Incidence of Epiretinal Membrane Formation After Pars Plana Vitrectomy for Giant Retinal Tear-Associated Retinal Detachment.

Objective: To report the incidence of postoperative epiretinal membrane (ERM) formation after primary pars plana vitrectomy (PPV) for giant retinal tear associated retinal detachment (GRT-RD) repair as well as its clinical characteristics and visual outcomes at a level one trauma and tertiary referral academic center. Patients and Methods: Patients with primary RD repair for GRT-RD at West Virginia University from September 2010 to July 2021 were identified using the ICD-10 codes (H33.031, H33.032, H33.033 and H33.039). Imaging studies including optical coherence tomography (OCT) were manually reviewed pre- and post-operatively for ERM formation after PPV for GRT-RD repair in patients who underwent PPV or combined PPV and scleral buckle (SB). Univariate analysis was performed to analyze clinical factors for ERM formation. Results: The study included 17 eyes of 16 patients who underwent PPV for GRT-RD. Postoperative ERM was observed in 70.6% (13 of 17 eyes) of the patients. Anatomic success was achieved in all patients. The mean (range) preoperative and final best corrected visual acuity (BCVA) in logMAR units by macula status was 0.19 (0-0.5) and 0.28 (0-0.5) for macula-on and 1.7 (0.5-2.3) and 0.7 (0.2-1.9) for macular-off GRT-RDs. Clinical variables including use of medium-term tamponade with perfluorocarbon liquid (PFCL), cryopexy, endodiathermy, number of tears or total clock hours of tears did not correlate with an increased risk of ERM formation. Conclusion: Post-vitrectomized eyes for GRT-RD repair have a significantly higher incidence of ERM formation, nearing 70% in our study. Surgeons may consider prophylactic ILM peel at the time of removal of tamponade agents or weigh in ILM peel at the time of primary repair, a more challenging surgical technique in our opinion.

Diabetic retinopathy screenings in West Virginia: an assessment of teleophthalmology implementation.

BACKGROUND: The prevalence of diabetes in the state of West Virginia (WV) is amongst the highest in the United States, making diabetic retinopathy (DR) and diabetic macular edema (DME) a major epidemiological concern within the state. Several challenges exist regarding access to eye care specialists for DR screening in this rural population. A statewide teleophthalmology program has been implemented. We analyzed real-world data acquired via these systems to explore the concordance between image findings and subsequent comprehensive eye exams and explore the impact of age on image gradeability and patient distance from the West Virginia University (WVU) Eye Institute on follow-up. METHODS: Nonmydriatic fundus images of diabetic eyes acquired at primary care clinics throughout WV were reviewed by retina specialists at the WVU Eye Institute. Analysis included the concordance between image interpretations and dilated examination findings, hemoglobin A1c (HbA1c) levels and DR presence, image gradeability and patient age, and distance from the WVU Eye Institute and follow-up compliance. RESULTS: From the 5,512 fundus images attempted, we found that 4,267 (77.41%) were deemed gradable.  Out of the 289 patients whose image results suggested DR, 152 patients (52.6%) followed up with comprehensive eye exams-finding 101 of these patients to truly have DR/DME and allowing us to determine a positive predictive value of 66.4%. Patients within the HbA1c range of 9.1-14.0% demonstrated significantly greater prevalence of DR/DME (p < 0.01).  We also found a statistically significant decrease in image gradeability with increased age.  When considering distance from the WVU Eye Institute, it was found that patients who resided within 25 miles demonstrated significantly greater compliance to follow-up (60% versus 43%, p < 0.01). CONCLUSIONS: The statewide implementation of a telemedicine program intended to tackle the growing burden of DR in WV appears to successfully bring concerning patient cases to the forefront of provider attention.  Teleophthalmology addresses the unique rural challenges of WV, but there is suboptimal compliance to essential follow-up with comprehensive eye exams. Obstacles remain to be addressed if these systems are to effectively improve outcomes in DR/DME patients and diabetic patients at risk of developing these sight-threatening pathologies.

