The Wisconsin silicone oil study (report #1): anatomical and functional outcomes of repair of retinal detachment with proliferative vitreoretinopathy.

BACKGROUND: Silicone oil (SO) is a long-term tamponade for repair of complex retinal pathology but has limitations including late redetachment. This study describes our experience with SO tamponade for repair of retinal detachment with proliferative vitreoretinopathy (PVR), with attention to anatomic and functional outcomes. METHODS: Retrospective consecutive case series of eyes with retinal detachment (RD) complicated by proliferative vitreoretinopathy (PVR) receiving SO tamponade at the University of Wisconsin between 2013 and 2019. Group 1 defined as primary SO placement; Group 2 had SO placed after failing prior retinal detachment repair. RESULTS: Inclusion criteria of SO placement for repair of RD with PVR was met for 117 eyes. The final reattachment rate was 84% for all eyes, with no difference between Groups 1 and 2. Vision improvement was 2.1 lines for Group 1 (p = 0.06 from baseline) and 4.6 lines for Group 2 (p < 0.0001). The mean number of silicone oil placements was 1.4. Less improvement in vision was noted with repeat SO placement, though overall functional vision of 5/200 or better was achieved in 63.2% of patients. CONCLUSIONS: SO tamponade allows long-term anatomical stabilisation and substantial vision recovery in eyes with retinal detachment complicated by PVR. Rates of anatomic and functional success have improved significantly when compared to prior studies using oil tamponade for repair of PVR.

Ocular Findings Aid in Diagnosis of West Nile Virus.

INTRODUCTION: West Nile virus disease, which is endemic to the United States, is a rarely reported systemic infection that can be difficult to diagnose. Chorioretinitis is an uncommon manifestation of West Nile virus but has pathognomonic ocular findings that can aid in diagnosis. CASE PRESENTATION: A 66-year-old man presented with acute onset fever, chills, and dyspnea. He underwent an extensive but nondiagnostic workup during hospitalization. New visual complaints prompted ophthalmology consultation. Funduscopic examination showed macular hemorrhages and midperipheral chorioretinal lesions. Fluorescein angiography revealed target-like lesions in a radial distribution, which is pathognomonic for West Nile virus chorioretinitis. Serology confirmed the diagnosis of West Nile virus disease. Systemic and ocular symptoms improved with supportive care. DISCUSSION: West Nile virus disease has many nonspecific manifestations. History of recent mosquito exposure is not always readily elicited. In patients with visual symptoms, eye examination can help in its diagnosis. CONCLUSIONS: West Nile virus should be considered in patients with acute febrile or neurological illness during mosquito season.

Redefining the Spectrum of Pentosan Polysulfate Retinopathy: Multimodal Imaging Findings from a Cross-Sectional Screening Study.

PURPOSE: There is growing evidence of a direct association between pentosan polysulfate (PPS) therapy and the development of macular changes. Using standardized visual acuity (VA) testing and multimodal imaging, we investigated the impact of PPS therapy on vision and described an expanded spectrum of imaging findings among PPS users. DESIGN: Cross-sectional screening study. PARTICIPANTS: Thirty-nine patients who were current or recent users of PPS. METHODS: The participants underwent a brief eye examination and answered a comprehensive medical and ophthalmic history questionnaire. Color fundus photography, fundus autofluorescence (FAF), and spectral-domain OCT (SD-OCT) were performed. The images were evaluated by expert graders at Wisconsin Reading Center. Abnormalities were categorized as definite toxicity (DT) if seen on both FAF and SD-OCT and as questionable toxicity (QT) if seen on either FAF or SD-OCT. MAIN OUTCOME MEASURES: ETDRS and Snellen VA, the dosage and duration of PPS exposure, and the prevalence of retinal toxicity on imaging. RESULTS: The mean ETDRS and Snellen VA of the study cohort were 85 letters and 20/22, respectively. The mean PPS daily dose was 282 mg (range, 88-400 mg), whereas the mean cumulative dose was 915 g (range, 19-3650 g) over a mean period of 8.8 years (range, 2 months-25 years). There was evidence of retinopathy in 41% of the eyes; DT was identified in 24 eyes (31%) and QT in 8 eyes (10%). Retinal pigment epithelium (RPE) abnormalities (thickening or thinning or both) were present in all eyes with DT. Retinal pigment epithelium atrophy was seen in 7 eyes (9%). In addition to well-established findings, the unique SD-OCT features of this cohort included interdigitation zone abnormalities and the presence of a flying saucer-type defect. Fundus autofluorescence abnormalities were seen in 24 eyes (30.8%), with 20 (66.7%) of these exhibiting abnormalities located outside the central subfield and extending beyond the arcades. CONCLUSIONS: Findings from the masked grading of multimodal imaging at a centralized reading center suggest a wider phenotypic spectrum of structural abnormalities among patients taking PPS. Macular changes selectively involve the RPE and outer retina, with a range of findings often seen beyond the arcades. The subtle and atypical findings in this cohort should prompt clinicians to consider lowering the threshold for diagnosing PPS retinopathy.

