated with vitreomacular adhesion within 1,000 µm of the foveal center may be a risk factor for ellipsoid zone loss.

Bilateral neuroretinits and exudative retinal detachment with multifocal subretinal deposits secondary to Bartonella henselae infection.

PURPOSE: to describe a case of bilateral neuroretinitis with bullous retinal detachment and multiple subretinal lesions, in a 10-year-old immunocompetent girl. OBSERVATIONS: A broad workup for infectious, inflammatory and masquerade etiologies was done for the patient, resulting in positive IgM and IgG for Bartonella henselae. The patient demonstrated improvement in the visual acuity, and rapid resolution of the retinal detachment and subretinal lesions in both eyes in response to systemic rifampin, doxycycline and corticosteroids. CONCLUSIONS AND IMPORTANCE: Bartonella henselae neuroretinitis may present as an acute form of bullous retinal detachment with multiple subretinal lesions and markedly reduced vision. Significant visual improvement may occur with prompt treatment with a combination of systemic antibiotics and corticosteroids.

Vitamin Analysis Comparison Study.

PURPOSE: We compared and analyzed the concentrations of vitamin C, vitamin E, zinc, and copper in both national and regional brands of dietary supplements recommended for patients who are at risk for macular degeneration. DESIGN: Prospective cross-sectional study. METHODS: National brand name and generic multivitamin formulations for age-related macular degeneration were obtained. Comparative analysis of the vitamin C and vitamin E content was performed by gas chromatography-mass spectrometry and the zinc and copper content was analyzed by atomic absorption spectroscopy in an institutional chemistry laboratory. RESULTS: All national brand name vitamins, both tablet and gel capsule formulations, and generic brands in tablet form were relatively accurate in their product labeling. For most of the samples tested, the measured quantities of vitamin C, vitamin E, zinc, and copper were slightly higher than labeled but not to an amount that would cause any systemic toxicity if taken at the recommended dosages. CONCLUSIONS: Physicians may recommend national brand name vitamins and generic brands in tablet form to their patients with some confidence; however, the content may have some inaccuracies regarding labeling.

Lighting conditions and perceived visual function in ophthalmic conditions.

PURPOSE: To determine the influence of different lighting conditions on perceived visual function in patients of different age, gender, race, and in various ophthalmic diseases. METHODS: A prospective study. A survey given to patients seen in general ophthalmic and retina clinics. Patients were asked four questions: Is your vision better, worse, or the same in (1) bright light vs dim light, (2) indoors or outdoors, (3) beginning or end of the day, and (4) sunny or cloudy day? Parameters tested were age, race, gender, visual acuity, and a variety of ophthalmic conditions. Multivariable models for each question were fit using multinomial regression. Association was considered significant if p < 0.05. RESULTS: A total of 722 patients were enrolled in the study. Patients with lower vision (LogMAR ≥ 0.3) were more likely to indicate they either had better vision indoors or outdoors compared with better vision patients (LogMAR < 0.1). Patients with pseudophakia were also more likely to indicate they had better vision on a cloudy day (OR = 1.9). White patients had double the odds of selecting bright light compared with others. Males were less likely than females to indicate better vision indoors (OR = 0.62). There were no significant associations with age-related macular degeneration (AMD) in the multivariable model. CONCLUSIONS: Most patients did not note any difference in lighting conditions, and although there is explanatory rational for some of the findings in this study, those questions concerning lighting conditions or time of day are not useful for screening of disease. Gender and ethnicity were found to have associations with lighting preferences which needs to be further studied.

Foveal vasculature changes and nonperfusion in patients with diabetes types I and II with no evidence of diabetic retinopathy.

