Autologous anterior lens capsule flap and serum transplant in managing idiopathic and refractory full-thickness macular holes.

PURPOSE: To report the results of pars plana vitrectomy (PPV) with inner limiting membrane (ILM) peeling alongside phacoemulsification and intraocular lens (IOL) implantation with autologous anterior lens capsule flap (ALCF) and autologous serum transplantation (AST) into full-thickness macular holes (FTMH) and 14% perfluoropropane (C3F8) tamponade for idiopathic and refractory FTMHs. METHODS: Retrospective study involving eleven patients with idiopathic FMTHs and seven with refractory FMTHs after standard surgery with PPV, ILM peeling, and gas tamponade. All eyes underwent a 'combination procedure' of PPV with ILM peeling alongside phacoemulsification and IOL implantation with autologous ALCF and AST into the FTMH and 14% C3F8 tamponade. A face-down position for one week was recommended. RESULTS: The mean preoperative FMTH size was 558.95 ± 186.30 µm. Seven patients aged 64 ± 5 years had a refractory FMTH and eleven patients with a mean age of 63.72 ± 4.97 years had an idiopathic FMTH. The main BCVA improvement six months postoperatively was 0.3 ± 0.29 logMAR. Seventeen macular holes fully closed six months postoperatively, with one FTMH closure failure because of a retinal detachment. CONCLUSIONS: ALCF transplantation alongside AST may help to improve the closure rate and visual outcomes in both idiopathic and refractory FMTHs.

Primary lacrimal sac melanoma: a case report describing the novel use of fine needle aspiration cytology (FNAC) for diagnosis, together with literature review and immunotherapy treatment update.

Primary lacrimal sac melanoma (PLSM) is exceedingly rare and associated with high morbidity and mortality. Unfortunately, PLSM often presents insidiously resulting in delayed detection and poor prognosis. A 69-year-old Black man was suspected of having a lacrimal sac tumour following presentation with a left sided watery eye, bloody tears, and a lacrimal mass. Due to the patient's implantable pacemaker, defibrillator, and high anticoagulation, an ultrasound-guided FNAC was performed instead of incisional biopsy, revealing a PLSM. Diagnosis was confirmed following complete tumour resection with free flap reconstruction and neck dissection. Unfortunately, disease progression ensued despite further neck dissection and three cycles of both pembrolizumab and iplimumab. This is the first description of FNAC to accurately diagnose PLSM and highlights its use as an accurate, rapid, and minimally invasive technique that may allow an earlier screening diagnosis of lacrimal sac tumours. We also discuss the outcome of immunotherapy in recent similar cases.

Myopic macular hole detachment associated with intravitreal ocriplasmin.

PURPOSE: To describe a case of macular hole retinal detachment in a high myope following intravitreal ocriplasmin injection. OBSERVATIONS: A 71-year-old highly myopic (-18.63 Dioptres) female received 125 µg of intravitreal ocriplasmin (Jetrea, Oxurion, Leuven, Belgium) to treat a right, full-thickness macular hole (FTMH) with vitreomacular adhesion. Presenting best-corrected visual acuity (BCVA) letter score was 45, using the Early Treatment Diabetic Retinopathy Study chart. Past ocular history in the affected, pseudophakic eye included anisometropic amblyopia, but with a documented pre-morbid BCVA of 75 letters. One week post-injection the vitreomacular adhesion persisted. One month post-injection, a large posterior macular hole retinal detachment developed with BCVA of 45 letters. Over the course of one year she underwent three pars plana vitrectomies aiming to treat the retinal detachment and close the FTMH. The detachment was treated successfully but the FTMH persisted, albeit with a reduced diameter. Final BCVA was 55 letters. CONCLUSIONS: The pathogenesis of this macular hole detachment may be related to the combination of a FTMH and high myopia. Ocriplasmin functions in a twofold manner; inducing a posterior vitreous detachment and as a proteolytic enzyme digesting the fibronectin and laminin at the pathological vitreoretinal interface. With access through a FTMH, ocriplasmin may exert an enzymatic effect on the interphotoreceptor matrix and the photoreceptor-retinal pigment epithelium interface that normally helps maintain neuroretinal adhesion to the retinal pigment epithelium. The reported increase in basal diameter of FTMHs following ocriplasmin supports this hypothesis. High myopia was another likely contributing factor. Highly myopic patients were excluded from the initial ocriplasmin registration studies, mainly due to the risk of retinal detachment, but were eligible for subsequent large trials. IMPORTANCE: Clinicians should be aware of a potential association between ocriplasmin and macular hole detachments in eyes with high myopia.

