Preoperative and postoperative features of macular holes on en face imaging and optical coherence tomography angiography

AbstractPurposeTo characterize and quantify the pre- and postoperative foveal structural and functional patterns in full-thickness macular holes.MethodsSubjects presenting with a full-thickness macular hole that had pre- and postoperative imaging were included. En face optical coherence tomography (OCT) and OCT angiography (OCTA) was performed. Foveal avascular zone (FAZ) area, macular hole size, number and size of perifoveal cysts were measured.ResultsFive eyes from 5 patients were included in the study. The hole was closed in all eyes after the initial surgery. OCTA showed enlargement of the FAZ and delineation of the holes within the FAZ. Mean preoperative FAZ area was 0.41 ± 0.104 mm2. Visual acuity was improved and mean FAZ area was reduced to 0.27 ± 0.098 mm2 postoperatively (P < 0.05) with resolution of the macular hole and adjacent cystic areas. En face images of the middle retina showed a range of preoperative cystic patterns surrounding the hole. Smaller holes showed fewer but larger cystic areas and larger holes had more numerous but smaller cystic areas.Conclusions and ImportanceQuantitative evaluation of vascular and cystic changes following macular hole repair demonstrates the potential for recovery due to neuronal and vascular plasticity. Perifoveal microstructural patterns and their quantitative characteristics may serve as useful anatomic biomarkers for assessment of macular holes

Corticosteroid implants for chronic non-infectious uveitis.

BACKGROUND: Uveitis is a term used to describe a heterogeneous group of intraocular inflammatory diseases of the anterior, intermediate, and posterior uveal tract (iris, ciliary body, choroid). Uveitis is the fifth most common cause of vision loss in high-income countries, accounting for 5% to 20% of legal blindness, with the highest incidence of disease in the working-age population.Corticosteroids are the mainstay of acute treatment for all anatomical subtypes of non-infectious uveitis and can be administered orally, topically with drops or ointments, by periocular (around the eye) or intravitreal (inside the eye) injection, or by surgical implantation. OBJECTIVES: To determine the efficacy and safety of steroid implants in people with chronic non-infectious posterior uveitis, intermediate uveitis, and panuveitis. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (Issue 10, 2015), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to November 2015), EMBASE (January 1980 to November 2015), PubMed (1948 to November 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to November 2015), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (last searched 15 April 2013), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for studies. We last searched the electronic databases on 6 November 2015.We also searched reference lists of included study reports, citation databases, and abstracts and clinical study presentations from professional meetings. SELECTION CRITERIA: We included randomized controlled trials comparing either fluocinolone acetonide (FA) or dexamethasone intravitreal implants with standard-of-care therapy with at least six months of follow-up after treatment. We included studies that enrolled participants of all ages who had chronic non-infectious posterior uveitis, intermediate uveitis, or panuveitis with vision that was better than hand-motion. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed studies for inclusion. Two review authors independently extracted data and assessed the risk of bias for each study. MAIN RESULTS: We included data from two studies (619 eyes of 401 participants) that compared FA implants with standard-of-care therapy. Both studies used similar standard-of-care therapy that included administration of prednisolone and, if needed, immunosuppressive agents. The studies included participants from Australia, France, Germany, Israel, Italy, Portugal, Saudi Arabia, Spain, Switzerland, Turkey, the United Kingdom, and the United States. We assessed both studies at high risk of performance and detection bias.Only one study reported our primary outcome, recurrence of uveitis at any point during the study through 24 months. The evidence, judged as moderate-quality, showed that a FA implant probably prevents recurrence of uveitis compared with standard-of-care therapy (risk ratio (RR) 0.29, 95% confidence interval (CI) 0.14 to 0.59; 132 eyes). Both studies reported safety outcomes, and moderate-quality evidence showed increased risks of needing cataract surgery (RR 2.98, 95% CI 2.33 to 3.79; 371 eyes) and surgery to lower intraocular pressure (RR 7.48, 95% CI 3.94 to 14.19; 599 eyes) in the implant group compared with standard-of-care therapy through two years of follow-up. No studies compared dexamethasone implants with standard-of-care therapy. AUTHORS\u27 CONCLUSIONS: After considering both benefits and harms reported from two studies in which corticosteroids implants were compared with standard-of-care therapy, we are unable to conclude that the implants are superior to traditional systemic therapy for the treatment of non-infectious uveitis. These studies exhibited heterogeneity in design and outcomes that measured efficacy. Pooled findings regarding safety outcomes suggest increased risks of post-implant surgery for cataract and high intraocular pressure compared with standard-of-care therapy