Central Retinal Thickness and Visual Acuity Outcomes After Vitrectomy for Epiretinal Membrane With and Without Internal Limiting Membrane Peel.

Purpose: This work compares best-corrected visual acuity (BCVA) and central retinal thickness (CRT) outcome measures following pars plana vitrectomy (PPV) with and without internal limiting membrane (ILM) peel for epiretinal membrane (ERM). Methods: A retrospective cohort study was conducted of 114 eyes of 114 patients with visually significant ERM undergoing PPV with membrane peel (PPV/MP) at a single institution. CRT measurements were collected from Heidelberg and Zeiss spectral-domain optical coherence tomography imaging units. Results compared preoperative and postoperative CRT and BCVA among patients with at least 60 days of follow-up. Results: A total of 114 eyes with ERM met the inclusion criteria. Eighty-one eyes (71%) underwent PPV/MP with ILM peel and 33 eyes (29%) underwent PPV/MP without ILM peel. There was no statistically significant difference between preoperative CRT between the 2 study groups (P = .95). The mean follow-up time of eyes undergoing PPV/MP without ILM peel and with ILM peel was 391 days and 319 days, respectively. There was no statistical difference in the mean reduction of CRT between the 2 groups (P = .470). Both groups had improvement of BCVA following surgery and there was no statistical difference in final logMAR visual acuity when comparing the 2 groups (P = .738). Conclusions: There was an overall improvement of CRT and BCVA among patients undergoing PPV/MP for ERM with or without ILM peel. There was no statistically significant difference in the final BCVA or CRT between the 2 groups.

Bilateral Macular Holes in Adult Vitelliform Macular Dystrophy.

Purpose: This report describes a case of bilateral macular holes (MHs) in adult vitelliform macular dystrophy (AVMD). Methods: A retrospective case report of a patient with AVMD and sequential onset of bilateral MHs is presented. Results: Bilateral MHs were observed after vitreomacular traction was identified on optical coherence tomography. Holes in both eyes were repaired with pars plana vitrectomy (PPV) with C3F8 (perfluoropropane) gas tamponade; only the right eye underwent internal limiting membrane peeling. In the right eye, 2 PPVs were required for hole closure. In both eyes, long-term atrophy of the retina and retinal pigment epithelium was observed. Conclusions: MHs in AVMD may be preceded by vitreomacular traction. Surgical repair with PPV and gas tamponade was successful. Retinal and retinal pigment epithelium atrophy developed postoperatively, but the patient's vision still improved.

STENOTROPHOMONAS MALTOPHILIA ENDOPHTHALMITIS 1 MONTH AFTER INTRAVITREAL AFLIBERCEPT.

PURPOSE: Endophthalmitis caused by Stenotrophomonas maltophilia is rare and has been described after cataract surgery and open globe injuries. We report a patient with endophthalmitis caused by this organism after uncomplicated intravitreal aflibercept injection. METHODS: A 70-year-old man with a history of anti-vascular endothelial growth factor therapy for diabetic macular edema presented 23 days after aflibercept injection with clinical diagnosis of endophthalmitis. The patient initially had mild pain, conjunctival congestion, and anterior chamber cell; 2 days later, the patient returned with hand motion visual acuity, hypopyon, and dense vitritis. RESULTS: A tap and inject procedure was performed. The aqueous sample confirmed the presence of S. maltophilia. Antimicrobial testing showed susceptibility to ceftazidime which was used during the initial treatment. After resolution of the vitritis and hypopyon, the visual acuity returned to 20/70 at his 3-month follow-up examination. CONCLUSION: Stenotrophomonas maltophilia is a rare infectious agent associated with intravitreal injection and may present 1 month after treatment.

