Small-Gauge Pars Plana Vitrectomy for Visually Significant Vitreous Floaters.

Purpose: This article evaluates our experience at a retina-only private practice with small-gauge pars plana vitrectomy (PPV) for visually significant vitreous floaters. We review the surgical outcomes, complication rates, and percentage of second-eye surgery for the same indication. Methods: A retrospective, interventional case series was conducted of consecutive patients undergoing PPV for significant vitreous floaters from September 2014 to December 2018 at a high-volume vitreoretinal surgery practice. Preoperative visual acuity (VA), complication rates, and visual outcome following surgery were evaluated. Results: A total of 104 eyes in 81 patients underwent PPV for visually significant floaters; 35 (43.2%) patients had PPV in both eyes. Mean preoperative VA was 0.16 ± 0.17 logMAR (∼20/29 Snellen equivalent) and improved to 0.12 ± 0.15 logMAR (∼20/26 Snellen; Wilcoxon test, P = .008) at the last follow-up after PPV. All patients had improvement in VA at the final postoperative visit, with a VA of 20/40 or better achieved in 93.3% of cases. The complication rate of vitreous hemorrhage postoperatively was 0.96%. There were no cases of postoperative retinal tears, breaks, or endophthalmitis. Conclusions: Small-gauge PPV in the carefully selected patient is an effective and safe procedure to eliminate symptoms. VA following PPV for vitreous floaters significantly improved. Nearly half of the patients studied (43.2%) underwent PPV in the other eye.

CORRELATION OF SUBRETINAL HYPERREFLECTIVE MATERIAL MORPHOLOGY AND VISUAL ACUITY IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To evaluate the association of subretinal hyperreflective material (SHRM) morphological features with visual acuity in eyes with neovascular age-related macular degeneration. METHODS: Retrospective analysis of treatment-naïve patients with neovascular age-related macular degeneration enrolled in randomized anti-vascular endothelial growth factor (VEGF) and anti-platelet-derived growth factor clinical trials. Standardized spectral domain optical coherence tomography images were graded at baseline, 12-week, and 24-week follow-up visits. Masked readers evaluated the morphology of SHRM (reflectivity, shape, anterior, and posterior boundaries) and measured SHRM height, width, and area at the fovea, within the center 1 mm, and outside the center 1 mm. RESULTS: Baseline SHRM characteristics that correlated with worse visual acuity at 12 and 24 weeks included layered appearance (P = 0.006, 0.001), hyperreflective spots in SHRM (P = 0.001, 0.011), and separation between SHRM and outer retina (P = 0.03, 0.019). The disappearance of SHRM correlated with better visual acuity at Weeks 12 and 24 (P < 0.001). Layered appearance of SHRM at baseline was significantly associated with increased reflectivity at Weeks 12 and 24 (P = 0.009, 0.003). Decreasing reflectivity of SHRM lesion at Weeks 12 and 24 correlated with better visual acuity (P < 0.01, 0.01). Increased width and area of baseline SHRM at the foveal center correlated with worse visual acuity at 12 (P < 0.001, <0.001) and 24 weeks (<0.001, <0.001). CONCLUSION: Several attributes of SHRM including, layered appearance, increased reflectivity, larger size, and hyperreflective spots correlated with worse visual acuity at 12- and 24-week follow-ups. Baseline SHRM characteristics can help practitioners predict visual and morphological prognosis and guide therapy.

Subfoveal choroidal thickness as a prognostic factor in exudative age-related macular degeneration.