PURPOSE: To analyze the foveal avascular zone (FAZ) in patients with diabetes and no retinopathy vs. controls using OCT angiography (OCT-A). METHODS: Prospective, observational clinical study. Type I and II diabetics with no retinopathy and healthy control patients underwent OCT-A. The FAZ size and capillary density were calculated using Image J and Adobe Photoshop CS8. Statistical analysis was performed using one-way ANOVA with Tukey's multiple comparison test and the Pearson correlation test. RESULTS: Fifty-two eyes of 28 diabetic patients and 28 eyes of 16 healthy controls were enrolled. Type I diabetes patients had a longer disease duration than type II (30.3 ± 10.3 vs. 12.3 ± 9.7 years). The mean superficial capillary plexus (SCP) of the FAZ area was 0.27 ± 0.1, 0.36 ± 0.14, and 0.27 ± 0.12 mm2, for the type I, type II, and controls (p = 0.0058) and was significantly larger in type II diabetics (p < 0.05). The mean DCP (deep capillary plexus) FAZ was significantly larger in type II diabetics vs. controls (0.67 ± 0.2 and 0.52 ± 0.16 mm2 respectively) (p < 0.05). Both type I and type II SCP capillary density were significantly lower than the controls (p < 0.05, p < 0.005), and DCP capillary density was significantly lower in type II vs. controls (p < 0.005). CONCLUSIONS: Type I patients showed fewer changes in the FAZ than the type II group, although their duration of diabetes was longer. Larger studies are needed to better analyze the differences between type I and type II diabetics.

Outcomes After the Use of Silicone Oil in Complex Retinal Detachment Repair.

Purpose: This study compares visual acuity (VA), anatomic outcomes, and complications in eyes that underwent complex retinal detachment (RD) repair in which silicone oil (SO) was retained vs removed. Methods: A retrospective chart review of patients undergoing vitrectomy with SO tamponade. The eyes were divided into 2 groups based upon SO removal or retention. Main outcome measures were corrected VA, anatomic outcomes, and the presence of SO-related complications. Results: Fifty-seven eyes with removed SO and 53 eyes with retained SO were identified. In both groups, the mean best-corrected VA (BCVA) at the final visit was significantly better than at baseline. In the retained-SO group, vision improved from 1.79 ± 0.6 to 1.2 ± 0.7 logarithm of the minimum angle of resolution (logMAR) (Snellen, 20/1200 to 20/350) at the final visit (P < .001). In the removed-SO group, mean BCVA improved from 1.84 ± 0.5 at baseline to 1.55 ± 0.6 logMAR units (Snellen, 20/1400 to 20/700) at the visit preceding SO removal (P < .002) and to 1.43 ± 0.6 logMAR units (Snellen, 20/500) at the final visit (P < .001). Complication rates were similar in both groups, apart from RD, which occurred more frequently in the removed-SO group (P = .03). Conclusions: There was similarity in VA and complications among patients with removed or retained SO. Removal of SO may benefit eyes with SO-related complications, but SO retention may decrease the chance of RD and may be indicated in selected cases.

A NOVEL FINDING OF HYPERREFLECTIVE MATERIAL IN THE SILICONE-RETINA INTERFACE: An Optical Coherence Tomographic and Histopathological Study.

PURPOSE: To describe novel findings of hyperreflective material in the silicone-retina interphase on spectral domain optical coherence tomography (SD-OCT) imaging in eyes with silicone oil tamponade. METHODS: Retrospective observational clinical study of consecutive patients who underwent primary pars plana vitrectomy with silicone oil tamponade for rhegmatogenous retinal detachment. Repeat clinical examination and spectral domain optical coherence tomography macular imaging performed 3 months after surgery were evaluated to identify any macular pathologies, including formation of epiretinal membranes, intraretinal changes, subretinal fluid, and edema before scheduled secondary vitrectomy for silicone oil removal. RESULTS: Eighty-two patients (mean age 54 years, range 22-89) were included. Twelve eyes (14%) showed discrete preretinal hyperreflective organized coarse material in the silicone-retina interphase on spectral domain optical coherence tomography. The material was scattered in the posterior pole, with several foci showing additional hyperreflectivity of the inner retinal layers beneath. These findings did not resemble silicone oil emulsification in size, shape, or reflectivity. CONCLUSION: This is the first report on hyperreflective material detected by spectral domain optical coherence tomography in the silicone-retina interphase in eyes with silicone oil tamponade. These findings may represent an inflammatory response to silicone oil exposure that may be the initial manifestation of a future proliferative process, warranting a rigorous follow-up protocol for affected patients.

