Comparative analysis of visual outcomes with 2 enhanced monofocal intraocular lenses.

PURPOSE: To compare the visual performance, spectacle independence, and subjective visual quality of 2 enhanced monofocal intraocular lenses (IOLs): Eyhance ICB00 and ZOE Primus-HD. SETTING: Ophthalmology Department, San Raffaele Scientific Institute, Milan, Italy. DESIGN: Prospective case series. METHODS: Patients without ocular comorbidities and corneal astigmatism <0.75 diopters (D) undergoing cataract surgery with bilateral implantation of enhanced monofocal Eyhance and ZOE were included. 6 months postoperatively, the following parameters were analyzed: subjective and objective refraction; monocular and binocular corrected (4 m) and uncorrected (UDVA) distance visual acuities; corrected distance, intermediate (66 cm), and near (40 cm) visual acuities, as well as uncorrected intermediate (UIVA) and uncorrected near (UNVA) visual acuities; photopic contrast sensitivity; binocular defocus curve; halo and glare perception; and spectacle independence. RESULTS: 100 eyes of 50 patients were evaluated (25 patients per IOL group). The 2 IOLs showed superimposable visual performances, without significant differences in terms of refractive and visual outcomes, defocus curves, contrast sensitivity, scores of vision quality, and spectacle independence. Of note, monocular and binocular UDVA was excellent in both groups. The 2 IOL models achieved satisfactory binocular UIVA, with more than 70% of patients reaching a binocular UIVA of ≤0.1 logMAR. Up to 84% of patients eventually declared to feel comfortable frequently while staying at intermediate distance. CONCLUSIONS: The general visual outcome of the Eyhance ICB00 and the ZOE Primus-HD enhanced monofocal IOLs is similar, with special reference to the satisfactory spectacle independence for intermediate distance.

The long-term outcome of eyes with unexplained visual loss after gas tamponade for macula-on retinal detachment.

PURPOSE: To analyze the long-term outcome of eyes suffering from unexplained visual loss after gas tamponade for primary macula-sparing rhegmatogenous retinal detachment (RRD). METHODS: Cross-sectional analysis of all eyes with macula-on RRD experiencing an unexplained loss of vision after gas reabsorption that were treated and followed from 2010 to 2019. The investigational work-up included: best-corrected visual acuity (BCVA), clinical examination, spectral-domain optical coherence tomography (SD-OCT) and automated computerized perimetry. RESULTS: The 9 eyes of the 9 patients were analyzed after 5.9±2.4 years. BCVA improved by 0.54±0.50 logMAR from baseline, achieving a final value of 1.17±0.52 logMAR (∼20/320; p=0.0115). The thicknesses of the macula, of the macular ganglion cells and of the retinal nerve fiber layers were unchanged compared to the baseline, as well as the rate of ellipsoid zone defects (22.2%). The proportion of eyes with microcystoid macular edema (MME) significantly decreased to 44.4% (p=0.0294). Perimetry mean deviation increased from a baseline value of -18.06±2.72 to -17.23±2.29 dB (p=0.0390), with an unchanged pattern standard deviation (p=0.1289). In general, a reduction of the scotomata relative depth from baseline was evident in all eyes. CONCLUSIONS: Eyes with macula-on RRD suffering from unexplained visual loss after gas reabsorption, despite disclosing an overall unchanged structural macular morphology, showed a moderate, but significant, visual and perimetric improvement in the long-term.

Panuveitis of undetermined origin after diagnostic pars plana vitrectomy: clinical characterization and long-term outcome from a tertiary referral center.

