Evaluation of the (Baha) technique of scleral indentation using a self-retained scleral indenter during vitrectomy surgery: a randomized trial.

AIMS: The current study compared a novel technique of scleral indentation using the self-retaining Leyla retractor to the conventional scleral self-indentation with the chandelier light. METHODS: Patients with rhegmatogenous retinal detachment were randomized on a 1:1 basis to either have the (Baha) indentation using a tip of a thimble scleral indenter welded to the support for the Leyla retractor system or to have the conventional scleral indentation while using a 25-gauge chandelier light. A video was recorded for the surgery of all the cases and reviewed by another consultant masked to the type of indentation. The indentation duration (i.e., the time in seconds between the first appearance of a hump due to scleral indentation in the recorded video until its final disappearance) was measured for every case. RESULTS: The current study included 60 eyes of 60 adults with a mean age of 59.6 ± 9.8 years. Thirty-nine of the eyes were phakic and 21 were pseudophakic. The mean indentation time was 618 ± 87 and 696 ± 72 s in (Baha) indentation and conventional indentation groups, respectively. The difference was not statistically significant (p = 38). There was a positive correlation between the vertical palpebral fissure height and the indentation duration for both (Baha) indentation (r = 0.58) and conventional indentation groups (r = 0.42). Readjustment of the chandelier endo-illumination was required in 19 cases (63.3%) in the conventional indentation group. Iatrogenic breaks or accidental crystalline lens touch did not occur in any case. CONCLUSION: The (Baha) technique is effective and safe, especially in patients with a larger palpebral fissure.

Anatomical and Functional Outcomes of Vitrectomy with/without Intravitreal Methotrexate Infusion for Management of Proliferative Vitreoretinopathy Secondary to Rhegmatogenous Retinal Detachment.

PURPOSE: To assess the anatomical and functional outcomes of intravitreal infusion of methotrexate (MTX) during pars plana vitrectomy (PPV) for proliferative vitreoretinopathy (PVR) associated with rhegmatogenous retinal detachment (RRD). METHODS: Comparative interventional nonrandomized study including consecutive patients who had vitrectomy for RRD. The study included six groups. Groups I (established PVR), II (high risk of PVR), and III (no risk of PVR) comprised prospectively recruited study eyes, which received PPV and adjuvant intravitreal MTX infusion equivalent to 400 µg/0.1 mL. Groups IA, IIA, and IIIA comprised retrospectively recruited control groups. Main outcome measures were retinal reattachment at the end of 6 months, visual outcome, and complications. Chi-square test or Fisher's exact test analyzed categorical variables. ANOVA test and Kruskal-Wallis test analyzed quantitative variables. Mann-Whitney U-test and independent t-test evaluated the difference between each group and its control. Comparison between two paired groups was done by Wilcoxon Rank test. The Kaplan-Meier method was used for survival analysis and the log-rank test estimated differences in event-free survival across the groups. P was significant at <0.05. RESULTS: The study included 190 eyes of 188 patients. Study Groups I, II, and III included 42, 35, and 24 eyes, respectively. Mean age was 45 years. Male gender constituted 70% of patients. Mean follow-up period was 6 months. Control Groups IA, IIA, and IIIA included 30, 30, and 29 eyes, respectively. Mean age was 50 years. Male gender constituted 50%. Mean follow-up period was 7 months. Median rate of retinal reattachment was 82% in the study eyes versus 86% in the control eyes. The difference in the retinal reattachment rates between each study group and its respective control was not statistically significant, Group I-IA (p= 0.2), Group II-IIA (p=0.07), and Group III-IIIA (p=0.07). BCVA improved by a mean of 4 lines in the study eyes versus 3 lines in the control eyes. The difference in visual outcome between each study group and its respective control was statistically significant between Groups II-IIA and III-IIIA, p=0.03, but not between Groups I-IA, p=0.07. We did not detect complications attributed to MTX use in the study eyes. CONCLUSION: Intravitreal infusion of MTX during PPV is a safe adjuvant therapy in RRD patients with and without PVR. MTX yields superior functional outcomes in patients at high risk of PVR and in patients with no risk of PVR compared to PPV without MTX, but not in cases with established PVR. MTX did not confer an additional advantage in terms of retinal reattachment rate. Summary. Proliferative vitreoretinopathy is a major cause of failure in surgery for rhegmatogenous retinal detachment. Methotrexate as an adjuvant therapy blocks essential drivers in the pathogenetic cascade leading to PVR. Intravitreal infusion has the advantage of blocking the pathology in its nascence and obviates the need for repeated intravitreal injections of the drug.