Multi-modal imaging and anatomic classification of the white dot syndromes.

The white dot syndromes (WDS) are a diverse group of posterior uveitidies that share similar clinical findings but are unique from one another. Multimodal imaging has allowed us to better understand the morphology, the activity and age of lesions, and whether there is CNV associated with these different ocular pathologies. The "white dot syndromes" and their uveitic masqueraders can now be anatomically categorized based on lesion localization. The categories include local uveitic syndromes with choroidal pathology, systemic uveitic syndromes with choroidal pathology, and multifocal choroiditis with outer retinal/choriocapillaris pathology with uveitis and without uveitis. Neoplastic and infectious etiologies are also discussed given their ability to masquerade as WDS.

Is There an Increased Prevalence of Asteroid Hyalosis in Eyes with Uveal Melanoma? A Histopathologic Study.

During the planning meeting for the Collaborative Ocular Melanoma Study (COMS) prior to the start of patient recruitment in 1986, there was an interest expressed in determining whether a relationship existed between the presence of uveal melanoma (UM) and asteroid hyalosis (AH). To answer this question, the ophthalmic examination form (unlike the pathology form for enucleated eyes) for each COMS patient asked whether AH was present or not. Though an increased prevalence was not found, this result was never published. A recent unpublished study at the University of Wisconsin School of Veterinary Medicine indicated a higher prevalence of AH in canine eyes with UM when compared to control eyes (without tumor) enucleated for goniodysgenesis. This further increased our interest in revisiting the published literature, clinical records, and histopathology slides of the enucleated eyes from the COMS study, as well as the histopathology slides on file in the University of Wisconsin Eye Pathology Laboratory. While cases with both AH and UM were occasionally encountered in the literature, clinically, we could not find a previous study focusing on these two processes. This study was conducted to explore whether such an association exists.

Successful treatment of choroidal neovascularization secondary to persistent placoid maculopathy with intravitreal bevacizumab.

PURPOSE: To report a case of posterior placoid maculopathy with secondary choroidal neovascularization that responded favorably to repeat intravitreal injections of bevacizumab with long-term follow-up. METHODS: Patient data from all clinic visits were reviewed. These include visual acuity measurements and clinical examination findings, optical coherence tomography, color fundus photography, and fluorescein angiography images from the initial visit and follow-up encounters. RESULTS: This patient showed clear evidence of active leakage from choroidal neovascularization on presentation that promptly resolved with treatment. After his initial course of injections, all evidence of active exudation disappeared from his optical coherence tomography scans. However, when treatment was extended beyond 8 weeks, choroidal neovascularization leakage returned. In addition, the patient developed subretinal fibrosis in one eye despite regular treatments. Nevertheless, visual acuity has remained excellent through his most recent encounter. CONCLUSION: Persistent placoid maculopathy is an exceedingly rare clinical entity. In their original descriptive series, Golchet et al revealed that 9 of the 12 eyes went on to develop poor vision from complications of choroidal neovascularization. There is currently only one case in the literature that describes the use of anti-vascular endothelial growth factor medications in the treatment of persistent placoid maculopathy with promising results. This case adds supporting evidence for this treatment modality and highlights the need for continued follow-up and treatment till 18 months from presentation.

Response to aflibercept in patients with persistent exudation despite prior treatment with bevacizumab or ranibizumab for age-related macular degeneration.

BACKGROUND AND OBJECTIVE: This study examines the clinical response of patients transitioned to aflibercept, the newest anti-VEGF medication, due to persistent evidence of exudation on optical coherence tomography (OCT) despite regular treatment with bevacizumab and/or ranibizumab. PATIENTS AND METHODS: Aflibercept was administered to 111 patients considered for study inclusion. Eyes were included if they were transitioned to aflibercept for treatment of persistent exudation on OCT despite regular treatment with at least three injections of ranibizumab or bevacizumab. Retrospective data were collected from medical records. RESULTS: Complete resolution of exudation was seen in 34% of eyes at final follow-up. Clear improvement in exudation amount or severity without complete resolution was seen in 25%. No improvement was seen in 34%, and 6% demonstrated worsening of exudation. Snellen visual acuity at the time of transition versus final follow-up after aflibercept injection did not appreciably change (logMAR 0.494 to 0.505, Snellen equivalent 20/62 to 20/64; P = .84). The mean center point neurosensory retina thickness decreased from 228.6 to 176.9 µm (P = .001). CONCLUSION: Aflibercept may decrease the amount of exudation in a significant number of patients. However, this reduction did not result in an improvement in Snellen visual acuity.

