Phacofragmentation of Posteriorly Dislocated Lens Fragments: Limbal versus Pars Plana Approach.

PURPOSE: To assess intra-operative complications and feasibility of removing crystalline lens fragments from the vitreous cavity through a limbal incision compared to a pars plana approach. DESIGN: Retrospective cohort study. SUBJECTS: 16 eyes underwent phacofragmentation via a limbal approach (Group A) and 9 eyes through a pars plana approach (Group B) at an academic center over a 10-year period. METHODS: We collected pre-operative, intra-operative, and post-operative data. We compared rates of intraoperative complications, including corneal wound burn, iris or capsular damage, retinal tears, and hemorrhage, and recorded post-operative BCVA and IOP measurements at the one-month post-operative appointment. We also compared rates of post-operative complications, including corneal edema, choroidal detachment, or retinal detachment. MAIN OUTCOME MEASURES: Primary outcomes of the study were the rates of intraoperative complications and the feasibility of crystalline lens removal with the limbal approach. We defined the latter outcome as the ability to complete lens removal without switching to the pars plana route. RESULTS: Mean BCVA for group A was 1.6, and for group B was 2.0 (p = .19). There was no significant difference between the two groups in the incidence of intraoperative complications, including corneal wound burn, iris damage, anterior capsular tear, iatrogenic retinal tear, or suprachoroidal hemorrhage (p > .99). There was no significant difference in the incidence of intra-operative vitreous hemorrhage (p = .36). Additionally, there was no significant difference in post-operative corneal edema (p = .27), choroidal detachment (p = .52), or retinal detachment (p > .99). The mean post-operative BCVA was 1.0 in group A and 1.0 in group B (p = .75). We completed all cases in group A using the limbal approach without switching to the pars plana route. CONCLUSION: Phacofragmentation through a limbal incision provides a feasible option for dropped nuclear fragment removal and is not associated with a higher risk of complications than the pars plana route.

Belzutifan-induced regression of retinal capillary hemangioblastoma: A case-series.

Purpose: To report a series of three patients with von Hippel-Lindau (VHL) disease who demonstrated regression of their retinal hemangioblastomas (RH) using belzutifan in conjunction with photocoagulation therapy. Observations: Patient 1, a 23-year-old female, presented with multiple RHs in her right eye (OD) that were lasered. Her left eye (OS) revealed a large inferotemporal RH that measured approximately 2.1 mm2. Systemic belzutifan was administered. Four months after initiation of treatment, the lesion regressed to 1.4 mm2, but belzutifan was not well-tolerated and was discontinued due to side effects. At the date of belzutifan discontinuation, the lesion measured about 1.1 mm2. Focal laser photocoagulation was applied. The lesion regressed to around 0.6 mm2. Two additional laser treatments were applied one month later. On the most recent follow-up, the lesion was completely fibrosed.Patient 2, a 32-year-old male, presented with one RH OD and two RHs OS. Belzutifan was administered for one month before the patient began experiencing side effects of the medication. Consequently, the dose of belzutifan was decreased. After one month with the lowered dose, laser coagulation was applied to OS. In the most recent follow-up, five months after the initial presentation, the lesions remain less vascularized and reduced in size.Patient 3, is a 44-year-old male with a large RH OD. Following seven months of belzutifan daily, there was a significant reduction in the RH size. Conclusions: Belzutifan, a hypoxia-inducible factor inhibitor, is an FDA-approved medication for VHL disease associated with renal cell carcinoma, central nervous system hemangioblastomas, or pancreatic neuroendocrine tumors that do not require immediate surgical resection. Because of the high incidence of VHL-associated RHs, adjuvant laser photocoagulation therapy when belzutifan is suspended or withheld can allow for the regression of large lesions. In this case series, we also propose a reproducible and technically simple method to measure RH lesions size, using Optos fundus imaging.

Hybrid 23/25-Gauge Direct Perfluorocarbon Liquid-Silicone Oil Exchange.

