Office-based Air-Fluid Exchange for Diabetic Post-Operative Vitreous Cavity Hemorrhage

Post-operative vitreous cavity hemorrhage (POVCH) is observed in 6-75% of eyes undergoing pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR). We describe our technique for office-based Air fluid exchange (AFX) in the treatment of POVCH. Sixteen eyes (15 patients) with PDR and POVCH undergoing office-based AFX between January 2006 and November 2016 were retrospectively identified. The pre- and post- procedure visual acuity (VA) and complications were compared between eyes with and without traction retinal detachment (TRD). Medicare charges for office-based AFX versus PPV were also analyzed. Mean age at the time of AFX was 55.31 (± 8.02) years. Nine eyes (56.25%) had TRD prior to PPV and 11 eyes (68.75%) were pseudophakic. The improvements in mean (± standard deviation [SD]) logMAR VA at the last postoperative visit (3 - 8 months) were 1.38 (± 0.99), 0.82 (± 0.91) and 2.09 (± 0.53) in all eyes, TRD eyes and non-TRD eyes, respectively. Complications included cataract progression, hypotony, and recurrence of TRD and ghost cell glaucoma. The total cost of outpatient AFX was $1,409.59 less than that of PPV. Office-based AFX is a cost-effective alternative treatment for non-clearing diabetic POVCH with an acceptable risk profile

Office-based Air-Fluid Exchange for Diabetic Post-Operative Vitreous Cavity Hemorrhage

Post-operative vitreous cavity hemorrhage (POVCH) is observed in 6-75% of eyes undergoing pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR). We describe our technique for office-based Air fluid exchange (AFX) in the treatment of POVCH. Sixteen eyes (15 patients) with PDR and POVCH undergoing office-based AFX between January 2006 and November 2016 were retrospectively identified. The pre- and post- procedure visual acuity (VA) and complications were compared between eyes with and without traction retinal detachment (TRD). Medicare charges for office-based AFX versus PPV were also analyzed. Mean age at the time of AFX was 55.31 (± 8.02) years. Nine eyes (56.25%) had TRD prior to PPV and 11 eyes (68.75%) were pseudophakic. The improvements in mean (± standard deviation [SD]) logMAR VA at the last postoperative visit (3 - 8 months) were 1.38 (± 0.99), 0.82 (± 0.91) and 2.09 (± 0.53) in all eyes, TRD eyes and non-TRD eyes, respectively. Complications included cataract progression, hypotony, and recurrence of TRD and ghost cell glaucoma. The total cost of outpatient AFX was $1,409.59 less than that of PPV. Office-based AFX is a cost-effective alternative treatment for non-clearing diabetic POVCH with an acceptable risk profile

Sealed Unilateral Full-Thickness Macular Hole with Amniotic Membrane Graft in a Patient with Alport Syndrome: A Case Report

We present a case of unilateral full-thickness macular hole (MH) successfully repaired with an amniotic membrane (AM) graft in a patient with Alport syndrome. A 58-year-old Asian female with past medical history of Alport syndrome diagnosed at early stage, presented with a 5-week history of vision loss in her right eye. Examination of her eyes showed normal retinal vessels and an MH measuring 1,300 μm in basal diameter, 806 μm in minimum linear diameter, and 490 μm in height in the right eye and macular thinning with laser scars inferiorly in the left eye. The patient underwent 23-g pars plana vitrectomy with intraocular lens explantation. After multiple unsuccessful attempts in inducing a posterior vitreous detachment around the optic nerve and in the posterior pole, a 1 mm AM graft placed on the MH and the edges tucked under the edges of the hole using a bimanual technique. Five months after surgery, the MH remained sealed with improved final vision. MHs are rare manifestations of Alport syndrome, and surgical treatment of Alport syndrome-associated MHs is challenging. However, further studies to explore new techniques using AM are needed

Idiopathic Macular Hole: Algorithm for Nonsurgical Closure Based on Literature Review