Modulation of thrombospondin 1 and pigment epithelium-derived factor levels in vitreous fluid of patients with diabetes.

OBJECTIVE: To determine the levels of 2 endogenous inhibitors of angiogenesis, thrombospondin 1 (TSP-1) and pigment epithelium-derived factor (PEDF), in the vitreous fluid from patients with and without diabetes. METHODS: The levels of TSP-1 and PEDF in vitreous samples from diabetic and age-matched nondiabetic patients were determined by Western blot analysis. RESULTS: We observed significant amounts of TSP-1 and PEDF in the vitreous samples of control eyes. The TSP-1 levels varied in samples from patients with diabetes. In contrast, PEDF levels showed little or no change in vitreous samples from patients with or without diabetes. However, the PEDF protein exhibited variation in its molecular weight among the samples. We consistently observed lower levels of TSP-1 in diabetic patients who expressed the higher-molecular-weight PEDF isoform. CONCLUSIONS: In diabetes, changes in the TSP-1 level may play a role in shifting the angiogenic balance and contributing to the pathogenesis of diabetic retinopathy. Although the PEDF level did not change, the diabetic samples with the higher-molecular-weight PEDF isoform consistently showed lower levels of TSP-1. CLINICAL RELEVANCE: The presence of the higher-molecular-weight PEDF isoform may be associated with greater risk of severe diabetic retinopathy.

High dose zinc increases hospital admissions due to genitourinary complications.

PURPOSE: Zinc is a common dietary supplement that is widely believed to have beneficial health effects. To assess the impact of high dose supplemental zinc on genitourinary diseases we analyzed a recent randomized trial comparing zinc, antioxidants and their combination to placebo for complications related to the genitourinary tract. MATERIALS AND METHODS: In a further analysis of the recent Age-related Eye Disease Study we examined the data pool for primary International Classification of Diseases, 9th revision codes given for hospital admissions related to urological problems. The Age-Related Eye Disease Study randomized 3,640 patients with age related macular degeneration to 1 of 4 study arms, including placebo, antioxidants (500 mg vitamin C, 400 IU vitamin E and 15 mg beta-carotene), 80 mg zinc and antioxidant plus zinc. Statistical analyses using Fisher's exact test were performed. RESULTS: We found a significant increase in hospital admissions due to genitourinary causes in patients on zinc vs nonzinc formulations (11.1% vs 7.6%, p = 0.0003). The risk was greatest in male patients (RR 1.26, 95% CI 1.07-1.50, p = 0.008). In the study group of 343 patients requiring hospital admission the most common primary International Classification of Diseases, 9th revision codes included benign prostatic hyperplasia/urinary retention (benign prostatic hyperplasia), urinary tract infection, urinary lithiasis and renal failure. When comparing zinc to placebo, significant increases in urinary tract infections were found (p = 0.004), especially in females (2.3% vs 0.4%, RR 5.77, 95% CI 1.30-25.66, p = 0.013). Admissions for urinary lithiasis approached significance in men on zinc compared to placebo (2.0% vs 0.5%, RR = 4.08, 95% CI 0.87-19.10). There was no increase in prostate or other cancers with zinc supplementation. A significant decrease in prostate cancer diagnoses was seen in patients receiving antioxidants vs placebo (RR = 0.6, 95% CI 0.49-0.86, p = 0.049). Subgroup analysis revealed that this finding was significant in men who smoked but not in nonsmokers. CONCLUSIONS: Zinc supplementation at high levels results in increased hospitalizations for urinary complications compared to placebo. These data support the hypothesis that high dose zinc supplementation has a negative effect on select aspects of urinary physiology.

