Indications, Complications, and Early Postoperative Course of Recovery of Intraocular Lens Exchange Surgery: a Single-Center Retrospective Study.

PURPOSE: To analyze the indications, complications, and early course of recovery of intraocular lens (IOL) exchange surgery. MATERIAL AND METHODS: Records of patients who underwent IOL exchange during a 6-year period at a tertiary referral center were reviewed and the indications and complications after surgical intervention were analyzed. Their effects on postoperative corrected distance visual acuity (CDVA), intraocular pressure (IOP), use of IOP-lowering medications, and refractive cylindrical power were assessed. RESULTS: One hundred and seventy-one eyes (165 patients) were investigated. The most frequent indication for IOL exchange was lens dislocation in 163 eyes (95.32%). The main causes of IOL dislocation were pseudoexfoliation syndrome (PEX) in 98 eyes (57.31%) and complications during cataract surgery in 40 eyes (23.39%). During IOL exchange, an anterior iris-claw fixation was performed in 159 eyes (92.98%). After significant initial deterioration to 1.59 ± 1.08 logMAR on postoperative day 1 (p ≤ 0.001), the CDVA recovered to preoperative levels within 28 days. A significant decrease in IOP was observed on postoperative day 1 (p = 0.04). The most common postoperative complications were corneal edema in 114 eyes (66.67%) and vitreous hemorrhage in 67 eyes (39.18%). CONCLUSION: The high early postoperative prevalence of corneal edema and intraocular hemorrhage was found to affect visual recovery after IOL exchange, causing a significant initial deterioration of CDVA and a delay of full visual recovery. These findings suggest that surgical approaches minimizing the risk of this type of complications should be favored.

Microvascular abnormalities secondary to radiation therapy in neovascular age-related macular degeneration: findings from the INTREPID clinical trial.

PURPOSE: To report the incidence and features of retinal microvascular abnormalities (MVAs) occurring secondary to stereotactic radiotherapy (SRT) in a randomised double-masked sham-controlled clinical trial at 21 European sites. METHODS: Two hundred and thirty participants with neovascular age-related macular degeneration (AMD) treated with at least three intravitreal antivascular endothelial growth factor (anti-VEGF) injections prior to enrolment, and demonstrating a continuing need for re-treatment. INTERVENTIONS: 16 Gy, 24 Gy or sham SRT. All three groups received pro re nata anti-VEGF injections if the lesion was judged to be active at review visits. Colour fundus images from baseline and 6 months and fluorescein angiograms from baseline and annual visits were graded for measures of morphological outcome and safety using a prespecified protocol with accompanying definitions to distinguish RT-related MVA from non-specific retinal vessel abnormalities that are known to occur in neovascular AMD. The main outcome measure was MVA detected by months 12, 24 and 36 after enrolment. RESULTS: The frequency of MVAs in the combined SRT arms was 0% in year 1, 13.1% in year 2 and 30.3% in year 3. The area of MVA was small and the mean change in visual acuity in year 2 was similar in a subset of SRT eyes with MVAs, versus those without MVAs. MVA was considered to have possibly contributed to vision loss in 2 of 18 cases with MVA in year 2, and 5 of 37 cases in year 3. CONCLUSION: Treatment with SRT is associated with development of subtle MVAs that have little or no impact on visual outcome. These findings can help clinicians recognise the retinal MVAs that occur in response to SRT.

Photodynamic therapy in combination with intravitreal ziv-aflibercept and aflibercept injection in patients with chronic or repeatedly recurrent acute central serous chorioretinopathy: a single-center retrospective study.