Factors Affecting Predominantly Peripheral Lesion Identification and Grading.

Purpose: The purpose of this study was to determine factors affecting predominantly peripheral lesion (PPL) grading, such as qualitative versus quantitative assessment, device type, and severity of diabetic retinopathy (DR) in ultrawide field color images (UWF-CIs). Methods: Patients with DR had UWF-CI qualitatively graded for PPL using standardized techniques and had hemorrhages/microaneurysms (H/Mas) individually annotated for quantitative PPL grading on two different ultrawide field devices. Results: Among 791 eyes of 481 patients, 38.2% had mild nonproliferative DR (NPDR), 34.7% had moderate NPDR, and 27.1% had severe NPDR to proliferative DR (PDR). The overall agreement between qualitative and quantitative PPL grading was moderate (ĸ = 0.423, P < 0.001). Agreement rates were fair in eyes with mild NPDR (ĸ = 0.336, P < 0.001) but moderate in eyes with moderate NPDR (ĸ = 0.525, P < 0.001) and severe NPDR-PDR (ĸ = 0.409, P < 0.001). Increasing thresholds for quantitative PPL determination improved agreement rates, with peak agreements at H/Ma count differences of six for mild NPDR, five for moderate NPDR, and nine for severe NPDR-PDR. Based on ultrawide field device type (California = 412 eyes vs. 200Tx = 379 eyes), agreement between qualitative and quantitative PPL grading was moderate for all DR severities in both devices (ĸ = 0.369-0.526, P < 0.001) except for mild NPDR on the 200Tx, which had poor agreement (ĸ = 0.055, P = 0.478). Conclusions: Determination of PPL varies between standard qualitative and quantitative grading and is dependent on NPDR severity, device type, and magnitude of lesion differences used for quantitative assessment. Translational Relevance: Prior UWF studies have not accounted for imaging and grading factors that affect PPL, such factors need to be reviewed when assessing thresholds for DR progression rates.

Evaluation of the use of NGage® Nitinol stone extractor for intraocular foreign body removal.

PURPOSE: To describe a novel technique to use the NGage® Nitinol Stone Extractor for large IOFB extraction. METHODS: We conducted a retrospective case series study by reviewing the data of 4 eyes with retained large IOFB extracted with the use of the NGage® Nitinol Stone Extractor. The study was conducted in a single tertiary referral center on four eyes of four patients with large retained IOFB. Studied eyes were treated by pars plana vitrectomy (PPV) and IOFB extraction by using the NGage® Nitinol Stone Extractor through a limbal incision. RESULTS: Four eyes of four male patients with large Retained IOFB were included in the study. The nature of the IOFB was metallic in 2 eyes, glass in 1 eye or ceramic 1 eye. All the IOFB were removed from a limbal wound. Silicone oil tamponade was required in 3 eyes. Two eyes required reoperation. At 6 months postoperative, the final visual acuity using Snellen chart ranged between PL and 0.1. CONCLUSION: The NGage® Nitinol Stone Extractor can be a useful tool for the extraction of the large retained IOFB.

Trimanual vitrectomy for severe proliferative diabetic retinopathy.

