Vitreous Biomarkers for Proliferative Vitreoretinopathy Prognostication in Patients Undergoing Primary Retinal Detachment Repair.

Purpose: To compare baseline levels of exploratory biomarkers in the vitreous fluid of patients with primary retinal detachment who subsequently develop proliferative vitreoretinopathy (PVR) versus those who do not. Methods: In this exploratory case-control study, we evaluated the baseline protein biomarker levels from a biobank containing the vitreous fluid of patients who had undergone primary pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment. Undiluted samples were collected at the time of PPV and stored at -80°C. Samples from 13 patients who developed PVR within 6 months (PVR group) and 13 age- and gender-matched controls who did not develop PVR (control group) were included. Protein abundance levels were evaluated using a proximity extension assay, and a confirmatory enzyme-linked immunosorbent assay (ELISA) was used to measure the concentration of vimentin. Results: Baseline vimentin (Normalized Protein eXpression [NPX], 8.6 vs. 6.4, P < 0.0001) and heme oxygenase 1 (NPX 8.9 vs. 7.0, P < 0.001) levels were found to be elevated in vitreous fluid of patients who subsequently developed PVR compared to those who did not. Confirmatory analysis using ELISA demonstrated mean vimentin concentrations of 7254 vs. 2727 ng/mL in the PVR versus control groups (P = 0.0152). The odds ratio for developing PVR was 14 (confidence interval, 1.4-168; P = 0.03), assuming a baseline vimentin threshold of 7500 ng/mL. Conclusions: Vimentin is an intermediate filament protein expressed by retinal glial cells, and our data combined with prior evidence suggest that it may serve as an early vitreous biomarker for subsequent PVR formation and reactive gliosis. Furthermore, we found, for the first time, elevated baseline levels of heme oxygenase 1, a measurable indicator of oxidative stress. Translational Relevance: Our positive findings could impact clinical care for retinal detachment patients by facilitating risk stratification for targeted interventions or closer monitoring in those at the highest risk of developing PVR.

Clinical Outcomes of Retinal Arterial Macroaneurysms With Vitreous Hemorrhage Treated With Observation, Antivascular Endothelial Growth Factor Intravitreal Injections, or Pars Plana Vitrectomy.

Purpose: To evaluate the clinical outcomes of different types of treatment of retinal arterial macroaneurysm with vitreous hemorrhage. Methods: This retrospective cohort study comprised patients with retinal arterial macroaneurysm and vitreous hemorrhage who were examined at a single retina clinic between 2013 and 2021. Results: Treatment arms included observation (n = 33), intravitreal injections (IVIs) of antivascular endothelial growth factor agents (n = 5), and pars plana vitrectomy (PPV; n = 12). Baseline characteristics and final best-corrected visual acuity (BCVA) were similar in a combined analysis of all treatment groups (P > .05). The BCVA improved in all eyes, but the IVI and PPV arms had worse presenting BCVA. The mean number of injections was 3.6 ± 2.8. The incidence of subretinal hemorrhage was 18.2% in the observation arm, 25.0% in the PPV group (8.3% had subretinal tissue plasminogen activator), and 60.0% in the IVI group. The mean time to intervention was 13 ± 15.3 days for PPV and 38 ± 69.9 days for IVI. There was no correlation between the number of injections and the final BCVA (r = 0.13, P = .830). The IVI and PPV arms were more frequently on anticoagulants (P = .011). There was no difference in final BCVA between those using anticoagulants (0.52 ± 0.53) vs not using anticoagulants (0.55 ± 0.65) (P = .870). Conclusions: Most patients, regardless of treatment modality, demonstrated significantly improved BCVA and similar final visual outcomes. Patients with worse presenting BCVA were more likely to undergo PPV or IVI whereas those with better presenting BCVA had excellent outcomes with observation alone. Improved BCVA was not associated with the number of IVIs or anticoagulant use.

Clinical Outcomes of Rhegmatogenous Retinal Detachment Repair in Patients with Nystagmus.