AIMS: To investigate the relationship between subfoveal choroidal thickness (SFCT), visual acuity (VA), optical coherence tomography (OCT) features and total anti-vascular endothelial growth factor (VEGF) treatments to determine whether SFCT serves as a prognostic factor in age-related macular degeneration (AMD). METHODS: This is a retrospective case series of 62 consecutive treatment-naive patients with exudative AMD followed for 1 year and treated with treat-and-extend or pro re nata anti-VEGF protocols. SFCT was measured at three locations using Cirrus HD-OCT (the foveal centre and 500 um nasal and temporal to the fovea) at presentation, 3, 6 and 12 months. Demographic characteristics, OCT imaging biomarkers and VA were recorded. RESULTS: Mean SFCT at baseline was 187 µm (range: 70-361 µm). There was a trend of decreasing SFCT at 1 year (173 µm) compared with 3 months (175 µm) and baseline (188 µm) (p=0.2). There was no correlation between baseline SFCT and presence of subretinal fluid (p=0.2), intraretinal fluid (p=0.6) or subretinal hyper-reflective material (p=0.4) at baseline. The mean number of injections at 1 year was 6.6 (range: 2-12). Increased SFCT at baseline showed statistically significant correlation with a higher number of intravitreal injections at 1 year (p=0.004). Eyes with SFCT>1 SD above the mean required 50% more injections compared with others. There was no association between SFCT on presentation with baseline and 1 year VA (p=0.7 and p=0.2). CONCLUSIONS: SFCT in naïve patients with exudative AMD may be an important prognostic tool in determining treatment burden. Patients with thicker subfoveal choroid may require increased intravitreal injections.

Beta-Thalassemia Minor Manifesting as Proliferative Retinopathy.

Beta-thalassemia (ß-thalassemia) minor is characterized by a mutation in one of the two ß-globin genes (HBB) that produce the ß-globin chains in the hemoglobin molecule. Although other hemoglobinopathies have been frequently associated with retinal disease, there are limited reports of retinal pathology with ß-thalassemia minor. We report two patients with ß-thalassemia minor presenting with decreased vision, vitreous hemorrhage, and proliferative retinopathy. This case report highlights that patients with ß-thalassemia minor may require routine ocular examinations for peripheral retinal pathology, and ß-thalassemia minor should be considered in the differential diagnosis for proliferative retinopathy. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e161-e164.].

Intraoperative OCT for Uveitis-Related Vitreoretinal Surgery in the DISCOVER Study.

PURPOSE: To evaluate the feasibility and usefulness of intraoperative OCT (iOCT) for uveitis-related vitreoretinal surgeries. DESIGN: Prospective consecutive case series. PARTICIPANTS: Seventy-three consecutive patients (74 eyes) with a uveitis-related diagnosis. METHODS: Eyes undergoing surgery for a uveitis-related diagnosis in the prospective Determination of Feasibility of Intraoperative Spectral Domain Microscope Combined/Integrated OCT Visualization During En Face Retinal and Ophthalmic Surgery (DISCOVER) iOCT study. Intraoperative OCT was performed at various surgical milestones. Clinical details and evaluation of the role of iOCT were assessed. A standardized surgeon survey was completed to evaluate the usefulness of iOCT during surgery. MAIN OUTCOME MEASURES: Percentage of patients in whom iOCT provided valuable feedback and altered surgical decision making. RESULTS: Seventy-four consecutive eyes with a uveitis-related diagnosis were enrolled in the DISCOVER study. Successful imaging was obtained in 72 of 73 eyes (98.6%). Intraoperative OCT provided valuable feedback for fluocinolone acetonide implant placement in 11 of 13 eyes (84.6%), for chorioretinal biopsies in 13 of 16 eyes (81.2%), and for retinal detachment (RD) repairs in 20 of 27 eyes (74.1%). In subretinal and chorioretinal biopsies, iOCT altered surgical decision making in 38% of patients. In uveitis-related RD repairs, iOCT resulted in alterations in the surgical procedure in 48% of patients, predominantly related to additional membrane peeling. CONCLUSION: Intraoperative OCT during uveitis-related vitreoretinal surgery seems to provide valuable additional information that can impact surgical decision making and may enhance outcomes.

Pneumatic Displacement of Submacular Hemorrhage with Subretinal Air and Tissue Plasminogen Activator: Initial United States Experience.

