Outcomes of Pars Plana Vitrectomy With Membrane Peel for Lamellar Macular Holes and Related Conditions Using a New Optical Coherence Tomography Consensus Definition.

Purpose: To characterize the change in visual acuity (VA) in eyes treated with vitrectomy using the 2020 international consensus-based optical coherence tomography (OCT) definition of lamellar macular hole (LMH), macular pseudohole (MPH), and epiretinal membrane with foveoschisis (ERMF). Methods: A retrospective chart review was performed from 2000 to 2022 of patients who had vitrectomy for symptomatic decreased VA from LMH, MPH, or ERMF performed by the same surgeon at a community hospital. Preoperative spectral domain (SD-OCT) was reviewed to classify patients using the consensus guidelines. Primary outcomes were the mean change in best-corrected VA at 3 months, 1 year, and the final postoperative examination. Results: Fifty-one patients were included, 30 with LMH, 14 with MPH, and 7 with ERMF. The VA was 20/63 at baseline, 20/62 (P = .79) 3 months postoperatively, 20/40 (P = .003) at 1 year, and 20/52 (P = .10) at the final examination for LMH; 20/64, 20/50 (P = .16), 20/40 (P = .040), and 20/40 (P = .02), respectively, for MPH; and 20/53, 20/50 (P = .42), 20/30 (P = .03), and 20/38 (P = .04), respectively, for ERMF. Subgroup analysis showed that eyes with LMH without ellipsoid zone (EZ) disruption on SD-OCT improved from 20/57 at baseline to 20/39 (P = .01) at the final examination. Conclusions: There was no significant improvement in VA at the final postvitrectomy examination in eyes with LMH, while there was significant improvement in eyes with MPH and ERMF. This supports surgery in selected eyes with MPH and ERMF but possibly not in eyes with LMH, unless OCT shows no EZ disruption.

Prospective Study of Silicone Oil Microdroplets in Eyes Receiving Intravitreal Anti-Vascular Endothelial Growth Factor Therapy in 3 Different Syringes.

PURPOSE: To compare the prevalence of intravitreal silicone oil microdroplets detected by slit-lamp biomicroscopy in eyes with 6 or more injections of the same anti-vascular endothelial growth factor (VEGF) drug. DESIGN: Prospective, cross-sectional case series. PARTICIPANTS: A total of 260 consecutive eyes receiving 1 of 3 intravitreal anti-VEGF drugs for choroidal neovascularization, diabetic macular edema, or venous occlusive disease. The control group included 147 fellow eyes with no prior intravitreal injections. METHODS: The anterior and mid-vitreous were carefully examined using 12× to 16× magnification through dilated pupils with ocular saccades before an injection. Silicone oil microdroplets were graded on a scale from 0 to 4+ based on the number and size of droplets. MAIN OUTCOME MEASURES: Presence and severity of silicone oil microdroplets in the vitreous. RESULTS: Silicone oil microdroplets were observed in 78.3% of eyes receiving bevacizumab in Becton Dickinson (BD, Franklin Lakes, NJ) 0.3-mL polypropylene syringes, 14.4% of eyes receiving ranibizumab in 1.0-mL BD polypropylene syringes or more recently glass prefilled syringes, 48.5% of eyes receiving aflibercept in 1.0-mL BD polycarbonate syringes, and 0% of eyes in controls. The differences among the 4 groups were statistically significant at P < 0.001. The severity of silicone oil microdroplets was significantly greater in eyes using BD 0.3-mL polypropylene syringes than BD 1.0-mL polypropylene syringes, BD 1.0-mL polycarbonate syringes, or controls (P < 0.001). The severity of silicone oil microdroplets in eyes using BD 1.0-mL polycarbonate syringes was significantly greater than BD 1.0-mL polypropylene syringes (P = 0.012) and controls (P < 0.001). There was no significant difference between silicone oil microdroplet severity between BD 1.0-mL polypropylene syringes and controls (P = 1.0). CONCLUSIONS: The BD 0.3-mL polypropylene syringes with repackaged bevacizumab and the BD 1.0-mL polycarbonate syringes with aflibercept cause a higher likelihood of silicone oil microdroplets. Intravitreal injections in eyes receiving multiple regular anti-VEGF injections should be supplied in silicone-free syringes.