PURPOSE: To report the anatomical and visual outcomes of rhegmatogenous retinal detachment (RRD) repair in patients with congenital or acquired nystagmus. METHODS: This was a case series involving a retrospective review of medical records from January 1st, 2015, to April 1st, 2021 of 8 eyes of 8 patients (7 male, 1 female) with documented nystagmus who underwent RRD repair. Primary outcomes included final re-attachment rate and single surgical anatomic success (SSAS) at three months postoperatively. Secondary outcomes included final visual acuity and mean number of additional procedures required for retinal re-attachment. RESULTS: Mean age was 52.1 years (range: 14 to 77 years) and mean follow-up time was 18.6 months (range: 2.8 to 32.9 months). Pars plana vitrectomy (PPV) was performed in 4 patients (50.0%), scleral buckle (SB) in 3 (37.5%), and PPV-SB in 1 (12.5%). A repeat PPV was required in 3 eyes (37.5%) due to proliferative vitreoretinopathy (PVR), 2 of which initially underwent PPV and 1 had PPV/SB. Two eyes (25%) required a third PPV due to PVR or retinal breaks. Mean time to first re-detachment was 29 days. SSAS at 3 months was achieved in 5 patients (62.5%). Complete final retinal re-attachment was achieved in all patients. Final visual acuity improved or stabilized in 7 eyes (87.5%). CONCLUSIONS: Despite a 100% final retinal re-attachment rate, RRD repair can be challenging among patients with nystagmus, including postoperative complications such as recurrent retinal detachment due to retinal breaks. No silicone oil emulsification or related complications were observed in our series.

Appropriateness and Readability of ChatGPT-4-Generated Responses for Surgical Treatment of Retinal Diseases.

OBJECTIVE: To evaluate the appropriateness and readability of the medical knowledge provided by ChatGPT-4, an artificial intelligence-powered conversational search engine, regarding common vitreoretinal surgeries for retinal detachments (RDs), macular holes (MHs), and epiretinal membranes (ERMs). DESIGN: Retrospective cross-sectional study. SUBJECTS: This study did not involve any human participants. METHODS: We created lists of common questions about the definition, prevalence, visual impact, diagnostic methods, surgical and nonsurgical treatment options, postoperative information, surgery-related complications, and visual prognosis of RD, MH, and ERM, and asked each question 3 times on the online ChatGPT-4 platform. The data for this cross-sectional study were recorded on April 25, 2023. Two independent retina specialists graded the appropriateness of the responses. Readability was assessed using Readable, an online readability tool. MAIN OUTCOME MEASURES: The "appropriateness" and "readability" of the answers generated by ChatGPT-4 bot. RESULTS: Responses were consistently appropriate in 84.6% (33/39), 92% (23/25), and 91.7% (22/24) of the questions related to RD, MH, and ERM, respectively. Answers were inappropriate at least once in 5.1% (2/39), 8% (2/25), and 8.3% (2/24) of the respective questions. The average Flesch Kincaid Grade Level and Flesch Reading Ease Score were 14.1 ± 2.6 and 32.3 ± 10.8 for RD, 14 ± 1.3 and 34.4 ± 7.7 for MH, and 14.8 ± 1.3 and 28.1 ± 7.5 for ERM. These scores indicate that the answers are difficult or very difficult to read for the average lay person and college graduation would be required to understand the material. CONCLUSIONS: Most of the answers provided by ChatGPT-4 were consistently appropriate. However, ChatGPT and other natural language models in their current form are not a source of factual information. Improving the credibility and readability of responses, especially in specialized fields, such as medicine, is a critical focus of research. Patients, physicians, and laypersons should be advised of the limitations of these tools for eye- and health-related counseling. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Quantifying Head Position Following Vitrectomy Using a 3-Dimensional Position Sensor Embedded in a Novel Ophthalmic Shield: A Pilot Study.

PURPOSE: To assess head position following pars plana vitrectomy (PPV) using a novel low-energy, non-intrusive 3-D position sensor platform. METHODS: In this prospective non-randomized interventional case series, a low-energy Bluetooth smart sensor housed within a novel eye shield recorded 3-D positional data every five minutes. The device was placed on the patient immediately after PPV and data was retrieved at the postoperative day 1 visit. Readings were processed by vector analysis into 4 groups, stratified by the angle of deviation away from a completely prone head position. The primary outcome was the angle between vectors. RESULTS: Ten patients were enrolled in this pilot study. The mean (SD) age was 57.5 (17.4). A total of 2318 readings with a mean (SD) of 231.8 (26.8) readings per patient were obtained. The mean (SD) number of readings were 132.9 (34.7) while awake and 98.9 (27.9) during sleep. Of total readings, only 11.7% fell into group 1 while a majority of readings fell in group 2 (52.4%), and group 3 (32.4%), and only 3.5% fell into group 4. Positional deviation increased during sleep hours, with about 46.8% of readings at a reclined angle (group 3) and 4.9% supine, which was 21.6% and 2.5% respectively during the wake time (p<0.001, p=0.002, respectively). CONCLUSION: In this pilot study, a non-intrusive wireless 3-D position sensor-shield platform was tolerated well and capable of capturing positional data. Adherence to face-down positioning was low and positional deviation increased significantly while sleeping.