PURPOSE: To identify the characteristics and outcome of panuveitis of undetermined origin (PUO) after diagnostic vitrectomy. METHODS: Retrospective analysis of all patients who underwent vitrectomy for diagnostic/therapeutic purposes from 2013 to 2020, whose vitreous biopsies turned out negative and final diagnoses were not clinically supported. RESULTS: Of 122 operated eyes, 36 eyes (29.5%) were defined as PUO (67.8 ± 14.9 years). The presenting clinical picture revealed a predominantly bilateral condition (70% of eyes) with significant posterior segment involvement: 3.1 ± 0.6 vitritis, 61.1% of eyes with retinal vasculitis, 44.4% with macular edema, and 30.6% with exudative retinal detachment. Presenting visual acuity was 1.2 ± 0.7 logMAR, and up to 90% remained stable or improved vision over a ~ 3.5 year observation period. None of the presenting clinical features turned out to be predictive of final visual outcome or survival. CONCLUSIONS: PUO is present in up to 30% of cases after diagnostic/therapeutic vitrectomy. This mainly bilateral condition shows chronic and overall stable long-term outcome, generally with retained steady visual function.

INVERTED INTERNAL LIMITING MEMBRANE FLAP FOR SMALL-SIZED (<250 µ m) FULL-THICKNESS MACULAR HOLE : Anatomical and Functional Outcome.

PURPOSE: To compare the anatomical and functional outcome of small (<250 µ m) and medium (250-400 µ m) full-thickness macular holes (FTMHs) treated with internal limiting membrane (ILM) inverted flap (IF) or with the standard technique. METHODS: Retrospective longitudinal analysis of successfully operated eyes with small or intermediate FTMH. Outcome measures were best-corrected visual acuity (BCVA), microperimetric sensitivity (with fixation stability), and restoration of the external limiting membrane (ELM) and ellipsoid zone (EZ) at 6 months. RESULTS: Fifty small and 50 intermediate eyes with FTMH were included, half of each group (25) treated with the standard technique, half with IF. BCVA increased in every subgroup, similarly within the same stage regardless the technique. Small FTMH treated with IF disclosed inferior foveal sensitivity at 6 months (20.79 ± 0.48 dB) compared with the standard technique (21.51 ± 0.79 dB; P = 0.0035). At 1 month, inferior rates of ELM (24%) and EZ (24%) restoration were also found, compared with the standard technique (56% ELM P = 0.0420; 64% EZ P = 0.0095). At 6 months, ELM and EZ were similarly restored. CONCLUSION: The surgical repair of small FMTH with ILM IF seem to delay the foveal structural repair and to gain an inferior foveal sensitivity compared to the standard technique.

Protective effect of vitrectomy on the course of diabetic retinopathy: A case report.

PURPOSE: To hypothesize the protective role of vitrectomy on the natural course of diabetic retinopathy. METHODS: Case report. RESULTS: A 66-year-old lady with a history of type 1 diabetes mellitus since the age of 10 was referred for evaluation. She received laser treatment in her left eye for proliferative diabetic retinopathy 6 years earlier, while her right eye underwent vitrectomy for retinal detachment 17 years before. Diabetic retinopathy was found to be substantially asymmetrical, as the vitrectomized right eye had only mild macular edema without significant vascular abnormalities, whereas the left eye had a complete confluent panretinal photocoagulation with advanced atrophic macular changes. Other reasons for this asymmetry, such as axial length disparity, carotid circulation impairment, or history of branch retinal vein occlusion, were not identified. CONCLUSIONS: Vitreous removal, performed for a reason other than diabetic retinopathy, may inhibit the retinal complications often associated with longstanding diabetes. Further clinical studies should be considered to ascertain such evidence.

Increased risk of postsurgical macular edema in high stage idiopathic epiretinal membranes.