Comparison of the visual outcome between macula-on and macula-off rhegmatogenous retinal detachment based on the duration of macular detachment.

OBJECTIVE: To compare the visual outcomes between macula-on and macula-off primary rhegmatogenous retinal detachment (RRD) based on the duration of macular detachment (DMD). METHODS AND ANALYSIS: Retrospective study including 96 eyes with RRD (34 macula-on and 62 macula-off) repaired between June 2012 and March 2020. The final visual acuity (VA) was compared after the patients were divided by the status of the macula and their DMD. RESULTS: The mean final VA of patients with macula-on RRD (group A) was logarithm of the minimum angle of resolution (logMAR) 0.04±0.07, which was not statistically different from that of individuals with macula-off RRD with DMD ≤3 days (group B; logMAR 0.05±0.06) (p=0.79). There were statistically significant differences in the final VA between group A and patients with macula-off RRD with DMD of 4-7 days (group C; logMAR 0.15±0.15) (p=0.017) as well as between group A and those with macula-off RRD with DMD ≥8 days (group D; logMAR 0.36±0.29) (p<0.001). There was no significant difference in the final VA between group B and C (p=0.33). CONCLUSION: The mean final VA of patients with macula-on RRD was comparable to that of the macula-off patients with DMD ≤3 days. Our findings suggest that if macula-on RRD could not be immediately repaired, a repair within 72 hours may result in similar outcomes, even if the macula detaches within that time frame. However, once the macula detaches, we do not observe statistically significant differences in outcome for repairs done within 7 days.

An atypical case of acute posterior multifocal placoid pigment epitheliopathy with recurrent strokes.

PURPOSE: To report an atypical case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) with central nervous system (CNS) vasculitis and recurrent strokes. OBSERVATIONS: A 57 year-old female presented with APMPPE after a febrile illness and rash. She developed an acute infarct on magnetic resonance imaging. Computed tomography angiography of the cerebral vasculature was normal. Cerebrospinal fluid (CSF) analysis and an extensive serum lab workup were also unremarkable. She was treated with high-dose corticosteroids and eventually transitioned to methotrexate. A month after being on treatment she developed a second stroke. A cerebral angiogram was obtained and did not show evidence of CNS vasculitis. The methotrexate was eventually stopped and the prednisone was tapered. Approximately 3 months later she developed a third stroke and worsening APMPPE-associated maculopathy in both eyes. She was eventually started on oral cyclophosphamide. CONCLUSIONS & IMPORTANCE: Although rare, CNS vasculitis is a known complication of APMPPE. This case is atypical given the development of multiple recurrent strokes, lack of inflammatory evidence on CSF analysis, and normal imaging of the cerebral vasculature. This report highlights the need for a high level of clinical suspicion for CNS vasculitis with APMPPE despite noncontributory cerebral angiographic imaging and normal CSF analysis.

A unique case of chronic myeloid leukemia presenting as monocular vision loss with unilateral retinopathy.

PURPOSE: To report a case of unilateral leukemic retinopathy secondary to chronic myeloid leukemia (CML). OBSERVATIONS: Patient presented to clinic with a visual acuity (VA) of 20/200 in the right eye (OD) after several months of progressive monocular vision loss and was found to have dense pre-retinal hemorrhage. Patient underwent 23-gauge pars plana vitrectomy to clear the preretinal hemorrhage along with a complex macula-off retinal detachment repair to address retinal tear and multilayer retinal hemorrhage. The patient was subsequently diagnosed with CML as she was found to be positive for the fusion protein of break point cluster gene (BCR) with Abelson tyrosine kinase (ABL1), BCR-ABL1, upon systemic work-up. Imatinib therapy resulted in complete hematologic and cytogenetic resolution after one month, however, the patient's vision remained unchanged six months after surgery. CONCLUSION AND IMPORTANCE: To the authors' knowledge, this is the first reported case of unilateral leukemic retinopathy secondary to low risk CML, as determined by the Sokal and Hasford prognostic scoring systems. CML should be included in the differential diagnosis of patients with progressive monocular vision loss with suspicious multi-layer retinal compromise.