Outcomes of Laser Retinopexy for Retinal Tears in Pseudophakic Eyes with Multifocal Versus Monofocal Intraocular Lenses: A Matched Cohort Study.

PURPOSE: Performing laser retinopexy through multifocal intraocular lenses may be challenging due to aberrations of the peripheral retinal view. This study investigated the influence of multifocal versus monofocal intraocular lenses on outcomes of laser retinopexy for retinal tears. METHODS: Pseudophakic eyes (multifocal and monofocal intraocular lenses) that underwent in-office laser retinopexy for retinal tears, with a minimum follow-up of 3 months, were retrospectively analyzed. Eyes with multifocal intraocular lenses were matched to controls with monofocal intraocular lenses in a 1:2 ratio for age, gender, number, and location of retinal tears. The main outcome measure was the rate of complications. RESULTS: We included 168 eyes in the study. Fifty-six eyes (51 patients) with multifocal intraocular lenses were matched with 112 eyes (112 patients) with monofocal intraocular lenses. The mean follow-up was 26 months. Baseline characteristics were similar between two groups. No significant differences were noted in the rate of successful laser retinopexy without additional procedures (91% vs. 86% at 3 months and 79% vs. 74% during follow-up, in the multifocal intraocular lens and monofocal intraocular lens group, respectively). No significant differences were observed in the rate of subsequent rhegmatogenous retinal detachment (multifocal, 4% vs. monofocal, 6%, p=.716) or need for additional laser retinopexy for new tears (14% vs. 15%; p=.939). The surgery rates for vitreous hemorrhage (0% vs. 3%; p=.537), epiretinal membrane (2% vs. 2%; p=.553), and vitreous floaters (5% vs. 2%, p=.422) were not significantly different. Visual outcomes were also similar. CONCLUSION: Multifocal intraocular lenses did not appear to negatively impact the outcomes of in-office laser retinopexy for retinal tears.

Polymicrobial odontogenic periorbital and orbital necrotizing fasciitis (PONF): A case report.

PURPOSE: To present a case of periorbital and orbital necrotizing fasciitis (PONF) from an odontogenic source with a distinct microbiologic profile and highlight the need for emergent multidisciplinary management. OBSERVATIONS: A 39-year-old man presented with periorbital swelling, pain, and erythema following facial trauma. Imaging revealed peri-dental collections, accompanying maxillary sinusitis, and pre- and post-septal involvement. Immediate surgical debridement of necrotic tissue along with broad-spectrum antibiotics were pursued for management. Cultures grew multiple organisms, most notably Streptococcus milleri group and Staphylococcus lugdunensis. CONCLUSIONS AND IMPORTANCE: PONF is a rare yet potentially fatal disease. Streptococcus milleri group and a fulminant course are to be suspected when the source is odontogenic. Timely multidisciplinary surgical debridement and medical management with intravenous antibiotics is critical for best outcomes.

Translational and clinical advancements in management of proliferative vitreoretinopathy.

PURPOSE OF REVIEW: Despite advancement in the surgical instrumentation and techniques, proliferative vitreoretinopathy (PVR) remains the most common cause for failure of rhegmatogenous retinal detachment (RRD) repair. This review discusses ongoing translational and clinical advancements in PVR. RECENT FINDINGS: PVR represents an exaggerated and protracted scarring process that can occur after RRD. The primary cell types involved are retinal pigment epithelium, glial, and inflammatory cells. They interact with growth factors and cytokines derived from the breakdown of the blood-retinal barrier that trigger a cascade of cellular processes, such as epithelial-mesenchymal transition, cell migration, chemotaxis, proliferation, elaboration of basement membrane and collagen and cellular contraction, leading to overt retinal pathology. Although there are currently no medical therapies proven to be effective against PVR in humans, increased understanding of the risks factors and pathophysiology have helped guide investigations for molecular targets of PVR. The leading therapeutic candidates are drugs that mitigate growth factors, inflammation, and proliferation are the leading therapeutic candidates. SUMMARY: Although multiple molecular targets have been investigated to prevent and treat PVR, none have yet demonstrated substantial evidence of clinical benefit in humans though some show promise. Advancements in our understanding of the pathophysiology of PVR may help develop a multipronged approach for this condition.

Novel Guarded Needle Trans-Scleral Biopsy for Uveal Melanoma: A Pilot Study.