PURPOSE: To present the initial multicenter experience of using subretinal air injection in combination with tissue plasminogen activator (tPA) at the time of pars plana vitrectomy (PPV) to displace submacular hemorrhage (SMH). DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Patients with SMH resulting from age-related macular degeneration or polypoidal choroidal vasculopathy. METHODS: Chart review of patients who underwent displacement of SMH with PPV, subretinal injection of air and tPA (125 mg/mL), partial fluid-air exchange with gas tamponade, and preoperative, intraoperative, or postoperative intravitreal injection of anti-vascular endothelial growth factor agent at 5 sites in the United States. None of the surgeons had prior experience with using subretinal air. MAIN OUTCOME MEASURES: Frequency and extent of SMH displacement, preoperative and postoperative visual acuities and retinal thickness, and postoperative complications. RESULTS: Twenty-four eyes of 24 patients were included (11 men; mean age, 79.1 years) with a mean follow-up of 12.5 months (range, 3-28 months). At 3 months after surgery, complete displacement of SMH from the foveal center was achieved in 24 eyes (100%), displaced beyond the arcades in 75% and beyond the equator in 20%. Residual subretinal pigment epithelial hemorrhage was seen in 5 eyes (20.8%). Mean preoperative and postoperative visual acuity was 1.95 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/1783) and 0.85 logMAR (Snellen equivalent, 20/141; P < 0.0001), respectively. Visual acuity improved in 23 eyes (95.8%) and was unchanged in 1 eye. Mean central retinal thickness improved from 463.7 µm before surgery to 311.3 µm at the final visit (P = 0.026). CONCLUSIONS: This initial experience of injecting subretinal air at the time of tPA injection during PPV showed the technique to be effective, with high consistency to displace SMH away from the fovea and even out to the periphery, and resulted in improved VA and retinal thickness. Some cases of subretinal pigment epithelial hemorrhage also benefit from this technique.

Quantifying Glaucoma Medication Adherence: The Relationship Between Self-Report, Electronic Monitoring, and Pharmacy Refill.

PURPOSE: Glaucoma medications reduce the risk of progressive visual field loss, but adherence to these medications is often poor. A better understanding of the appropriate metrics for quantifying glaucoma medication adherence is needed. We describe and compare different means of quantifying glaucoma medication adherence. METHODS: Adults with glaucoma were enrolled in a prospective 2-site study. Participants completed a self-report instrument and received electronic medication monitors to use for ∼3 months. Pharmacy records were queried regarding requested refills over the monitoring period; medication possession ratio (MPR) was calculated. RESULTS: Of the 137 total participants, those who answered "Very confident" to the question, "How confident are you that you always remember to use your glaucoma medications?" and "No" to the question, "In the past 4 weeks, did you ever forget to take your medicine?" were more likely [odds ratio (OR) 2.78, 95% confidence interval (CI) 1.19-6.52] to take ≥80% of the prescribed doses according to electronic medication monitors. Mean MPR was 1.49, standard deviation (SD) 0.82, range 0.1-5.31. The proportion of participants taking greater than or equal to 80% of the prescribed doses according to the electronic monitors was 59% for participants with MPR <1.2 (n = 27), 63% for participants with MPR 1.2-1.8 (n = 27), and 88% for MPR >1.8 (n = 25). CONCLUSIONS: Asking about confidence may be a good method of screening for poor adherence for glaucoma medication. MPR may be an inadequate representation of glaucoma medication adherence.

Primary adenocarcinoma of pigmented ciliary epithelium in a phthisical eye.

We report a case of adenocarcinoma of the pigmented ciliary epithelium arising in a phthisical eye. A 92-year-old man who initially presented with severe ocular pain had calcification extending from the posterior pole to ciliary body on B-scan ultrasonography to a degree not previously reported. We highlight the importance of screening for intraocular neoplasms in adults with a long-standing phthisical eye.

Klebsiella pneumonia: An unusual cause of ophthalmia neonatorum in a healthy newborn.

Ophthalmia neonatorum is one of the most common infections during the neonatal period. Chlamydia trachomatis and Neisseria gonorrhoea must be ruled out, given their high virulence and systemic complications. We describe a case of ophthalmia neonatroum from Klebsiella pneumonia. Gram-negative organisms have been reported in hospital-acquired conjunctivitis (HAC), but we are unaware of any published reports of K. pneumonia conjunctivitis in an otherwise healthy full-term infant born in the United States who has received prophylaxis. It is important to promptly identify and treat Klebsiella conjunctivitis because it can lead to severe complications.