Real-world incidence of fingolimod-associated macular oedema.

BACKGROUND: Fingolimod (Gilenya, Novartis, Basel Switzerland) 0.5 mg orally once-daily is widely used for relapsing-remitting multiple sclerosis. Patients are usually screened four months after starting fingolimod for fingolimod-associated macular oedema (FAME). Large registration trials with stringent eligibility criteria have reported a FAME incidence of 0 - 2.08%. OBJECTIVES: To determine the real-world incidence of FAME in a London population, and to describe the clinical characteristics and management of confirmed cases. METHODS: All patients started on fingolimod from September 2012 to September 2018 were referred for ophthalmology clinical examination and macular spectral-domain optical coherence tomography (SD-OCT) at four months after starting treatment. Exclusion criteria were failure to attend or non-gradable OCT images. RESULTS: Of 228 patients, two had FAME at initial screening, giving an incidence of 0.88% (95% confidence interval 0.10-3.10). Another case emerged subsequently, at 637 days, resulting in a final incidence of 1.32% (95% confidence interval 0.30-3.80). Fingolimod was discontinued in two cases. FAME resolved in all cases within two to 10 months, with no persistent visual loss or symptoms. CONCLUSIONS: The real-world FAME incidence is consistent with fingolimod registration studies. FAME may have a delayed onset and may be better detected with newer OCT devices.

A double Descemet's stripping endothelial keratoplasty on a penetrating keratoplasty.

A patient with keratoconus underwent a penetrating keratoplasty (PK) in his right eye. This failed after 12 years following phacoemulsification surgery. A Descemet's stripping endothelial keratoplasty (DSEK) was carried out which failed and detached after 4 months. Subsequently, a second DSEK was performed which failed after 2 months but remained attached. This graft was retained in the cornea and a third DSEK button was placed without removing the failed DSEK graft. The cornea cleared well and patient's vision was 6/9 at 18 months postsurgery. Optical coherence tomography showed the two DSEK grafts closely applied to each other and to the recipient cornea. Stripping a failed DSEK graft performed for a previous failed PK carries the risk of internal dehiscence of the PK graft-host junction. This was avoided by placing the second DSEK graft on the failed previous DSEK graft with good visual outcome indicating that this option can be clinically considered.

Posterior Segment Distortion in Ultra-Widefield Imaging Compared to Conventional Modalities.

BACKGROUND AND OBJECTIVES: To describe posterior segment distortions in Optos ultra-widefield images (Optos 200TX; Optos, Dunfermline, United Kingdom) compared to Topcon retinal camera images (Topcon, Tokyo, Japan) using optic disc dimensions and exploring a proposed method for correcting these distortions. PATIENTS AND METHODS: Comparative image analysis study on 20 eyes with color fundus images from Optos and Topcon. A model eye with vertical and horizontal grids imaged with Optos in the conventional position and rotated 90° was analyzed. RESULTS: Mean vertical-to-horizontal disc diameter ratios were 0.956 [95% CI, 0.919-0.993] for Optos and 1.083 [95% CI, 1.045-1.121] for Topcon (P < .001). This was 0.910 in the conventional position and 1.072 with the object rotated 90° for the model eye with Optos and 1.008 and 0.999, respectively, using Topcon. The average of the measurements taken using both images from Optos yielded a ratio of 0.987. CONCLUSION: Optos incorporates a consistent horizontal stretch to images. Combining images taken at right angles reduces the distortion. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:644-651.].

The association of exposure to hepatitis B and C viruses with lung function and respiratory disease: a population based study from the NHANES III database.