PURPOSE: The objective of the study was to assess the effect of off-label photodynamic therapy (PDT) in combination with intravitreal off-label ziv-aflibercept or off-label aflibercept injection in patients with chronic or repeatedly recurrent acute central serous chorioretinopathy (CSC). PATIENTS AND METHODS: Changes in best corrected visual acuity (BCVA) and subfoveal subretinal fluid (sSRF) and maximum subretinal fluid (mSRF) were retrospectively analyzed in a single-center cohort study of 17 patients (18 eyes) with persistent subretinal fluid for more than 3 months of duration of CSC. Treatment efficacy was measured between injection and PDT at 30±15 days, 90±15 days and 180±30 days after PDT. RESULTS: Significant reduction of sSRF and mSRF was shown after therapy with ziv-aflibercept and aflibercept combined with PDT (p<0.001). Course of BCVA showed non-significant improvement within 6 months (p=0.065). One case of allergic reaction after fluorescein angiography and one case of ophthalmic migraine after ziv-aflibercept injection were documented. One case of reversible vision loss occurred during 6 months after combination therapy. No other adverse events or side effects were reported. CONCLUSION: Combination therapy of ziv-aflibercept and aflibercept with PDT seems to be beneficial, even in cases of chronic or repeatedly recurrent acute CSC. This includes cases of CSC resistant to or recurrent after medical treatment, PDT alone or therapy with anti-vascular endothelial growth factor alone.

Conjunctival lymphangioma in a 4-year-old girl revealed tuberous sclerosis complex.

Background: To present a case of conjunctival lymphangioma in a 4-year-old girl with tuberous sclerosis complex. Methods/results: A 4-year-old girl presented with a relapsing cystic lesion of the bulbar conjunctiva in the right eye with string-of-pearl-like dilation of lymphatic vessels and right-sided facial swelling with mild pain. Best-corrected vision was not impaired. Examination of the skin revealed three hypomelanotic macules and a lumbal Shagreen patch. Magnetic resonance imaging (MRI) findings displayed minimal enhancement of buccal fat on the right side. Cranial and orbital MRI showed signal enhancement in the right cortical and subcortical areas. Genetic analysis revealed a heterozygous deletion encompassing exon 1 and 2 of the TSC1 gene (tuberous sclerosis complex 1 gene), confirming the diagnosis of tuberous sclerosis complex. Conclusion: In conjunctival lymphangioma, tuberous sclerosis complex should be considered as the primary disease.

Postoperative subconjunctival bevacizumab injection as an adjunct to 5-fluorouracil in the management of scarring after trabeculectomy.

PURPOSE: Scarring after glaucoma filtering surgery remains the most frequent cause for bleb failure. The aim of this study was to assess if the postoperative injection of bevacizumab reduces the number of postoperative subconjunctival 5-fluorouracil (5-FU) injections. Further, the effect of bevacizumab as an adjunct to 5-FU on the intraocular pressure (IOP) outcome, bleb morphology, postoperative medications, and complications was evaluated. METHODS: Glaucoma patients (N = 61) who underwent trabeculectomy with mitomycin C were analyzed retrospectively (follow-up period of 25 ± 19 months). Surgery was performed exclusively by one experienced glaucoma specialist using a standardized technique. Patients in group 1 received subconjunctival applications of 5-FU postoperatively. Patients in group 2 received 5-FU and subconjunctival injection of bevacizumab. RESULTS: Group 1 had 6.4 ± 3.3 (0-15) (mean ± standard deviation and range, respectively) 5-FU injections. Group 2 had 4.0 ± 2.8 (0-12) (mean ± standard deviation and range, respectively) 5-FU injections. The added injection of bevacizumab significantly reduced the mean number of 5-FU injections by 2.4 ± 3.08 (P ≤ 0.005). There was no significantly lower IOP in group 2 when compared to group 1. A significant reduction in vascularization and in cork screw vessels could be found in both groups (P < 0.0001, 7 days to last 5-FU), yet there was no difference between the two groups at the last follow-up. Postoperative complications were significantly higher for both groups when more 5-FU injections were applied. (P = 0.008). No significant difference in best corrected visual acuity (P = 0.852) and visual field testing (P = 0.610) between preoperative to last follow-up could be found between the two groups. CONCLUSION: The postoperative injection of bevacizumab reduced the number of subconjunctival 5-FU injections significantly by 2.4 injections. A significant difference in postoperative IOP reduction, bleb morphology, and postoperative medication was not detected.