Acute Posterior Multifocal Placoid Pigment Epitheliopathy Associated with Gastrointestinal Stromal Tumor and Hurthle Cell Tumor.

Acute posterior multifocal placoid pigment epitheliopathy (APMPEE) is a chorioretinal inflammatory disease of unknown origin. Patients usually present with a rapid loss of central/paracentral vision over the course of a week in both eyes. The fundus exhibits rapid appearance of multiple deep subretinal yellow-white, flat lesions at the RPE/choriocapillaris level. This in turn causes changes of both the ellipsoid zone and RPE which can result in permanent central vision loss. The pathogenesis is controversial but is associated with a recent viral illness and can involve the central nervous system with concern for cerebral vasculitis. Rare reports of APMPEE associated with systemic vasculitis such as Wegener's granulomatosis and malignancy such as clear cell renal carcinoma have been reported. We report a case of APMPEE with concurrent diagnosis of gastrointestinal stromal tumor and Hurthle cell tumor. While such association may well be coincidental, the near simultaneous presentation raised our suspicion for potential association.

Delayed suprachoroidal hemorrhage after cataract surgery.

PURPOSE: To describe the clinical course of 61-year-old man who developed a delayed suprachoroidal hemorrhage 4 days after cataract surgery. METHOD: This is an observational case report. The patient's clinical course is reviewed, and his clinical findings are correlated to B-scan ultrasonography and posterior funduscopic photography. We describe a successful surgical intervention with external sclerotomy and partial drainage of the suprachoroidal hemorrhage. RESULTS: Initial medical management of delayed suprachoroidal hemorrhage failed to improve the patient's pain, vision, and clinical findings. Two weeks later, an external sclerotomy with partial drainage of the suprachoroidal blood resulted in an expedited pain relief, with complete resolution of the suprachoroidal hemorrhage and restoration of baseline visual acuity. CONCLUSION: Delayed suprachoroidal hemorrhage is a well-recognized but rare postoperative complication of cataract surgery. This case highlights the benefits of a timely surgical intervention after conservative management. We propose that a conservative external surgical approach with partial drainage of a suprachoroidal hemorrhage and closure by secondary intention was sufficient to tip the balance of intraocular hemodynamics and led to full recuperation.

EMMPRIN mediates beta-adrenergic receptor-stimulated matrix metalloproteinase activity in cardiac myocytes.

Extracellular matrix metalloproteinase inducer (EMMPRIN) expression is increased in myocardium from patients with dilated cardiomyopathy and animal models of heart failure. However, little is known about the regulated expression or functional role of EMMPRIN in the myocardium. In rat cardiac cells, EMMPRIN is expressed on myocytes but not endothelial cells or fibroblasts. Therefore, we tested the hypothesis that EMMPRIN expression regulates matrix metalloproteinase (MMP) activity in rat ventricular myocytes in vitro. In adult rat ventricular myocytes (ARVM), beta-adrenergic receptor (betaAR) stimulation and H(2)O(2) (24 h) each increased EMMPRIN expression as assessed by immunoblotting. Pretreatment with a catalase/superoxide dismutase mimetic or adenoviral-mediated expression of catalase or a dominant-negative c-jun N-terminal kinase-1 (JNK) mutant inhibited the betaAR- and H(2)O(2)-stimulated increases in EMMPRIN expression suggesting that EMMPRIN expression is regulated via a reactive oxygen species-dependent JNK pathway. To determine whether EMMPRIN expression regulates matrix metalloproteinase (MMP) activity, EMMPRIN activity was inhibited by adenoviral expression of an inhibitory mutant of EMMPRIN. Expression of mutant EMMPRIN inhibited the betaAR-stimulated increases in MMP2 expression and zymographic MMP activity. Thus, in cardiac myocytes betaAR stimulation induces the expression of EMMPRIN via the ROS-dependent activation of JNK. The resulting increase in EMMPRIN activity stimulates MMP expression and activity. These findings suggest that in the myocardium the regulated expression of EMMPRIN is a determinant of MMP activity and may thus play a role in myocardial remodeling.