SURGICAL MANAGEMENT OF RETINAL DETACHMENT IN OSTEOGENESIS IMPERFECTA: CASE REPORT AND REVIEW OF THE LITERATURE.

PURPOSE: To describe a case of scleral buckling in a patient with severe (Type III) osteogenesis imperfecta. METHODS: Single interventional case report of a 37-year-old woman, with clinically diagnosed osteogenesis imperfecta Type III, presenting with an inferior retinal detachment of the right eye. The patient was promptly treated with scleral buckling. RESULTS: Long-term follow-up has shown a good clinical outcome, with no recurrence of the retinal detachment. Eighteen months postsurgery, an ischemic branch retinal vein obstruction has developed in the right eye, complicated by macular edema. The patient was treated successfully with bevacizumab injections, with restoration of visual acuity to 20/25. CONCLUSION: Scleral buckle may provide a good surgical option in selected patients with osteogenesis imperfecta, yielding excellent anatomical and functional results.

Prevalence of choroidal nevus and retinal pigment epithelial alterations in vitiligo patients.

PURPOSE: To investigate ocular manifestations in patients with vitiligo by multimodal imaging, including optical coherence tomography (OCT), color fundus photography, and fundus autofluorescence (FAF). METHODS: In this prospective, observational clinical study, vitiligo patients underwent ophthalmologic and dermatologic clinical assessment and imaging by spectral-domain OCT, FAF, and color fundus imaging. Ocular echography was performed as indicated. Statistical analysis was performed using paired T test and Pearson correlation. RESULTS: A total of 61 eyes of 31 vitiligo patients were examined. Ocular findings consisted of choroidal nevi (n = 10, 32%), of which four (40%) were bilateral; two patients (6.5%) had a prominent choroidal pattern, two (6.5%) had hypopigmentary retinal pigment epithelium (RPE) lesions, and one (3.2%) had peripapillary atrophy of the RPE. Choroidal nevi were demonstrated only in eyes of patients with generalized vitiligo and were more common with upper body involvement (p = 0.02) and more prevalent in women (p = 0.02). Hypopigmentary lesions were detected in two patients and demonstrated on OCT as RPE atrophy and as photoreceptor/RPE changes. CONCLUSIONS: In this case series, vitiligo patients had a higher rate of choroidal nevi than previously reported. The hypopigmentary vitiliginous fundus lesions were depicted on OCT as photoreceptor and RPE atrophy. These findings may suggest the advisability of regular ocular monitoring for vitiligo patients.

CHANGES IN CHOROIDAL THICKNESS IN CLINICALLY SIGNIFICANT PSEUDOPHAKIC CYSTOID MACULAR EDEMA.

PURPOSE: To investigate choroidal thickness in eyes with clinically significant pseudophakic cystoid macular edema (PCME) during the acute phase and following resolution of the edema, using enhanced depth imaging spectral domain optical coherence tomography (EDI-OCT). METHODS: This is a retrospective, observational clinical study. Patients' records were reviewed for cases of clinically significant PCME after uneventful phacoemulsification surgery. Choroidal thickness was measured at time of PCME diagnosis in both eyes and after CME resolution in the affected eye using enhanced depth imaging spectral domain optical coherence tomography (Spectralis; Heidelberg Engineering). Measurements were taken subfoveal and 1.5 mm nasal, temporal, inferior, and superior from the center of the fovea. Statistical analysis was performed using paired t-test and Pearson correlation. RESULTS: Mean subfoveal choroidal thickness in 34 eyes with PCME measured 258 ± 83 µm at baseline and decreased to 215 ± 79 µm after CME resolution (P < 0.001). Mean subfoveal choroidal thickness measured at baseline in fellow eyes was significantly lower (194 ± 77 µm) compared to acute PCME (P < 0.001) and after CME resolution (P = 0.011). CONCLUSION: Choroidal thickness is increased in eyes with PCME and decreases following edema resolution. These findings may strengthen the hypothesis of an inflammatory pathogenesis in PCME.