PURPOSE: To assess the rate of occurrence and the risk factors of postsurgical macular edema (PSME) in eyes with idiopathic epiretinal membrane (iERM) or full-thickness macular hole (FTMH). METHODS: Retrospective longitudinal analysis of all subjects scheduled for vitrectomy with or without combined cataract surgery over a 6-month period. Electronic medical charts and imaging data were analyzed preoperatively and at 1, 3 and 6 months after surgery. RESULTS: From 101 patients diagnosed with iERM or FTMH, 71 patients were eligible for the study. Forty-nine eyes with iERM (69.0%) and 22 eyes with FTMH (31.0%) underwent vitrectomy either isolated (31.0%) or combined with cataract extraction (69.0%). The overall rate of PSME was 26.7%, without differences between the two groups (P = 0.9479). Combined cataract extraction did not affect the overall occurrence of PSME rate in both groups (P = 0.9255 in FTMH and P = 0.8658 in iERM). If grouped by stage, eyes with stage 4 iERM though disclosed an increased rate of PSME (57.1%) compared to lower (1 to 3) stages (14.3%, P = 0.0021), particularly when combined with cataract surgery (71.4% vs. 15.4% in stages ≤ 3, P = 0.0021). The PSME odds ratio for a stage 4 iERM is 8 (95% CI: 1.933-33.1; P = 0.0041) compared to stages 3 and below. CONCLUSIONS: PSME remains a clinically relevant and frequent event after surgery for iERM and FTMH. Patients with stage 4 iERM have an 8-fold higher likelihood of developing PSME in a 6-month postsurgical period compared to iERM in 1-3 stages, especially when combined with cataract extraction.

Intraoperative efficacy and clinical outcomes of two commercial staining solutions used in idiopathic epiretinal membrane surgery.

PURPOSE: To compare two commercially available staining solutions (MembraneBlue Dual® by D.O.R.C., Netherlands, and TWIN by AL.CHI.MI.A. S.R.L., Italy), in terms of intraoperative handling, staining efficacy and safety, in eyes undergoing surgery for idiopathic epiretinal membrane (ERM). METHODS: In this observational cross-sectional study, the performance of the dyes used during the procedure (cohesion, ERM and internal limiting membrane [ILM] staining efficacy) was scored by the surgeon using a customized questionnaire after 10 procedures with each of the two dyes. Best-corrected visual acuity (BCVA), central foveal thickness (CFT), blue-light fundus autofluorescence (BAF), and microperimetry-determined retinal sensitivity were reviewed preoperatively and then at 1 and 3 months after surgery. RESULTS: ILM staining efficacy with TWIN was scored 2.89 ± 0.33 by the surgeons, which turned out to be higher than with MembraneBlue Dual® (1.90 ± 0.31, P = 0.0002). The cohesion score was 2.70 ± 0.48 for TWIN and resulted significantly higher than with MembraneBlue Dual® (1.60 ± 0.51, P = 0.0010). BCVA, CFT and retinal sensitivity were similar in the two groups, 1 and 3 months postoperatively (P nonsignificant for all). CONCLUSIONS: Both TWIN and MembraneBlue Dual® dyes showed suitable staining properties and equivalent safety and efficacy profiles, both intra- and postoperatively. The TWIN dye might offer a solution for surgeons who prefer a more cohesive and stable dye.

UNEXPLAINED VISUAL LOSS AFTER GAS TAMPONADE FOR MACULA-ON RETINAL DETACHMENT: Incidence and Clinical Characterization.

PURPOSE: To identify the incidence rate and the clinical characteristics of unexplained visual loss after gas tamponade for primary macula-sparing rhegmatogenous retinal detachment. METHODS: Retrospective longitudinal analysis of all subjects undergoing vitrectomy with gas for primary macula-on rhegmatogenous retinal detachment from 2010 to 2019. Outcome was the unexplained visual loss evaluated after gas absorption, defined as a loss of vision to less than 20/200 without evident causes. The diagnostic workup was reviewed. RESULTS: Nine eyes with unexplained visual loss of 357 surgeries were found. The incidence proportion was 2.52 new cases every 1,000 eyes affected by macula-on rhegmatogenous retinal detachment treated with gas per year. All subjects had an absolute central scotoma, with a median postoperative visual acuity of 20/1,600 (counting fingers). Structural findings were consistent with an axonal damage; all eyes had microcystoid macular edema and reduced thickness of both macular ganglion cell and retinal nerve fiber layers. No photoreceptor structural damages were noted. CONCLUSION: The incidence of unexplained visual loss after gas tamponade for primary macula-on rhegmatogenous retinal detachment is 2.52 new cases every 1,000 eyes per year. This rare complication, which findings are suggestive of an axonal damage within retinal ganglion cells, remains a serious and unexplained concern for vitreoretinal surgeons.