PURPOSE: To describe and evaluate a novel technique of pars plana vitrectomy (PPV) under chandelier illumination which is aided with the vital dyes and perfluorocarbon liquids for the management of the complex diabetic vitrectomy cases. METHODS: We conducted a prospective interventional comparative study on 40 eyes of 36 patients with advanced diabetic eye disease requiring PPV. The study was conducted in a single tertiary referral center. Eyes were divided on 1:1 basis by stratified randomization into two groups. Group 1 had trimanual vitrectomy done assisted with chandelier illumination, perfluorocarbon liquid (PFCL) and vital dyes. Group 2 had the conventional bimanual vitrectomy done assisted with chandelier illumination only. All patients were followed up for a minimum of 6 months after the surgery. RESULTS: Forty eyes of 36 patients with the mean age of 51.42 years (range 28-69) were evaluated. The anatomical success at 6 months could be achieved in all the eyes in both groups. The complete removal of the pre-retinal proliferations could be accomplished in all the eyes in the trimanual PPV group, and only in 85% of the eyes in the bimanual PPV group. Operative time was significantly shorter in the trimanual PPV group (p < 0.001). More eyes in the trimanual PPV group (55.0%) could achieve better vision (> 6/60) 6 months after the operation compared to the bimanual PPV group (50.0%), but this difference was not statistically significant. CONCLUSION: Trimanual PPV is a novel, safe and effective technique that can improve the results of the complex diabetic PPV.

Autologous Retinal Transplantation for Primary and Refractory Macular Holes and Macular Hole Retinal Detachments: The Global Consortium.

PURPOSE: To report the anatomic and functional outcomes of autologous retinal transplantation (ART). DESIGN: Multicenter, retrospective, interventional, consecutive case series. PARTICIPANTS: One hundred thirty eyes of 130 patients undergoing ART for the repair of primary and refractory macular holes (MHs), as well as combined MH-rhegmatogenous retinal detachment (MH-RRD), between January 2017 and December 2019. METHODS: All patients underwent pars plana vitrectomy and ART, with surgeon modification of intraoperative variables. A large array of preoperative, intraoperative, and postoperative data was collected. Two masked reviewers graded OCT images. Multivariate statistical analysis and subgroup analysis were performed. MAIN OUTCOME MEASURES: Macular hole closure rate, visual acuity (VA), external limiting membrane and ellipsoid zone (EZ) band integrity, and alignment of neurosensory layers (ANL) on OCT. RESULTS: One hundred thirty ART surgeries were performed by 33 vitreoretinal surgeons worldwide. Patient demographics were: mean age of 63 ± 6.3 years, 58% female, 41% White, 23% Black, 19% Asian, and 17% Latino. Preoperative VA was 1.37 ± 0.12 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, approximately 20/500), which improved significantly to 1.05 ± 0.09 logMAR (Snellen equivalent, approximately 20/225; P < 0.001) after surgery (mean follow-up, 8.6 ± 0.8 months). Autologous retinal transplantation was performed for primary MH repair in 27% of patients (n = 35), for refractory MH in 58% of patients (n = 76; mean number of previous surgeries, 1.6 ± 0.2), and for MH-RRD in 15% of patients (n = 19). Mean maximum MH diameter was 1470 ± 160 µm, mean minimum diameter was 840 ± 94 µm, and mean axial length was 24.6 ± 3.2 mm. Overall, 89% of MHs closed (78.5% complete; 10% small eccentric defect), with a 95% closure rate in MH-RRD (68.4% complete; 26.3% small eccentric defect). Visual acuity improved by at least 3 lines in 43% of eyes and by at least 5 lines in 29% of eyes. Reconstitution of the EZ (P = 0.02) and ANL (P = 0.01) on OCT were associated with better final VA. Five cases of ART graft dislocation (3.8%), 5 cases of postoperative retinal detachment (3.8%), and 1 case of endophthalmitis (0.77%) occurred. CONCLUSIONS: In this global experience, patients undergoing ART for large primary and refractory MHs and MH-RRDs achieved good anatomic and functional outcomes, with low complication rates despite complex surgical pathologic features.

The Pigtail Sign: A New Spectral Domain Optical Coherence Tomography Finding After Inverted ILM Flap Surgery for Idiopathic Macular Hole.

PURPOSE: To report a new spectral domain optical coherence tomography (OCT) finding called the pigtail sign. It was found during follow-up of idiopathic macular hole cases after inverted internal limiting membrane (ILM) flap surgery. METHODS: This is a retrospective case series of 12 eyes (12 patients) who underwent inverted ILM flap technique for idiopathic macular hole closure. Spectral domain optical coherence tomography images were analyzed for the presence of this new finding. RESULTS: A new spectral domain OCT finding of a curved coiled line hanging above the surface of the retinal layers was seen in all patients. The mean preoperative best corrected visual acuity (BCVA) logMAR value was 1.25 ± 0.11. At the 6-month follow-up visit, the mean LogMAR BCVA was 0.35 ± 0.18. All the cases showed macular hole closure after surgery. CONCLUSION: This new spectral domain OCT sign can be seen in some OCT scans during follow-up of idiopathic macular hole cases after inverted ILM flap surgery.