FIVE-YEAR FOLLOW-UP AFTER EPIRETINAL MEMBRANE SURGERY: A Single-Center Experience.

PURPOSE: To evaluate the rate of epiretinal membrane (ERM) recurrence in eyes that underwent ERM peeling surgery at least 5 years earlier. METHODS: Retrospective interventional case series study of 37 patients (15 women and 22 men; mean age, 70 ± 7.6 years) operated on for ERM removal with a follow-up of at least 5 years. The patients underwent testing for visual acuity, an ophthalmic examination, and optical coherence tomography imaging, all of which were assessed preoperatively, postoperatively, and at the 5-year follow-up. RESULTS: Visual acuity significantly improved at 1 year after peeling compared with baseline (P = 0.045), and the improved results were maintained at 5 years (P = 0.804) 0.766 logarithm of the minimum angle of resolution (Snellen 6/35). The central macular thickness decreased significantly at the 1-year follow-up compared with baseline and continued to decrease as measured at the 5-year follow-up (P = 0.04). At 5 years, the ERM recurrence rate reached 58% (28% extrafoveal). Photoreceptor atrophy and retinal pigment epithelium changes correlated with diabetes mellitus (P = 0.028). CONCLUSION: The recurrence rate of ERM after peeling surgery was reported as being around 5% to 12%. It was 58% in the current study. Because the recurrent ERM is generally mild, visual acuity was unaffected.

Massive subretinal and subretinal pigment epithelial hemorrhage displacement with perfluorocarbon liquid using a two-step vitrectomy technique.

PURPOSE: The purpose of this study was to evaluate the efficacy and visual outcome of massive submacular hemorrhage (SMH) displacement with a planned two-step pars plana vitrectomy (PPV) using tissue plasminogen activator (tPA) and perfluorocarbon liquid (PFCL) tamponade. METHODS: A retrospective case series of patients with age related macular degeneration and SMH was used. All patients underwent a 23G PPV, subretinal tPA injection and a medium term PFCL tamponade. A second stage PPV for PFCL removal was performed 7-17 days later. The main outcome was the change in macular and sub-RPE thickness after 6 months. Secondary outcomes were visual acuity and complications. RESULTS: Seven patients (seven eyes) with mean age of 79.85 years were enrolled. The average SMH size was 17.5 disc area (range 4.5-33) with mean symptoms of a duration of 9.5 days (range: 2-21). SMH was successfully displaced in six eyes. Mean macular and sub-RPE thickness decreased from 1505µ to 711.3µ and 900 µ to 457µ, respectively. Visual acuity (VA) remained stable in five eyes. Complications included corneal edema and transient intraocular pressure elevation in three patients. CONCLUSIONS: SMH displacement using subretinal tPA injection and medium term PFCL tamponade is an effective alternative treatment option. In our experience, it can be safely performed, avoiding complications commonly attributed to other techniques.

Blinding Orbital Apex Syndrome due to Onodi Cell Mucocele.

The onodi cell is a posterior ethmoidal cell that is pneumatized laterally or superiorly to the sphenoid sinus with close proximity to the optic nerve. A mucocele, a benign, expansile, cyst-like lesion of the paranasal sinuses, may uncommonly involve the onodi cell causing compression of the optic nerve and nearby structures. In this paper, we report a rare case of onodi cell mucocele causing orbital apex syndrome, with prompt recovery after endoscopic removal. However, optic neuropathy did not improve and the patient remained blind.

Long-term outcomes of triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss.