Blind patients in end-stage inherited retinal degeneration: multimodal imaging of candidates for artificial retinal prosthesis.

PURPOSE: To characterize the imaging features of blind patients with end-stage inherited retinal degeneration (IRD) and to assess possible morpho-functional correlations. METHODS: In this observational cross-sectional study, we reviewed the clinical data and multimodal imaging of 40 eyes of 21 blind (light perception or less) institutional patients affected by end-stage IRD screened for Alpha AMS (Retina Implant AG, Reutlingen, Germany) retinal prosthesis eligibility. Analysis was carried out using spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography and fundus autofluorescence. RESULTS: Among patients with IRD-related low vision, the extrapolated prevalence of the blind was roughly 10%, median age 60.4 years with a disease duration of 40.4 years, showing epiretinal membranes (80%), hyperreflective intraretinal nodules (90%) and the absence of the ellipsoid zone (77.5%) on SD-OCT examination. Cystoid macular oedema was present in 52.5% of eyes, the majority of which being of the microcystoid subtype (42.5%), while 37.5% of eyes also lacked outer and inner retinal layer segmentation. Disease duration was found to be predictive of disrupted retinal layers (P = 0.029) and microcystoid macular oedema (P = 0.035), which was also more frequent in eyes without light perception (P = 0.013). CONCLUSIONS: Eyes without vision due to end-stage IRD have a typical imaging pattern, predominantly characterized by epiretinal membranes, hyperreflective intraretinal nodules and the absence of the ellipsoid zone. Furthermore, microcystoid macular oedema and retinal layer disruption may be considered as signs of longstanding disease.

Silicone oil-induced displacement of subretinal hemorrhage in age-related macular degeneration.

PURPOSE: To describe the use of silicone oil (SO) in combination with subretinal recombinant tissue plasminogen activator (rtPA) to achieve dislocation of large subretinal hemorrhage secondary to exudative age-related macular degeneration (AMD). METHODS: A single-eye 81-year-old woman, known for exudative AMD, presented for a profound vision loss in her left eye since 7 days due to a massive subretinal hemorrhage. She promptly underwent standard three-port pars plana vitrectomy with subretinal injection of rtPA and SO tamponade. RESULTS: The surgical technique showed favorable anatomical and functional outcomes, achieving a substantial peripheral displacement of blood and visual improvement. CONCLUSION: This report favorably supports the use of SO in adjunction to subretinal rtPA in selected cases of subretinal hemorrhage secondary to wet AMD.

The Conceptual Tragedy in Studying Defense Mechanisms.

The concept of defense mechanism is interwoven with psychoanalytic theories of anxiety and psychic conflict. From its first formulation in 1894, its usefulness resides in the degree to which it helps to explain otherwise mysterious phenomena. Statistical approaches to the study of defense mechanisms, which have significantly increased in popularity in the past three decades, test isolated assumptions without reflection on how these are integrated into psychoanalytic theory, nor on what should be regarded as psychoanalytic data. Consequently, their results and their models have not provided useful insights into psychoanalytic theory. This paper aims to show how these issues in statistical approaches largely stem from disregarding discussions on the ontological status of defense mechanisms and the epistemological consequences linked to them. Studying defense mechanisms as they are manifested in external lifestyles, clouds the distinction between constructs (explanatory terms) and phenomena (empirical referents), which is furthermore necessary for a theoretical model to have explanatory value. Concrete examples are given regarding problems in statistical conceptualizations of defense mechanisms as well as the cursory explanations these tend to describe. Implications for future research are discussed.

Idiopathic epiretinal membrane surgery: safety, efficacy and patient related outcomes.