PURPOSE: To describe a novel technique for direct perfluorocarbon liquid (PFCL)-silicone oil exchange that aims to reduce the inherent risk of intraoperative intraocular pressure spike. METHODS: We use the conventional setup for passive PFCL-silicone exchange, but intentionally create a mismatch between the passive PFCL aspiration and the active silicone injection that favors the PFCL extrusion. This is achieved by converting one port to a large gauge one-23 or 20-gauge. RESULTS: We did not note the occurrence of high intraocular pressure spikes with this technique as noted by disk pallor or attenuated vessels. CONCLUSION: A hybrid 23/25-gauge technique for direct PFCL-silicone oil exchange is safe and reduces the risk of intraoperative intraocular pressure spike.

HEMOGLOBIN C TRAIT PRESENTING WITH BILATERAL CENTRAL RETINAL VEIN OCCLUSION.

PURPOSE: To report a case of bilateral sequential, central retinal vein occlusion (CRVO) in a man with newly diagnosed hemoglobin C trait. METHODS: A 67-year-old man presented with a one-month history of declining visual acuity. He was diagnosed with left CRVO. Bilateral temporal retinal ischemia and arteriovenous anastomoses on fluorescein angiography suggestive of sickle cell retinopathy prompted a systemic work-up. Hemoglobin electrophoresis revealed an underlying hemoglobin C trait. Six-months after his initial presentation, the patient developed symptomatic right CRVO. RESULTS: The initial left CRVO was complicated by optic disc swelling and macular edema. Intravitreal antiangiogenic therapy was initiated and the macular edema resolved. The left eye subsequently developed an epiretinal membrane which was surgically removed. Macular edema in the right eye also resolved after intravitreal antiangiogenic therapy. CONCLUSION: This is the first reported case of bilateral CRVO in a case of hemoglobin C trait. It is possible that erythrocyte inflexibility, caused by hemoglobin C-induced dehydration and crystallization, acted concomitantly with hypertension to produce occlusive microangiopathy. This case highlights the need for further investigation in patients presenting with central retinal vein occlusion, especially when bilateral, or when retinal angiography reveals bilateral pathology.

Rapidly Progressive Bilateral Vitreoretinal Lymphoma.

A 56-year-old male who presented with unilateral localized sub-retinal lesions suspicious for primary vitreoretinal lymphoma (PVRL) developed florid bilateral ocular involvement and was found to have lesions on MRI of the brain in a five-week period despite the absence of vitreous involvement during the entire course of his disease. His ocular lesions were monitored while on systemic treatment and an excellent clinical response was achieved. His central nervous system (CNS) lesions, however, continued to progress despite chemotherapy and whole-brain radiation. He died 12 months from his time of ocular diagnosis. To our knowledge, this case represents the most rapid progression of PVRL reported in the literature - from unilateral, localized lesions in the sub-retinal space to bilateral ocular involvement and identification of CNS involvement in a five-week period. This case highlights the potential for rapid ocular progression of PVRL stressing the need for early diagnosis. Therefore, we recommend prompt vitreous and, if necessary, sub-retinal biopsy in cases of suspected vitreoretinal lymphoma in addition to neuro-imaging. We emphasize the importance of coordination between pathologists, ophthalmologists, and oncologists for prompt, accurate diagnosis. Delay in diagnosis and treatment can result in rapid intraocular progression and central nervous system spread.

Persistent Subretinal Fluid Following Successful Rhegmatogenous Retinal Detachment Surgery.

PURPOSE: To provide an updated, critical summary of the literature on the topic of persistent subretinal fluid (PSF) following successful rhegmatogenous retinal detachment surgery. METHODS: Narrative literature review. RESULTS: PSF remains an insufficiently studied topic. Incidence rates vary significantly between reports, but pars plana vitrectomy seems associated with lower rates than buckle surgery. Multiple etiologies and risk factors have been proposed, none being conclusive. PSF gradually resolves in most cases which may be a lengthy process, often with no effect on potential final visual acuity. There is concern that some cases with PSF may sustain photoreceptor damage, retinal displacement, or retinal fold formation. There is no current evidence to support any treatment modality over observation in uncomplicated cases of PSF. CONCLUSION: Future large, well-controlled, prospective trials could help elucidate incidence rate, etiological factors, and sequelae of PSF, as well as the value of different interventions in its prevention and management.

Non-arteritic Anterior Ischemic Optic Neuropathy with Macular Star following COVID-19 Vaccination.