Optical coherence tomography-based consensus definition for lamellar macular hole.

BACKGROUND: A consensus on an optical coherence tomography definition of lamellar macular hole (LMH) and similar conditions is needed. METHODS: The panel reviewed relevant peer-reviewed literature to reach an accord on LMH definition and to differentiate LMH from other similar conditions. RESULTS: The panel reached a consensus on the definition of three clinical entities: LMH, epiretinal membrane (ERM) foveoschisis and macular pseudohole (MPH). LMH definition is based on three mandatory criteria and three optional anatomical features. The three mandatory criteria are the presence of irregular foveal contour, the presence of a foveal cavity with undermined edges and the apparent loss of foveal tissue. Optional anatomical features include the presence of epiretinal proliferation, the presence of a central foveal bump and the disruption of the ellipsoid zone. ERM foveoschisis definition is based on two mandatory criteria: the presence of ERM and the presence of schisis at the level of Henle's fibre layer. Three optional anatomical features can also be present: the presence of microcystoid spaces in the inner nuclear layer (INL), an increase of retinal thickness and the presence of retinal wrinkling. MPH definition is based on three mandatory criteria and two optional anatomical features. Mandatory criteria include the presence of a foveal sparing ERM, the presence of a steepened foveal profile and an increased central retinal thickness. Optional anatomical features are the presence of microcystoid spaces in the INL and a normal retinal thickness. CONCLUSIONS: The use of the proposed definitions may provide uniform language for clinicians and future research.

Serological Evidence for Henipa-like and Filo-like Viruses in Trinidad Bats.

Bat-borne zoonotic pathogens belonging to the family Paramxyoviridae, including Nipah and Hendra viruses, and the family Filoviridae, including Ebola and Marburg viruses, can cause severe disease and high mortality rates on spillover into human populations. Surveillance efforts for henipaviruses and filoviruses have been largely restricted to the Old World; however, recent studies suggest a potentially broader distribution for henipaviruses and filoviruses than previously recognized. In the current study, we screened for henipaviruses and filoviruses in New World bats collected across 4 locations in Trinidad near the coast of Venezuela. Bat tissue samples were screened using previously established reverse-transcription polymerase chain reaction assays. Serum were screened using a multiplex immunoassay to detect antibodies reactive with the envelope glycoprotein of viruses in the genus Henipavirus and the family Filoviridae. Serum samples were also screened by means of enzyme-linked immunosorbent assay for antibodies reactive with Nipah G and F glycoproteins. Of 84 serum samples, 28 were reactive with ≥1 henipavirus glycoprotein by ≥1 serological method, and 6 serum samples were reactive against ≥1 filovirus glycoproteins. These data provide evidence of potential circulation of viruses related to the henipaviruses and filoviruses in New World bats.

Cytomegalovirus Retinitis in a Patient Taking Tocilizumab: A Case Report.

Purpose: This report discusses a case of cytomegalovirus (CMV) retinitis in a patient taking tocilizumab for maintenance and remission of giant cell arteritis (GCA). Methods: A case report is presented. Results: A 78-year-old African American woman with no significant past medical history and an ocular history of primary open-angle glaucoma presented to the retina clinic with vitritis in the right eye. Four months earlier, she had been diagnosed with biopsy-proven GCA and prescribed 30 mg of prednisone daily and 162 mg tocilizumab subcutaneously weekly. Diagnostic vitrectomy with polymerase chain reaction of the vitreous was positive for CMV. Her retinitis gradually resolved after 3 months of treatment with valganciclovir, with no recurrence 4 months after discontinuing the valganciclovir. Conclusions: Physicians should be aware of the potential to develop CMV retinitis in the setting of tocilizumab use for GCA treatment.

Office Examinations-Directed Treatment Paradigms Reduce Travel Burden, Decrease Treatment Cost, and Improve Quality-Adjusted Life-Years for Patients With Exudative Age-Related Macular Degeneration Undergoing Antivascular Endothelial Growth Factor Therapy.