INTRODUCTION: Trans-scleral biopsy of uveal melanoma (UM) poses an inherent risk of tumor and possibly retinal perforation. We describe a novel technique for trans-scleral biopsy of UM and evaluate its safety and efficacy in an initial cohort of patients. METHODS: A retrospective, consecutive observational case series was conducted from October 14, 2019, to April 15, 2020, at Kaiser Permanente, San Francisco, CA among patients with UM of the ciliary body or anterior choroid undergoing trans-scleral fine-needle aspiration biopsy using a novel guarded needle technique. RESULTS: A total of 6 patients were included in the study, with a mean age of 64.3 (range 35-77) years (5 women 83%). Mean (±SD) tumor thickness and maximal basal diameter were 6.4 (±2.66) and 11.9 (±2.13) mm, respectively. Five out of 6 patients achieved a successful biopsy with reliable gene expression profiling (GEP) results. The only failure to obtain specimen occurred in the first attempted patient and, after a minor technique modification, all subsequent biopsies were successful. No intraoperative or short-term postoperative complications were observed in any patient. CONCLUSION: This novel trans-scleral biopsy technique appears to be safe and effective when obtaining UM tissue for GEP. This method may provide a more controlled biopsy depth thereby minimizing the risk of tumor perforation and its associated complications while still obtaining adequate biopsy yield.

Bilateral superior ophthalmic vein thrombosis associated with high altitude.

We report a case of a 47-year-old female who experienced periorbital swelling while descending from a Himalayan mountain climb and was found to have bilateral superior ophthalmic vein thromboses (SOVT). Infectious, autoimmune, and hypercoagulability work-up were negative with no cavernous sinus involvement. Symptoms resolved upon initiation of anticoagulation and oral steroids. SOVT is a rare but serious condition and has a risk of extending into the cavernous sinus if not treated early. Although infection is the most common etiology, venous thrombosis can be precipitated under high altitude and low oxygen pressure environments. We present a case of superior ophthalmic vein thrombosis associated with high-altitude conditions.

A Randomized Controlled Trial of Early versus Late Surgical Decompression for Thoracic and Thoracolumbar Spinal Cord Injury in 73 Patients.

Convincing clinical evidence exists to support early surgical decompression in the setting of cervical spinal cord injury (SCI). However, clinical evidence on the effect of early surgery in patients with thoracic and thoracolumbar (from T1 to L1 [T1-L1]) SCI is lacking and a critical knowledge gap remains. This randomized controlled trial (RCT) sought to evaluate the safety and efficacy of early (<24 h) compared with late (24-72 h) decompressive surgery after T1-L1 SCI. From 2010 to 2018, patients (≥16 years of age) with acute T1-L1 SCI presenting to a single trauma center were randomized to receive either early (<24 h) or late (24-72 h) surgical decompression. The primary outcome was an ordinal change in American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade at 12-month follow-up. Secondary outcomes included complications and change in ASIA motor score (AMS) at 12 months. Outcome assessors were blinded to treatment assignment. Of 73 individuals whose treatment followed the study protocol, 37 received early surgery and 36 underwent late surgery. The mean age was 29.74 ± 11.4 years. In the early group 45.9% of patients and in the late group 33.3% of patients had a ≥1-grade improvement in AIS (odds ratio [OR] 1.70, 95% confidence interval [CI]: 0.66-4.39, p = 0.271); significantly more patients in the early (24.3%) than late (5.6%) surgery group had a ≥2-grade improvement in AIS (OR 5.46, 95% CI: 1.09-27.38, p = 0.025). There was no statistically significant difference in the secondary outcome measures. Surgical decompression within 24 h of acute traumatic T1-L1 SCI is safe and is associated with improved neurological outcome, defined as at least a 2-grade improvement in AIS at 12 months.

EN FACE VERSUS 12-LINE RADIAL OPTICAL COHERENCE TOMOGRAPHY SCAN PATTERNS FOR DETECTION OF MACULAR FLUID IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To compare fluid detection of autosegmented en face to 12-line radial spectral domain optical coherence tomography scan patterns in neovascular age-related macular degeneration. METHODS: Retrospective observational case series. Sixty-seven patients (94 eyes) with neovascular age-related macular degeneration underwent autosegmented en face optical coherence tomography (with associated 304-line raster scan) and 12-line radial scan patterns. Sensitivity and specificity of fluid detection for en face scan and 12-line radial scans were determined by combining radial and 304-line raster scans as a gold standard. RESULTS: Two hundred and fifty-eight en face and 12-line radial spectral domain optical coherence tomography scans were interpreted. Seventy-five scans (58.1%) had fluid, whereas 54 scans (41.9%) did not. En face scan pattern fluid detection sensitivity and specificity was 89.3% and 61.1%, respectively. Twelve-line radial scan pattern fluid detection sensitivity and specificity was 97.3% and 100%, respectively. The difference in fluid detection between scan patterns was statistically significant (P = 0.01). Decreased central macular thickness was associated with false-positive (P = 0.035) and false-negative (P = 0.01) fluid detection on en face scans. CONCLUSION: En face optical coherence tomography alone is not as sensitive or specific as the 12-line radial scan pattern in detecting fluid in neovascular age-related macular degeneration. En face scans should be corroborated with other optical coherence tomography protocols to guide clinical decision making.