Disparity of microaneurysm count between ultrawide field colour imaging and ultrawide field fluorescein angiography in eyes with diabetic retinopathy.

AIMS: To compare microaneurysm (MA) counts using ultrawide field colour images (UWF-CI) and ultrawide field fluorescein angiography (UWF-FA). METHODS: Retrospective study including patients with type 1 or 2 diabetes mellitus receiving UWF-FA and UWF-CI within 2 weeks. MAs were manually counted in individual Early Treatment Diabetic Retinopathy Study (ETDRS) and extended UWF zones. Fields with MAs ≥20 determined diabetic retinopathy (DR) severity (0 fields=mild, 1-3=moderate, ≥4=severe). UWF-FA and UWF-CI agreement was determined and UWF-CI DR severity sensitivity analysis adjusting for UWF-FA MA counts performed. RESULTS: In 193 patients (288 eyes), 2.4% had no DR, 29.9% mild non-proliferative DR (NPDR), 32.6% moderate (NPDR), 22.9% severe NPDR and 12.2% proliferative DR. UWF-FA MA counts were 3.5-fold higher (p<0.001) than UWF-CI counts overall, 3.2x-fold higher in ETDRS fields (p<0.001) and 5.3-fold higher in extended ETDRS fields (p<0.001) and higher in type 1 versus type 2 diabetes (p<0.001). In eyes with NPDR on UWF-CI (n=246), UWF-FA images had 1.6x-3.5x more fields with ≥20 MAs (p<0.001). Fair agreement existed between imaging modalities (k=0.221-0.416). In ETDRS fields, DR severity agreement increased from k=0.346 to 0.600 when dividing UWF-FA counts by a factor of 3, followed by rapid decline in agreement thereafter. Total UWF area agreement increased from k=0.317 to 0.565 with an adjustment factor of either 4 or 5. CONCLUSIONS: UWF-FA detects threefold to fivefold more MAs than UWF-CI and identifies 1.6-3.5-fold more fields affecting DR severity. Differences exist at all DR severity levels, thus limiting direct comparison between the modalities. However, correcting UWF-FA MA counts substantially improves DR severity agreement between the modalities.

Submacular Injection of Ranibizumab as a New Surgical Treatment for Refractory Diabetic Macular Edema.

PURPOSE: In this study, we describe a new surgical technique for the treatment of refractory DME. The technique consists of vitrectomy with ILM peeling with a subretinal injection of ranibizumab. METHODS: This is a prospective interventional noncomparative study including patients with refractory DME. Included patients were subjected to the new surgical technique of pars plana vitrectomy with subretinal injection of ranibizumab. RESULTS: The study included 19 eyes with refractory macular edema, in which this novel technique was attempted. There were 10 males and 9 females. The age of the patients ranged from 17 to 67 years with a mean of 55.58 ± 13.242 years. The duration of diabetes before enrollment in the study ranged from 7 to 25 years with a mean of 16.3 years. Preoperatively, the mean CMT of the eyes ranged from 352 to 883 microns with mean ± SD of 498.58 ± 152.16 microns. Postoperatively, this improved significantly to 373.5 ± 100.3, 355.9 ± 89.8, and 365.74 ± 120.12 microns at 1, 3, and 6 months, respectively (p ≤ 0.001 for all). CONCLUSION: This novel surgical procedure of vitrectomy with ILM peeling with a subretinal injection of ranibizumab is effective in cases of refractory DME. The study has been registered in Contact ClinicalTrials.gov PRS Identifier: NCT03975088.

Modified technique of internal limiting membrane staining in idiopathic macular hole surgery.