PURPOSE: To report the long-term outcomes of triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss. SETTING: Tel Aviv Medical Center, Tel Aviv, Israel. DESIGN: Case series. METHODS: Consecutive patients who had triamcinolone acetonide-assisted anterior vitrectomy for complicated cataract surgery with vitreous loss between January 2010 and January 2012 were studied. The main outcome measures were the results of the ocular examination and spectral-domain optical coherence tomography of the macula at the last follow-up visit 12 months or more postoperatively. The ocular examination included corrected distance visual acuity (CDVA), intraocular pressure (IOP), and anterior segment and fundus biomicroscopy. RESULTS: The study included 15 patients (15 eyes) with a mean age of 71 years (range 50 to 92 years). The mean follow-up was 21 months (range 12 to 29 months). At the last follow-up, the mean CDVA was statistically significantly better than preoperatively (0.24 logMAR ± 0.31 [SD] versus 0.89 ± 0.81 logMAR) (P=.0033); all patients had improved CDVA over the preoperative values. Except for 1 patient with a macular scar, all the patients had a CDVA between 20/40 and 20/20. At last follow-up, 1 patient required 2 IOP-lowering medications that had been used preoperatively as well. The mean IOP was 15.3 ± 2.4 mm Hg. There were no cases of residual vitreous strands in the anterior chamber, inflammatory reactions, triamcinolone acetonide crystals, retinal breaks, retinal detachment, or pseudophakic cystoid macular edema. CONCLUSION: Triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss was safe and effective.

Intermediate term follow-up after a single-piece-acrylic intraocular lens implantation in the ciliary sulcus- a cross-sectional study.

BACKGROUND: Implantation of a single-piece-acrylic intraocular lens (SPA-IOL) in the ciliary sulcus during phacoemulsification complicated with posterior capsule tear (PCT) may be associated with severe complications. The purpose of this study was to report the efficacy and safety of sulcus implantation of a SPA-IOL, designed for both in-the-bag and sulcus positioning. METHODS: A prospective cross-sectional study including 12 patients, who underwent phacoemulsification with PCT and sulcus implantation of SPA-IOL designed for both in-the-bag and sulcus positioning (Seelens AF, Hanita, Israel) between January 2009 and March 2012 (follow-up 12-37 months). Preoperatively corrected distance visual acuity (CDVA), subjective refraction and intraocular pressure (IOP) were recorded. Postoperative evaluation included anamnesis for IOL edge symptoms and transient visual obscurations (TVO) along with CDVA, subjective refraction IOP, anterior segment biomicroscopy, gonioscopy, assessment of IOL centration, fundus biomicroscopy and spectral-domain optical coherence tomography of the macula. RESULTS: Preoperatively, mean CDVA was 0.84 ± 0.60 LogMAR (Counting Finger-20/33) improving to 0.18 ± 0.13 LogMAR (20/40-20/20) at last examination (p = 0.004), as all the patients gained better CDVA. Mean preoperative spherical equivalent was -0.2 ± 2.5 Diopter (D) (-4.0D to +5.4D) reaching -1.9 ± 0.9 (-4.0D to -0.6D) at last examination (p = 0.12). Mean preoperative refractive astigmatism magnitude was 1.0 ± 0.6D (0.3D to 2.3D) changing to 1.1 ± 1.0D (0.0D to 3.0D) at last examination (p = 0.88). Mean preoperative IOP was 14.7 ± 3.2 mmHg (11-23 mmHg) without medications reaching 15.9 ± 3.3 mmHg (10-21 mmHg) at last follow up (p = 0.21). Postoperatively one patient required two medications for IOP control in his study and contralateral eyes. None of the patients had symptoms of IOL edge or TVO. There were no intraocular hemorrhages, inflammatory reactions, or pigment dispersion and the IOLs were well centered in all cases. Central foveal thickness was 280 ± 33 µm (193-310 µm). CONCLUSIONS: Appropriately designed SPA-IOL may be implanted in the ciliary sulcus during phacoemulsification with PCT rather than switching to another backup IOL demanding wound enlargement.