Comparison of phacotrabeculectomy versus phacocanaloplasty in the treatment of patients with concomitant cataract and glaucoma.

BACKGROUND: Cataract and glaucoma are both common comorbidities among older patients. Combining glaucoma surgery with minimal invasive phacoemulsification (phaco) is a considerable option to treat both conditions at the same time, although the combination with filtration surgery can produce a strong inflammatory response. Combined non-penetrating procedures like canaloplasty have shown to reduce intraocular pressure (IOP) comparable to trabeculectomy without the risk of serious bleb-related complications. The purpose of this retrospective study was to compare the outcomes of phacotrabeculectomy and phacocanaloplasty. METHODS: Thirty-nine eyes with concomitant cataract and glaucoma who underwent phacotrabeculectomy (n=20; 51.3%) or phacocanaloplasty (n=19; 48.7%) were included into this trial on reduction of IOP, use of medication, success rate, incidence of complications and postsurgical interventions. Complete success was defined as IOP reduction by 30% or more and to 21 mmHg or less (definition 1a) or IOP to less than 18 mmHg (definition 2a) without glaucoma medication. RESULTS: Over a 12-month follow-up, baseline IOP significantly decreased from 30.0 ± 5.3 mmHg with a mean of 2.5 ± 1.2 glaucoma medications to 11.7 ± 3.5 mmHg with a mean of 0.2 ± 0.4 medications in eyes with phacotrabeculectomy (P< .0001). Eyes with phacocanaloplasty had a preoperative IOP of 28.3 ± 4.1 mmHg and were on 2.8 ± 1.1 IOP-lowering drugs. At 12 months, IOP significantly decreased to 12.6 ± 2.1 mmHg and less glaucoma medications were necessary (mean 1.0 ± 1.5 topical medications; P< .05). 15 patients (78.9%) with phacotrabeculectomy and 9 patients (60.0%) in the phacocanaloplasty group showed complete success according to definition 1 and 2 after 1 year (P= .276). Postsurgical complications were seen in 7 patients (36.8%) of the phacocanaloplasty group which included intraoperative macroperforation of the trabeculo-Descemet membrane (5.3%), hyphema (21.1%) and bleb formation (10.5%). Although more complications were observed in the phacotrabeculectomy group, no statistically significant difference was found. CONCLUSIONS: Phacocanaloplasty offers a new alternative to phacotrabeculectomy for treatment of concomitant glaucoma and cataract, although phacotrabeculectomy yielded in better results in terms of IOP maintained without glaucoma medications.

Intracorneal hematoma after canaloplasty and clear cornea phacoemulsification: surgical management.

PURPOSE: This is a case report of intracorneal hematoma after canaloplasty and clear cornea phacoemulsification. METHODS: A 75-year-old woman presented with primary open angle glaucoma and visually significant cataract. Canaloplasty and clear corneal phacoemulsification were performed. Postoperatively she had an intracorneal hematoma, which was removed through a clear corneal tunnel. RESULTS: Preoperative best-corrected visual acuity (BCVA) was 20/40 in the right eye and mean intraocular pressure (IOP) was 20 mmHg. Uneventful canaloplasty, clear corneal phacoemulsification, and implantation of a posterior chamber intraocular lens were performed. One day after the operation, BCVA was 20/400 in the right eye. The IOP was 8 mmHg. Anterior segment examination revealed a nasally located intrastromal hematoma between corneal stroma and Descemet membrane. The intracorneal hematoma was removed through a clear corneal tunnel. Six months postoperatively, BCVA was 20/25 in the right eye. The IOP with one medication was 17 mmHg. CONCLUSIONS: This operation was a minimally invasive technique to remove intrastromal hematocornea after viscocanaloplasty.