Ocriplasmin for Vitreoretinal Diseases

Fibronectin and laminin are clinically relevant plasmin receptors in the eye. Located at the vitreoretinal interface, they are cleaved by ocriplasmin (Microplasmin, ThromboGenics, Iselin, NJ), a novel ophthalmic medication. A series of clinical trials to study ocriplasmin for the treatment of vitreoretinal diseases such as vitreomacular traction, macular hole, and exudative age-related macular degeneration are underway. The results are promising and may impact patient care

Current Practice Preferences and Safety Protocols for Intravitreal Injection of AntieVascular Endothelial Growth Factor Agents

Purpose: To assess current practice preferences and safety measures used for intravitreal injection (IVI) of antievascular endothelial growth factor (VEGF) medications and to assess the variability of practice patterns between academic and nonacademic and between early- and later-career ophthalmologists. Design: Cross-sectional survey. Participants: Practicing retina specialists who administer intravitreal anti-VEGF injections from the membership pool of the American Society of Retina Specialists. Methods: Participants were contacted by e-mail to participate in an anonymous 31-question survey on a common online platform, SurveyMonkey. Main Outcome Measures: Preferred practices for various aspects of administering IVIs and adherence to the most recently published guidelines on IVI techniques. Results: Preinjection antibiotic drops were used always or often by 10.9% (43/396) of participants. Antibiotics after injection were used always or often by 16.6% (66/398) of participants. Longer (>15 years) compared with shorter (0-15 years) duration of practice was associated with always or often instilling preinjection antibiotics (13.7% vs. 6.7%; P = 0.028), scrubbing eyelids or lashes with antiseptic (43.6% vs. 30.5%; P = 0.008), and being less likely to instill antiseptic immediately before injection (89.7% vs. 95.7%; P = 0.029). Practicing for more than 25 years was associated with always or often instilling antibiotics after injection (22.5% vs. 13.3%; P = 0.017). Academic compared with nonacademic providers were more likely to wear a cap (16.3% vs. 6.8%; P = 0.006), mask (43.0% vs. 29.9%; P = 0.022), and gloves (64.0% vs. 52.1%; P = 0.050) and to drape the patient (17.4% vs. 9.1%; P = 0.027). Conclusions: Techniques for IVIs vary widely. Use of periprocedure antibiotics has declined, consistent with new evidence demonstrating lack of efficacy in endophthalmitis prevention as well as their potential harm. However, later-career physicians were more likely to continue to use antibiotics and other techniques advised against in the most recent recommendations of expert consensus groups in the United States and Europe. Academic practitioners were more likely to use protective wear during the procedure. (C) 2019 by the American Academy of Ophthalmolog

PARACENTRAL ACUTE MIDDLE MACULOPATHY ASSOCIATED WITH RETINAL ARTERY OCCLUSION AFTER COSMETIC FILLER INJECTION

To report a single case of paracentral acute middle maculopathy in association with retinal artery occlusion in the setting of ipsilateral facial cosmetic filler injection. Case report. A 35-year-old woman presenting with sudden vision loss to finger count vision immediately after left nasal fat pad cosmetic filler injection. Dilated funduscopic examination revealed a swollen optic disc with multiple branch arterial occlusions with visible embolic material. Fluorescein angiography confirmed multiple branch arterial occlusions in addition to a focal choroidal infarction in the macula. Spectral-domain optical coherence tomography revealed middle retinal hyperreflectivity in the superotemporal macula consistent with paracentral acute middle maculopathy. En face optical coherence tomography demonstrated a superotemporal area of whitening at the level of the deep capillary plexus corresponding to the paracentral acute middle maculopathy lesion seen on spectral-domain optical coherence tomography. On twelve-month follow-up, final visual acuity was 20/100 due to optic neuropathy. Emboli from cosmetic facial filler injections may rarely result in ipsilateral arterial occlusions and now have a novel association with paracentral acute middle maculopathy likely due to deep capillary plexus feeder vessel occlusion

Ocriplasmin for vitreoretinal diseases.

Fibronectin and laminin are clinically relevant plasmin receptors in the eye. Located at the vitreoretinal interface, they are cleaved by ocriplasmin (Microplasmin, ThromboGenics, Iselin, NJ), a novel ophthalmic medication. A series of clinical trials to study ocriplasmin for the treatment of vitreoretinal diseases such as vitreomacular traction, macular hole, and exudative age-related macular degeneration are underway. The results are promising and may impact patient care

PARACENTRAL ACUTE MIDDLE MACULOPATHY ASSOCIATED WITH POSTVIRAL PURTSCHER-LIKE RETINOPATHY

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. Case report, multimodal imaging. 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. 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