Comparison of Residual Subfoveal Fluid by Intraoperative OCT After Macula-Involving RRD Repair Using Direct Drainage, Drainage Retinotomy, or Perfluoro-n-Octane.

BACKGROUND AND OBJECTIVE: This study evaluated the residual subfoveal fluid (SFF) immediately after rhegmatogenous retinal detachment (RRD) repair using intraoperative optical coherence tomography (iOCT). PATIENTS AND METHODS: This retrospective cohort study assessed fovea-involving RRD repaired by pars plana vitrectomy (PPV) using different drainage techniques. iOCT images were acquired through the fovea at the start of the case prior to initiating vitrectomy and then again immediately prior to introduction of tamponade. RESULTS: Ten eyes (32.3%) received perfluoro-n-octane (PFO), 12 (38.7%) underwent a posterior drainage retinotomy, and nine (29.0%) had drainage through the retinal break. There was no significant difference in the mean SFF thickness between eyes in either group (P = .85). There was no significant association between SFF thickness on iOCT and functional or anatomic outcomes (P > .05). CONCLUSION: There is no difference in the amount of residual SFF as measured on iOCT during RRD repair with pars plana vitrectomy using either direct drainage, drainage retinotomy, or PFO. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:497-503.].

PARACENTRAL ACUTE MIDDLE MACULOPATHY ASSOCIATED WITH POSTVIRAL PURTSCHER-LIKE RETINOPATHY.

PURPOSE: To report the imaging findings of a single case of paracentral acute middle maculopathy associated with bilateral Purtscher-like retinopathy in the setting of recent viral illness. METHODS: Case report, multimodal imaging. RESULTS: A 21-year-old woman who awoke with sudden-onset bilateral finger count vision in the setting of a recent viral illness. Initial examination and imaging was consistent with a bilateral Purtscher-like retinopathy with evidence of paracentral acute middle maculopathy and ellipsoid zone thickening and hyperreflectivity on spectral domain optical coherence tomography (OCT). Baseline fluorescein angiography and OCT angiography revealed normal perfusion and flow, respectively. All laboratory investigation was negative for possible causative etiology. The patient was followed for 6 months with steady visual improvement to 20/20 in both eyes. En face OCT demonstrated near-complete restoration of the ellipsoid layer. The patient still noted bilateral scotomas which were mapped out on microperimetry and found to correlate to en face OCT findings. CONCLUSION: Purtscher-like retinopathy in the setting of recent viral illness is a rare cause of vision loss that may be associated with the finding of paracentral acute middle maculopathy on spectral domain OCT. Despite poor presenting vision, in the presence of normal perfusion near total visual recovery is possible.

Determining the effect of low-dose isotretinoin on proliferative vitreoretinopathy: the DELIVER trial.

PURPOSE: To examine the effect of low-dose, oral isotretinoin in lowering the risk of proliferative vitreoretinopathy (PVR) following rhegmatogenous retinal detachment (RRD) repair. METHODS: Prospective, open label, dual-cohort study with pathology-matched historical controls. The prospective experimental arms included two cohorts, composed of 51 eyes with recurrent PVR-related RRD and 58 eyes with primary RRD associated with high-risk features for developing PVR. Eyes in the experimental arms received 20 mg of isotretinoin by mouth once daily for 12 weeks starting the day after surgical repair. The primary outcome measure was single surgery anatomical success rate at 3 months following the study surgery. RESULTS: The single surgery anatomic success rate was 78.4% versus 70.0% (p=0.358) in eyes with recurrent PVR-related retinal detachment exposed to isotretinoin versus historical controls, respectively. In eyes with RRD at high risk for developing PVR, the single surgery success rate was 84.5% versus 61.1% (p=0.005) for eyes exposed to isotretinoin versus historical controls, respectively. For eyes enrolled in the experimental arms, the most common isotretinoin-related side effects were dry skin/mucus membranes in 106 patients (97.2%), abnormal sleep/dreams in 4 patients (3.7%) and fatigue in 3 patients (2.8%). CONCLUSION: The management and prevention of PVR is challenging and complex. At the dose and duration given in this study, oral istotretinoin may reduce the risk of PVR-associated recurrent retinal detachment in eyes with primary RRD at high risk of developing PVR.