Our purpose is to review the closure time and optical coherence tomography (OCT) biomarkers that result in the non-surgical repair of idiopathic full-thickness macular holes (IFTMH). Our methodology consisted of a comprehensive literature review of the nonsurgical resolution of IFTMH followed by the calculation of the estimated closure time using the structural equation model. Forty-nine studies were found eligible yielding 181 eyes with IFTMH: 81.1% being small holes (<250 μm) with a median diameter of 166 μm. Final vision (mean 20/41) was related to initial vision (mean 20/65) and mean age (67 years). The hole diameter was correlated with initial vision and closure time (mean 3.9 months). Closure time was related to hole diameter and initial vision in the following algorithm: Closure time (month)= −0.057 + 0.008 diameter (μm) + 0.021 age (year) + 2.153 initial vision (logMAR). Biomarkers by OCT for self-closure included in decreasing frequency: pointed edge, de-turgescence of cystic macular edema (CME) with reversal of bascule bridge, and vitreomacular traction (VMT) release. The crucial function of Muller cell bridging in sealing the hole attests to its exceptional capacity for regeneration. After the hole has begun to close; however in less than 5%, a delayed restoration of the ellipsoid layer or a persistent outer foveal defect may prevent visual recovery and reopening of the hole is possible. In conclusion, eyes with small-size IFTMH and good baseline vision can have the additional option of close OCT monitoring for biomarkers of self-sealing biomarkers. When rehabilitative activity seems to be lacking, surgery is therefore mandatory

Ocular Complications from Retained Intraocular Ointment Discovered 33 Months after Cataract Surgery

Topical antibiotic and steroid ointments are sometimes used topically at the conclusion of intraocular surgery, and inadvertent entry into the eye has been reported. Dispersed ointment droplets or consolidated globules in the anterior chamber (AC) can sometimes be visualized on exam. Occasionally, intraocular ointment is found incidentally without apparent toxic effect, but retained ointment usually presents with early or delayed intraocular inflammation, pressure rise, macular edema, or corneal edema. The usual treatment for toxicity from retained ointment is removal of the ointment. While the complication of ointment-induced cystoid macular edema has been reported, there is paucity of literature on the anatomical response and eventual visual outcome of patients who have been treated for long-standing edema from retained ointment. We present a case of a patient who presented with history of poor vision since the time of cataract surgery 33 months prior, who had cystoid macular edema, reduced endothelial cell count, and apparent Maxitrol ointment (neomycin, polymyxin B sulfate, and dexamethasone in paraffin vehicle; Novartis Pharmaceuticals UK) floating in the AC. The patient was treated with AC washout and sub-Tenon injection of triamcinolone. His vision, retinal architecture by optical coherence tomography, endothelial cell count, and pachymetry has been followed for 9 months following this treatment

RP2-associated X-linked Retinopathy: Clinical Findings, Molecular Genetics, and Natural History

PURPOSE: To review and describe in detail the clinical course, functional and anatomical characteristics of RP2-associated retinal degeneration. DESIGN: Retrospective case series. PARTICIPANTS: Males with disease-causing variants in the RP2 gene. METHODS: Review of all case notes and results of molecular genetic testing, retinal imaging (fundus autofluorescence (FAF) imaging, optical coherence tomography (OCT)) and electrophysiology assessment. MAIN OUTCOME MEASURES: Molecular genetic testing, clinical findings including best-corrected visual acuity (BCVA), qualitative and quantitative retinal imaging analysis, and electrophysiology parameters. RESULTS: Fifty-four molecularly confirmed patients were identified, from 38 pedigrees. Twenty-eight disease-causing variants were identified; with 20 not previously clinically characterized. Fifty-three patients (98.1%) presented with retinitis pigmentosa. The mean age of onset (range, ±SD) was 9.6 years of age (1-57 years, ± 9.2 years). Forty-four patients (91.7%) had childhood-onset disease, with mean age of onset of 7.6 years. The commonest first symptom was night blindness (68.8%). Mean BCVA (range, ±SD) was 0.91 LogMAR (0-2.7, ±0.80) and 0.94 LogMAR (0-2.7, ±0.78) for right and left eyes respectively. Based on the WHO visual impairment criteria, 18 patients (34%) had low vision. The majority (17/22) showed ERG evidence of a rod-cone dystrophy. Pattern ERG P50 was undetectable in all but 2 patients. A range of FAF findings was observed, from normal to advanced atrophy. There were no statistically significant differences between right and left eyes for ellipsoid zone (EZ) width and outer nuclear layer (ONL) thickness. The mean annual rate of EZ width loss was 219 μm/year and the mean annual decrease in ONL thickness was 4.93 μm/year. No patient with childhood-onset disease had identifiable EZ after the age of 26 years at baseline or follow-up. Four patients had adulthood-onset disease and a less severe phenotype. CONCLUSIONS: This study details the clinical phenotype of RP2 retinopathy in a large cohort. The majority presented with early-onset severe retinal degeneration, with early macular involvement and complete loss of the foveal photoreceptor layer by the third decade of life. Full-field ERGs revealed rod-cone dystrophy in the vast majority, but with generalised (peripheral) cone system involvement of widely varying severity in the first two decades of life