PURPOSE: To describe a new method of ILM staining with TB under perfluorocarbon in cases of full thickness idiopathic macular hole using the inverted ILM flap technique. METHODS: This study was a prospective interventional case series that included 42 eyes of 42 patients who had full thickness idiopathic macular hole with a minimum diameter more than 400 µm. Patients consecutively underwent vitrectomy with inverted ILM flap technique using the modified ILM staining method. RESULTS: Anatomic success was achieved in 40 patients (95.2%). The other two patients had flat-open macular holes with bare RPE (foveal defect of neurosensory retina). Among the 40 eyes with closed holes, 25 eyes were of the U-type closure (normal foveal contour) and 15 eyes were of the V-type closure (steep foveal contour). These 40 eyes remained closed during the 6 months follow-up period. CONCLUSION: The modified technique of ILM staining using TB under PFCL is safe and effective in cases of idiopathic macular hole combined with the inverted ILM flap technique.

Comparison of refractive outcome using intraoperative biometry and partial coherence interferometry in silicone oil-filled eyes.

INTRODUCTION: A-scan ultrasound is currently the most widely used technique for axial length measurement; however, this method is not optimal in silicone-oil filled eyes. Two techniques that may be more accurate for axial length measurements in these eyes are intraoperative measurement of axial length after silicone oil removal or measurement by Laser interferometry using the IOL Master. The purpose of this study is to evaluate and compare the accuracy of both intraoperative biometry and partial coherence interferometry in silicone oil-filled eyes. PATIENT AND METHODS: Axial length measurement of 22 cataractous silicone-filled eyes of 21 patients using both IOL Master Biometry and intraoperative A-scan biometry was performed. IOL power was then computed using the SRK-T formula. Accuracy of intraoperative biometry and partial coherence interferometry was evaluated by determining the mean actual postoperative refractive error. RESULTS: Comparing the predictability of intraoperative A-scan biometry and IOL Master Biometry, the two techniques showed small predictive postoperative refractive errors without a statistically significant difference in the predictive errors of the two techniques. CONCLUSION: Both intraoperative biometry by A-scan ultrasonography and partial coherence interferometer by IOL Master proved to have good equal predictability for absolute postoperative refractive error in cataract surgery for eyes filled with silicone oil.

Wandering nematode in the vitreous cavity.

BACKGROUND: Bancroftian filariasis is focally endemic in Egypt. There have been many reports of intraocular filariasis; the question of why one filarial nematode should cause ocular disease while another does not may be related to the behavior of the microfilaria and the location of the cross-reacting ocular antigen. METHODS: A 35-year-old woman with a white worm approximately 3 disk diameters in length penetrating the left macula, moving in the vitreous cavity, with a part of its length in the vitreous cavity while the rest was embedded subretinally, is described. Pars plana vitrectomy was performed and the worm was aspirated successfully. RESULTS: Parasitologic study of the aspirated worm identified juvenile Wuchereria bancrofti. Ivermectin 150 µg/kg was given orally to the patient after identification of the worm. Six weeks later, the patient's visual acuity had improved to 20/200. CONCLUSION: Intravitreal parasites should be surgically removed as soon as possible.

The role of streptokinase in induction of posterior vitreous detachment: a scanning and transmission electron microscopic study of the retina in rabbits.

PURPOSE: To evaluate the possibility of inducing a posterior vitreous detachment (PVD) by intravitreal injection of streptokinase using electron microscopy and electrophysiological study. METHODS: The current study was performed on 30 eyes of 15 male white rabbits. The rabbits were divided into three equal groups. The right eye of the three groups received an intravitreal injection of streptokinase at three different concentrations (150, 1,500 and 15,000 IU in 0.1 mL balanced salt solution) in the mid vitreous cavity. The left eye in all animals received an intravitreal injection of balanced salt solution and was considered the control group. Electroretinography was performed 1 day and 1 week after injection. The rabbits were killed after 10 days, and the enucleated eyes were processed for transmission and scanning electron microscopic examination. RESULTS: In Group 1, scanning electron microscopy showed the retinal surface covered with thin collagen fibers, whereas in Group 2, a complete PVD with bare retinal surface was seen. Group 3 showed a bare retinal surface with hemorrhagic reaction and toxic effects on the retina by transmission electron microscopy. CONCLUSION: An intravitreal injection of 1,500 IU of streptokinase can lead to a PVD without major toxic effects on the retina.