This review aims to give to the reader an overview selectively oriented on safety and efficacy of surgery, providing concise and direct answers about crucial questions of trainees and experts. Surgery for idiopathic epiretinal membrane (ERM) is a safe and effective procedure that can achieve long-term stable postoperative visual and anatomical improvement, with an overall low recurrence and complication rate. Young patients, with a short onset of symptoms and with better initial visual acuity achieve higher levels of visual outcome. The preoperative degree of metamorphopsia is the prognostic factor for their postoperative degree. Successful results may be obtained in eyes with specific optical coherence tomography criteria, such as thin ganglion cell layers, thin internal plexiform layer, longer photoreceptors outer segment, regular ellipsoid zone and cone outer segment tips line, and without ectopic inner foveal layer. Internal limiting membrane peeling demonstrates positive anatomical and functional outcomes, but final positions about its safety remain controversial.

Reduced perfusion density of superficial retinal capillary plexus after intravitreal ocriplasmin injection for idiopathic vitreomacular traction.

BACKGROUND: To investigate, using optical coherence tomography angiography (OCT-A), changes in perfusion density and in the foveal avascular zone (FAZ) in eyes with idiopathic vitreomacular traction (VMT) after ocriplasmin injection. METHODS: In this pilot study, we enrolled sixteen VMT eyes treated with intravitreal ocriplasmin injection. Sixteen healthy eyes were considered as controls. Macular perfusion density in 3 plexuses [superficial capillary plexus (SCP), deep capillary plexus (DCP), choriocapillaris (CC)] was calculated at baseline and at 1 month after injection. RESULTS: After injection, VMT anatomically resolved in 9 eyes (56.2%), whereas 7 eyes (43.8%) achieved an incomplete VMT separation. Superficial capillary plexus perfusion density was reduced significantly after injection (from 0.427 ± 0.027 to 0.413 ± 0.028; p = 0.0146), while no differences were noted in the DCP (p = 0.2717) nor in the CC (p = 0.6848). Study-eye perfusion density was statistically similar to control eyes in all three plexuses, both at baseline and at follow-up. The FAZ in the SCP area remained unchanged after injection (p = 0.168) but was significantly inferior to controls both at baseline and at 1 month (0.198 ± 0.074 vs. 0.196 ± 0.070; p = 0.007). CONCLUSIONS: Eyes with VMT have a perfusion density comparable to healthy controls, but a smaller FAZ. After ocriplasmin injection the perfusion density in the SCP is reduced, regardless the anatomical success. Limited by the small sample size and the pilot nature of the study, we found microvascular changes after ocriplasmin injection, which may be due to retinal traction release.

Surgical Management and Techniques.

Technical advancements have substantially extended the indications for surgery in diabetic retinopathy (DR) during the last 40 years, from the traditional indications including non-clearing vitreous hemorrhage, traction retinal detachment (RD), and traction-rhegmatogenous RD, to epiretinal membrane (ERM), vitreomacular traction, diffuse macular edema, neovascular glaucoma, and anterior hyaloid fibrovascular proliferation. The goals of vitreoretinal surgery in DR are multiple: clearing media opacities, release of traction (anteroposterior and/or tangential), segmentation and/or removal of traction bands, peeling of ERMs, hemostasis, laser photocoagulation, and tamponade of retinal breaks with gas or silicone oil. The best management is achieved with integrated care provided by physicians with expertise in medical management of diabetes and surgical care of DR. In this chapter, the indications for surgery, preoperative considerations, surgical techniques, and complications, together with their management, will be discussed.

Retinal vascular changes after vitrectomy for idiopathic epiretinal membrane: a pilot study with dynamic vessel analysis.