Purpose: In the United States, most intravitreal injections are performed the same day as an office examinations; however, federal agencies and insurance payers suggest these same-day examinations charges are overused and have recommended scrutiny. In this study, we estimate the cost vs benefit to society of same-day office examinations during intravitreal injections for wet age-related macular degeneration (wAMD). Methods: An Excel spreadsheet was used to model different antivascular endothelial growth factor treatment scenarios for wAMD, including automatic treatment, injection series' treat and extend (T&E), and as-needed treatment, with increasing same-day examinations in the order listed. Treatment parameters were estimated using US population statistics, published literature, and Centers for Medicare & Medicaid Services, provider utilization data. Costs and benefits were compared for the 4 treatment scenarios. Results: Although yearly examinations and optical coherence tomography costs were higher for injection series, T&E, and as-needed protocols compared with automatic treatment, our model predicts reduced yearly injection and travel costs for those same treatment scenarios also, saving $2.9 billion (injection series), $7.2 billion (T&E), and $6.1 billion (as-needed) annually for the US population. Same-day injections accounted for 21%, 8%, and 9% of the savings, respectively, because of reduced travel burden. Furthermore, early detection of wAMD in the fellow eye during office examinations allows for a 1.8, 2.1, and 2.5 quality-adjusted life-year benefit, respectively. Conclusions: Office examinations-directed antivascular endothelial growth factor therapy for wAMD reduces travel and treatment expenses and improves screening of the fellow eye, resulting in robust cost savings and quality-adjusted life-year benefit for the US population.

Randomized Placebo-Controlled Trial Evaluating the Ophthalmic Safety of Single-Dose Tafenoquine in Healthy Volunteers.

INTRODUCTION: Tafenoquine has been recently registered for the prevention of relapse in Plasmodium vivax malaria. OBJECTIVE: This study assessed the pharmacodynamic effects of 300-mg single-dose tafenoquine on the retina. METHODS: This phase I, prospective, multicenter, randomized, single-masked, placebo-controlled, parallel-group study was conducted between 2 February 2016 and 14 September 2017 at three US study centers. Adult healthy volunteers were randomized (2:1) to receive either a single 300-mg oral dose of tafenoquine or matched placebo on day 1. Ophthalmic assessments, including spectral domain optical coherence tomography (SD-OCT) and fundus autofluorescence (FAF), were conducted at baseline and day 90 and evaluated for pre-determined endpoints by an independent, masked reading center. RESULTS: One subject in each group met the composite primary endpoint for retinal changes identified with SD-OCT or FAF, i.e., one out of 306 (0.3%) with tafenoquine, one out of 161 (0.6%) with placebo. Both cases had unilateral focal ellipsoid zone disruption at day 90 with no effect on best-corrected visual acuity. The tafenoquine-treated subject had this abnormality at baseline, and was enrolled in error. There was no difference in ophthalmic safety between tafenoquine and placebo. CONCLUSION: There was no evidence of any pharmacodynamic effect of 300-mg single-dose tafenoquine on the retina or any short-term clinically relevant effects on ophthalmic safety. This clinical trial is registered with ClinicalTrials.gov (identifier: NCT02658435).

Cataract Formation and Progression in Patients Less Than 50 Years of Age after Vitrectomy.