BACKGROUND: Globally, 500 million people are chronically infected with Hepatitis B virus (HBV) and Hepatitis C virus (HCV). While these viruses are notorious for their detrimental effect on the liver they are also known to affect multiple organs in the body including the lungs. AIM: To investigate if exposure to HBV and HCV is associated with lung function and respiratory diseases. METHODS: Data from the Third National Health and Nutrition Examination Survey (NHANES III) was analysed using multiple linear regressions to investigate the association between exposure to HBV and HCV with the various measures of lung function, while multiple logistic regressions were used to evaluate the association with the respiratory diseases asthma and chronic obstructive pulmonary disease (COPD). RESULTS: Exposure to HCV was significantly associated with an increase in Forced Expiratory Volume in 1 s, FEV1 (Coef: 97.94 ml, 95% CI: 38.87 to 157.01) and Full Vital Capacity, FVC (Coef: 90 ml, 95% CI: 14.50 to 166.24). Individuals who had been exposed to both HBV and HCV also had a significantly higher FEV1 (Coef: 145.82, CI: 60.68 to 230.94) and FVC (Coef: 195.09, CI: 78.91 to 311.26). There was also a significant association between exposure to HBV and asthma (OR: 1.28, 95% CI: 1.05 to 1.58). These associations were no longer significant after additionally adjusting for cocaine and marijuana use as well as poverty income ratio. CONCLUSION: Our research implies that hepatotropic viruses may affect the respiratory system, but more work at a population level is needed to further explore these associations.

Observations on the epidemiology of gastrointestinal and liver cancers in the Asia-Pacific region.

Gastric cancer (GC) has long been thought to be an Asian type of cancer that is broadly associated with poverty, whereas colorectal cancer (CRC) has been thought to be a Western type of cancer associated with affluence. The incidence of GC has declined dramatically in the West but has a very high incidence in East Asia. The age-standardized incidence rates (ASR) have also declined. The decrease in the incidence of GC is associated with the decrease in the prevalence of Helicobacter pylori (H. pylori) infection worldwide. The discrepancy between a high H. pylori infection rate and a low GC incidence is seen chiefly among southern Asians of Indian origin and has been aptly termed the "Indian enigma". CRC is a new emerging cancer in this region. Some of the highest CRC ASR have been reported from Asian countries, in many of which it has now surpassed that of GC. Liver cancer is also an important cancer in the Asia-Pacific region. The highest ASR worldwide is reported from the Asian countries of Mongolia, Korea and Japan. The predominant underlying etiology across the region has been hepatitis B virus infection, except in Japan, where hepatitis C is an important cause of hepatocellular carcinoma (HCC). With mass vaccination of hepatitis B at birth and improved public health measures in many countries, hepatitis B and C are set to decline with time. However, the exponential increase in obesity and consequent non-alcoholic fatty liver disease portends a future epidemic of fatty liver-related HCC.

Obesity: an epidemiological perspective from Asia and its relationship to gastrointestinal and liver cancers.

Obesity is major health problem in the Asia-Pacific region. The proportion of people who are overweight and obese in the region has increased dramatically and is closely linked to the increasing affluence in the region. While the body mass index has been used as a yardstick in many published studies, it has been noted that Asian patients have a greater percentage body fat for a given body mass index and especially abdominal or visceral obesity. The association of obesity and cancers is intriguing and worrisome at the same time, as obesity is rising exponentially throughout the world especially in the Asia-Pacific region. Evidence of its association with gastrointestinal cancers is well documented and is reported with cardioesophageal, colorectal, liver, pancreatic, and gallbladder cancers. The strength of association varies between individual cancers but is of particular concern with colorectal cancer, which is perhaps the fastest emerging cancer in this region. Biological mechanisms for obesity-related carcinogenesis have been described, which includes insulin resistance and secretion of adipokines and chronic inflammation. A "dose-response" relationship between severity of excess body weight and risks of cancer has been reported. However, there is a paucity of data looking at a decrease in incidence of these cancers with a decrease in body weight with treatment, for example, bariatric surgery. Such studies will be difficult to perform and which would require a long period of longitudinal follow-up.