PURPOSE: To investigate, using the Dynamic Vessel Analyzer (DVA), the retinal vascular changes that may occur after vitrectomy for idiopathic epiretinal membrane (ERM). METHODS: Twenty-six eyes of 13 patients affected by unilateral idiopathic ERM were prospectively analyzed. 13 fellow eyes were used as control. The static (central retinal artery and vein equivalents) and dynamic (after flicker light stimulus) DVA analysis was performed at baseline (1 day before surgery) and 6 months after vitrectomy. RESULTS: The static DVA analysis did not highlight any significant change between investigational eyes and controls at baseline and 6 months after surgery. The DVA dynamic analysis showed similar arterial flicker response between cases and controls at baseline (p = 0.3396), but disclosed a significant reduction of the arterial flicker response after surgery in the study eyes compared to fellow eyes (p = 0.0024). No significant changes were appreciated in the venous flicker response after surgery between cases and controls, both at baseline (p = 0.3450) and at the follow-up examination (p = 0.4214). CONCLUSIONS: The physiological flicker-induced vasoconstriction is reduced after vitrectomy in arteries. The oxygen saturation change occurring after vitrectomy might have a role in the vascular tone modification.

Persistent subretinal fluid mimicking central serous retinopathy after scleral buckling surgery: possible vortex vein compression role.

PURPOSE: To describe the case of a woman who developed persistent subretinal fluid in the macular region after the placement of encircling band for retinal detachment surgery, possibly due to vortex vein compression. METHODS: Case report. RESULTS: A 66-year-old woman diagnosed with central serous retinopathy presented with poor vision and metamorphopsia in the left eye (LE). Her visual acuity had deteriorated to 20/100 in LE after retinal detachment surgery with scleral buckling 8 months before. Multimodal imaging including fundus autofluorescence and fluorescein angiography disclosed a gravitational hyperfluorescent area involving the macular region that appeared to originate from the superotemporal quadrant in correspondence with the buckling. This area corresponded to a serous retinal detachment on structural spectral-domain optical coherence tomography (SD-OCT). Interestingly, on indocyanine green angiography, the encircling band of the scleral buckling appeared located at the emergence of the superotemporal vortex vein. Based on these findings, the patient was diagnosed with gravitational serous retinal detachment secondary to vortex vein compression. Successful rapid visual recovery and decrease of retinal fluid on SD-OCT was achieved with prompt surgery of scleral buckling removal, confirming the diagnosis. CONCLUSIONS: Choroidal veins can be obliterated during retinal detachment surgery, especially when retinal breaks are posterior to the equator. Indocyanine green angiography is the gold standard to study choroidal circulation and in our case allowed us to visualize the compression of the superotemporal vortex vein at the site of scleral buckling.

Microincision 25G pars plana vitrectomy with peeling of the inner limiting membrane and air tamponade in idiopathic macular hole.

PURPOSE: To evaluate the success of a mini-invasive technique for operation of idiopathic macular hole (IMH). METHODS: We retrospectively examined 29 patients (30 eyes) in whom 25-G pars plana vitrectomy (PPV), peeling of the inner limiting membrane (ILM), and application of air tamponade were performed. The group of the patients included 7 males and 22 females (76%), age range 57-79 years (median 70). The follow-up period was 3-47 months (median 17). RESULTS: Pars plana vitrectomy was indicated only in the stages of full-thickness macular hole. Prior to operation, 13 eyes (43%) were in stage 2, 15 eyes (50%) in stage 3, and 2 eyes (7%) in stage 4. The IMH healed in 28 eyes after operation. Persistence of IMH occurred in 2 eyes (7%). After subsequent reoperation with extension of the peeling zone of the ILM and gas tamponade (with 10% C3F8), these macular holes also healed (100%). Prior to carrying out PPV, best-corrected visual acuity (BCVA) ranged between 20/40 and 20/500 (median 20/125). At the end of the follow-up period, BCVA was improved to 20/40 (median). The change in the final BCVA compared to the initial visual acuity was statistically significant (p = 0.008; Wilcoxon). CONCLUSIONS: The 25-G PPV with peeling of the ILM and air tamponade is an effective technique and presents no increased risks in comparison with routine procedures. The main benefit of the intervention is its good tolerance by the patient, particularly with respect to painfulness and postoperative irritation.