Intravitreal triamcinolone for the treatment of macular edema associated with central retinal vein occlusion.

OBJECTIVE: To investigate the safety and efficacy of intravitreal triamcinolone acetonide as treatment for macular edema associated with central retinal vein occlusion (CRVO). METHODS: We reviewed the medical records of 13 consecutive patients (13 eyes) with macular edema associated with CRVO who were treated with an injection of intravitreal triamcinolone acetonide (4 mg) at the University of Wisconsin and the Bascom Palmer Eye Institute. Each intravitreal injection was delivered through the pars plana using a 27- or 30-gauge needle. MAIN OUTCOME MEASURES: Change in Snellen visual acuity, clinical appearance of macular edema, measurement of foveal thickening with optical coherence tomography (OCT), and frequency of complications. RESULTS: The median age of the 13 patients was 67 years (interquartile range, 57-77 years), and the median duration of symptoms before injection was 8 months (interquartile range, 4-9 months). Mean baseline visual acuity was 20/500 in the affected eye. Mean visual acuity at the 6-month follow-up examination was 20/180 in the affected eye. All 13 patients completed the 6-month examination. Eyes with nonischemic CRVO (n = 5) demonstrated a significant improvement in visual acuity, whereas eyes with ischemic CRVO (n = 8) demonstrated a nonsignificant visual acuity improvement. No patient had a decrease in visual acuity. Mean baseline foveal thickness as measured by OCT was 590 micro m (retinal thickening = 416 micro m). Mean foveal thickness as measured by OCT at the 1-month follow-up examination in 12 patients was 212 micro m (retinal thickening = 38 micro m). At the 3-month follow-up examination, mean foveal thickness as measured by OCT for 13 patients was 193 micro m (retinal thickening = 19 micro m). Between the 3- and 6-month follow-up examinations, 4 patients developed a recurrence of macular edema. Three of the 4 patients were retreated with a second injection of triamcinolone. Two of these 3 patients experienced an improvement in visual acuity following retreatment. At the 6-month follow-up examination, mean foveal thickness as measured by OCT for 13 patients was 281 micro m (retinal thickening = 107 micro m). No adverse effects such as retinal detachment or endophthalmitis occurred. One patient experienced an increase in intraocular pressure that was controlled with 2 aqueous suppressants. CONCLUSIONS: Intravitreal injection of triamcinolone appears to be a possibly effective treatment in some patients with macular edema associated with CRVO. Patients with nonischemic CRVO may respond more favorably than patients with ischemic CRVO, and retreatment may be necessary in some patients. In this case series, severe complications were not noted.

The white dot syndromes.

PURPOSE: To review the distinctive and shared features of the white dot syndromes, highlighting the clinical findings, diagnostic test results, proposed etiologies, treatments, and prognosis. DESIGN: Review. METHODS: Review of the literature. RESULTS: Common white dot syndromes are reviewed, including acute posterior multifocal placoid pigment epitheliopathy, birdshot chorioretinopathy, diffuse unilateral subacute neuroretinitis, multiple evanescent white dot syndrome, multifocal choroiditis with panuveitis, serpiginous choroiditis, and acute zonal occult outer retinopathy. CONCLUSIONS: The white dot syndromes are a group of disorders characterized by multiple whitish-yellow inflammatory lesions located at the level of the outer retina, retinal pigment epithelium, and choroid. For clinicians and researchers alike, they present significant diagnostic and therapeutic challenges.

Ophthalmology on the internet: what do our patients find?

The Internet has become a favorite source of medical information for a growing number of patients. At the same time, content on the Internet represents an amalgamation of viewpoints, commercial interests, and various biases. A common way to access Internet information is through commercial portals with proprietary search engines. Often these search engines prioritize their rank list based on commercial interests. We evaluated whether Internet searches of ophthalmic issues are slanted toward commercial sites and whether any differences exist among the various search engines. We used age-related macular degeneration as an example. In this study, we found that some search engines are heavily tilted toward commercial partnerships, whereas others emphasize sites run by nonprofit and educational organizations. Our findings may guide physicians in recommending to their patients some internet portals rather than others. This type of evaluation can be conducted intermittently by physicians and other health care professionals to assess the type of information that reaches their patients and what biases may be influencing patient knowledge and decision making.