PURPOSE: To report a case of non-arteritic anterior ischemic optic neuropathy (NAAION) with macular star after receiving the second dose of SARS-CoV-2 vaccination. METHOD: Case report. OBSERVATION: A 51-year-old male presented with acute visual disturbances one day after the second dose of BNT162b2 mRNA SARS-CoV-2 vaccination. At presentation, best corrected visual acuity (BCVA) was 20/25 right eye (OD) and counting fingers at 3 feet left eye (OS). Anterior segment examination was normal in both eyes. Dilated fundoscopy was unremarkable OD, however, it disclosed optic nerve swelling and subretinal fluid OS. Patient was treated with a gradual tapering dose of oral prednisone over 1 month. At the five-week follow-up visit, optic disc swelling and subretinal fluid resolved with minimal improvement in BCVA to 20/400 OS. CONCLUSION: It is unclear whether COVID-19 vaccination was the triggering agent to the NAAION or just a coincidence, yet ophthalmologists should be aware of such a possible association.

Retinal Degeneration Associated With the G1606A Mitochondrial Mutation.

The guanine-to-adenine substitution at nucleotide 1606 (G1606A) mutation in the mitochondrial DNA transfer RNA-valine gene has been reported to cause sensorineural deafness, ataxia, myoclonus, seizures, and mental retardation. This study hereby presents a single case report of a new retinal phenotype associated with this mutation: a middle-aged woman with retinal pigment epithelium stippling, atrophy, and peripapillary (retinal pigment epithelium) dropout on fundus examination. The patient was administered an empiric trial of a mitochondrial cocktail with close monitoring of her systemic symptoms. This study identified a novel G1606A mutation to cause early-onset macular pathology resembling that previously described in the A3243G mutation. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:116-119.].

Endogenous endophthalmitis caused by Staphylococcus capitis.

PURPOSE: To report a rare case of endogenous endophthalmitis caused by Staphylococcus capitis. OBSERVATION: A 34-year-old male patient with a history of gonococcal urethritis and arthritis presented with right endogenous endophthalmitis. Vitreous biopsy culture confirmed Staphylococcus capitis involvement. The patient was treated with pars plana vitrectomy, intravitreal vancomycin, and ceftazidime injections and systemic antibiotics. CONCLUSION AND IMPORTANCE: Staphylococcus capitis-related endogenous endophthalmitis has rarely been reported in the literature. None of the published reports specifically describe its clinical course and management.

Corneal Abrasions in Total Joint Arthroplasty.

INTRODUCTION: Corneal abrasion (CA) is the most common ocular complication in patients undergoing nonocular surgery. Corneal abrasions can be caused by a variety of mechanisms, the most common being drying of the cornea due to reduced tear secretions, loss of eyelid reflex, and the loss of pain recognition during surgery. Though CA heals well with eye lubricants, it can result in significant ocular pain and some cases may go on to develop ocular complications. With the current switch to outpatient total joint replacement, CA could potentially lead to discharge delays. MATERIALS AND METHODS: We examined the results of a quality improvement project to reduce CA during general anesthesia to determine the rates of CA during hip and knee total joint replacement. We compared rates of CA for 6 months before and 6 months after the intervention. RESULTS: A total of 670 hip and knee arthroplasty procedures were performed during this period. Two events of CA occurred, one occurred before and one after the intervention to decrease eye injuries. Both incidences occurred during total hip arthroplasty (THA) procedures with the patient in the lateral decubitus position and recovered without long-term deficit. DISCUSSION: Surgeons and anesthesiologists alike should be cognizant of this avoidable complication and take precaution to protect the eyes during surgery, especially during THA when the patient is placed in the lateral decubitus position. CONCLUSION: Corneal abrasion during total joint arthroplasty is a rare complication and is infrequently addressed in the literature. CA is mostly self-limiting, however, but may lead to patient dissatisfaction and to delays if same-day discharge is attempted. Preventative measures and attentive care may help reduce the incidence of CA in patients undergoing total joint arthroplasty. The lateral decubitus position and longer surgeries times are risk factors for CA.

Simultaneous injection-aspiration technique of air/fluid exchange for in-office treatment of post-operative vitreous cavity hemorrhage.