PURPOSE: To measure the rate of cataract development and progression of nuclear sclerotic cataracts (NSC), posterior subcapsular cataracts (PSC), and cortical spoking cataracts in nondiabetic patients <50 years of age after a pars plana vitrectomy. DESIGN: Retrospective cohort study. SUBJECTS: Twenty-six eyes of 26 patients <50 years of age that had undergone a pars plana vitrectomy were included. METHODS: Clinical records were reviewed retrospectively. MAIN OUTCOME MEASURES: The NSC, PSC, and cortical spoking scores were recorded preoperatively and 1, 3, 6, 9, and 12 months after surgery until discharged from care, lost to follow-up, or last visit before cataract surgery. Eyes were graded on a scale of 0 to 4.0 using the lens opacities classification system LOCS II before and after pars plana vitrectomy for macular hole, epiretinal membranes, and vitreous hemorrhage. Linear regression analysis was performed to evaluate the rate of change in cataract score with elapsed time since surgery. RESULTS: The mean age at surgery was 30.6±14.3 years in 26 eyes with a median follow-up of 12 months. Eleven of 26 surgical eyes (42.3%) that had a baseline NSC and PSC score of zero in their surgical eye developed NSC, PSC, or both after vitrectomy. The mean progression for NSC, PSC, and cortical spoking were 0.327±0.14 (P = 0.032), 0.414±0.14 (P = 0.008), and 0.00±0.00 over a mean follow-up of 1.43 years, respectively. Linear regression analysis shows minimal increase in NSC (+0.09/year; P < 0.001; R2 = +0.331), a slight increase in PSC (+0.16/year; P < 0.001; R2 = +0.835), and a minimal decrease in cortical spoking (-0.02/year; P < 0.05; R2 = -0.09). CONCLUSIONS: Our findings suggest there is a minimal but significant increase in NSC and PSC scores for patients <50 years after pars plana vitrectomy. Cataract progression is not a significant factor in the first few years after vitrectomy in patients <50 years of age.

THE EFFECT OF INTERNAL LIMITING MEMBRANE PEELING ON IDIOPATHIC EPIRETINAL MEMBRANE SURGERY, WITH A REVIEW OF THE LITERATURE.

PURPOSE: To examine the effect of internal limiting membrane (ILM) removal on epiretinal membrane (ERM) surgery by comparing best-corrected visual acuity (BCVA), optical coherence tomography central macular thickness (CMT) changes, ERM recurrence, and need for repeat surgery. METHODS: Retrospective study of 251 consecutive patients (251 eyes) who underwent pars plana vitrectomy for idiopathic ERM by a single surgeon with over 1 year of follow-up data. Data were collected preoperatively and postoperatively at 3 months, 1 year, 2 years, and at the last visit. The ILM was not specifically removed in the earlier group of patients and was removed after staining of the ILM in the later group. RESULTS: One hundred and forty eyes (55.8%) did not have an ILM peel (non-ILM group), and 111 eyes (44.2%) did have an ILM peel (ILM group). There were no significant differences between groups in age, gender, preoperative BCVA, preoperative intraocular pressure, preoperative CMT on optical coherence tomography, and cataract status. Total follow-up time for the ILM group was 32.1 months and 45.4 months for the non-ILM group (P = 0.002). Both groups had improvement in BCVA. The ILM group improved by 12 Early Treatment Diabetic Retinopathy Study letters and the non-ILM group improved by 10.5 Early Treatment Diabetic Retinopathy Study letters. There was no significant difference in the final BCVA (P = 0.18) or total change of BCVA (P = 0.48). Cataract status preoperatively did not affect the total change of BCVA, but being phakic at the most recent visit was associated with a slight loss of visual acuity. Both groups had improvement in optical coherence tomography appearance, for the CMT in the ILM group decreased by 83 µm and the CMT in the non-ILM group decreased by 110 µm. There was no significant difference in the final CMT (P = 0.07); however, the non-ILM group tended to have a lower final CMT. Some degree of ERM recurrence was detected by slit-lamp biomicroscopy in 2 eyes (1.8%) of the ILM group and in 32 eyes (22.9%) of the non-ILM group (P ≤ 0.0001). None of the eyes with ILM removal required repeat vitrectomy, whereas 17 eyes (12.1%) of the non-ILM group did require vitrectomy, showing that ILM removal had a significant effect on the need for repeat vitrectomy (P < 0.0001) between non-ILM versus ILM peel groups. CONCLUSION: The rate of recurrent ERM and need for repeat ERM surgery is lower in eyes where the ILM is removed with the ERM, whereas BCVA and CMT were similar with or without ILM removal. Complete ILM removal around the macula should be considered for the treatment of eyes with idiopathic ERMs to reduce the incidence of ERM recurrences.