BACKGROUND: Post-operative vitreous cavity hemorrhage following pars plana vitrectomy is common. In-office drainage of the hemorrhage may be an option for some patients. TECHNIQUE: A new method for office-based air fluid exchange is described. A 30-gauge needle with a 10-mm syringe filled with sterile air is inserted 3.5-mm posterior to the limbus in the superotemporal quadrant. A second 30-gauge needle is inserted 3.5 mm from the limbus at 6 o'clock and connected to an empty 10-mm syringe with intravenous catheter tubing. The plunger of the air-filled syringe is pushed while the plunger of the empty syringe is pulled, so that the rate of fluid aspiration matches the rate of air injection. DISCUSSION: The method approximates conditions in pars plana vitrectomy, with balanced infusion and aspiration. Displaced vitreous cavity contents are collected in the aspiration syringe. The procedure is also cost effective. CONCLUSION: The simultaneous syringe method is an easy, safe, and effective way of clearing post-operative vitreous cavity hemorrhage.

Hemoglobin S/OArab: Retinal Manifestations of a Rare Hemoglobinopathy.

Hemoglobin S/OArab (Hgb S/OArab) disease is a rare hemoglobinopathy which presents similarly to sickle cell retinopathy, with only three prior reports that describe associated retinal findings. In this report, we present ophthalmic examination findings in 2 patients with Hgb S/OArab. One patient exhibited peripheral ischemia and sunburst lesions without neovascular disease, and the other patient developed proliferative retinopathy of both eyes and multiple posterior-pole branch retinal artery occlusions in one eye. To our knowledge, this is the first case of retinal arterial occlusive disease in Hgb S/OArab, and the first report of fundus autofluorescence and OCT angiography in Hgb/OArab retinopathy.

Modified hydrodissection to prevent intraoperative iris prolapse.

A modified hydrodissection technique to prevent intraoperative iris prolapse is presented. The phacoemulsification tip is inserted into the main ocular incision while hydrodissection is performed through a side-port incision. Placement of the phacoemulsification tip in this location prevents iris prolapse. This technique can be used routinely and might be especially applicable in cases with a high risk for iris prolapse, such as in intraoperative floppy-iris syndrome.

Novel and Unusual Retinal Findings in Two Patients with Neurofibromatosis Type 1.

Neurofibromatosis type 1 (NF1) is a phacomatosis known to be associated with several developmental abnormalities in multiple organ systems including the eyes. NF1 can present with varying ophthalmic manifestations, including Lisch nodules, retinal astrocytic hamartomas, capillary hemangiomas, plexiform neurofibromas, and choroidal nodules. We present 2 cases of NF1 with presentations that may represent underreported retinal abnormalities occurring in NF1. Case 1 presents a patient who developed spontaneous peripheral retinal dialysis with subsequent retinal detachment; case 2 discusses a patient with multiple pigmented choroidal lesions bilaterally.

Retinal Findings in Two Patients With Tumefactive Multiple Sclerosis.

Tumefactive multiple sclerosis (TMS) often presents a diagnostic challenge because it can mimic neoplastic, infectious, or ischemic disease. We describe 2 patients with TMS with retinal findings of venous sheathing and bone spicule pigmentation. Mechanisms for such findings are discussed.

Ocular Complications from Retained Intraocular Ointment Discovered 33 Months after Cataract Surgery.

Topical antibiotic and steroid ointments are sometimes used topically at the conclusion of intraocular surgery, and inadvertent entry into the eye has been reported. Dispersed ointment droplets or consolidated globules in the anterior chamber (AC) can sometimes be visualized on exam. Occasionally, intraocular ointment is found incidentally without apparent toxic effect, but retained ointment usually presents with early or delayed intraocular inflammation, pressure rise, macular edema, or corneal edema. The usual treatment for toxicity from retained ointment is removal of the ointment. While the complication of ointment-induced cystoid macular edema has been reported, there is paucity of literature on the anatomical response and eventual visual outcome of patients who have been treated for long-standing edema from retained ointment. We present a case of a patient who presented with history of poor vision since the time of cataract surgery 33 months prior, who had cystoid macular edema, reduced endothelial cell count, and apparent Maxitrol ointment (neomycin, polymyxin B sulfate, and dexamethasone in paraffin vehicle; Novartis Pharmaceuticals UK) floating in the AC. The patient was treated with AC washout and sub-Tenon injection of triamcinolone. His vision, retinal architecture by optical coherence tomography, endothelial cell count, and pachymetry has been followed for 9 months following this treatment.