RBP3-retinopathy - inherited high myopia and retinal dystrophy: Genetic Characterization, Natural History, and Deep Phenotyping

Objective: To examine the genetic and clinical features and the natural history of RBP3-associated retinopathy. // Design: Multi-center international, retrospective, case series. // Setting: Three tertiary referral centers. // Participants: Adults and children, with molecularly confirmed RBP3-associated retinopathy. // Main Outcomes and Measures: Multi-center, international, retrospective, consecutive observational study in three tertiary referral centers of adults and children, with molecularly confirmed RBP3-retinopathy. The genetic, clinical and retinal imaging findings, including optical coherence tomography (OCT) and fundus autofluorescence (FAF), were investigated both cross-sectionally and longitudinally. The results of International standard full-field and pattern electroretinography (ERG; PERG) were reviewed. // Results: We ascertained 12 patients (5 females), from 10 families, with four patients previously reported. Eight novel disease-causing RBP3 variants were identified. Ten patients were homozygous. The mean age (±SD, range) of the group was 21.4 years (±19.1, 2.9-60.5 years) at baseline evaluation. All 12 patients were highly myopic with a mean spherical equivalent of -16.0D (range; -7.0D to -33.0D). Visual acuity was not significantly different between eyes and no significant anisometropia was observed. Mean best corrected visual acuity (BCVA) was 0.48 LogMAR (range; 0.2-1.35, SD; ± 0.29 LogMAR) at baseline. Eleven patients had longitudinal BCVA assessment, with a mean BCVA of 0.46 LogMAR after a mean follow-up of 12.6 years. All patients were symptomatic with reduced VA and myopia by the age of 7 years. All patients had myopic fundi and features in keeping with high myopia on OCT, including choroidal thinning. The 4 youngest patients had no fundus pigmentary changes, with the rest presenting with a variable degree of mid-peripheral pigmentation and macular changes. FAF showed variable phenotypes, ranging from areas of increased signal to advanced atrophy in older patients. OCT showed cystoid macular edema at presentation in three patients, which persisted during follow-up in two patients and resolved to atrophy for the third patient. The ERGs were abnormal in 9 of 9 cases, revealing variable relative involvement of rod and cone photoreceptors with additional milder dysfunction post-phototransduction in some. All but one had PERG evidence of macular dysfunction, severe in most. // Conclusions: This study details the clinical and functional phenotype of RBP3-retinopathy in the largest cohort reported to date. RBP3-retinopathy is a disease characterized by early onset, slow progression over decades, and high myopia. The phenotypic spectrum and natural history as described herein has prognostic and counselling implications. RBP3-related disease should be considered in children with high myopia and retinal dystrophy

A Database Study of Visual Outcomes and Intraoperative Complications of Postvitrectomy Cataract Surgery

PURPOSE: To analyze the visual outcomes and rate of intraoperative complications of phacoemulsification surgery after prior pars plana vitrectomy (PPV). DESIGN: Retrospective, multicenter database study. PARTICIPANTS: Eyes that underwent phacoemulsification between June 2005 and March 2015 at 8 sites in the United Kingdom. METHODS: Study eyes were classified as vitrectomized (prior PPV group) or nonvitrectomized (reference group) depending on the vitreous state at the time of cataract surgery. Eyes with multiple intraocular surgeries or history of ocular diseases known to cause cataract progression or increased risk of intraoperative complications during phacoemulsification were excluded. MAIN OUTCOME MEASURES: Logarithm of the minimum angle of resolution (logMAR) visual acuity (VA), rate of intraoperative complications, and time interval to cataract surgery. RESULTS: Eyes in the prior PPV group (n = 2221) had worse preoperative logMAR VA (0.96±0.60 vs. 0.62±0.52, P \u3c 0.0001), were from younger patients, and had longer axial lengths than the nonvitrectomized group (n = 136 533). At all postoperative time points measured up to 24 weeks, mean vision was poorer in the prior PPV group (0.41±0.47 vs. 0.17±0.29 at 4-12 weeks, P \u3c 0.0001) and a smaller proportion of eyes achieved postoperative VA ≤0.30 logMAR (Snellen, ≥20/40) (60.8% vs. 86.5% at 4-12 weeks, P \u3c 0.0001). The rate of posterior capsular rupture was not different between the prior PPV (1.5%) and the nonvitrectomized (1.7%) groups, but the incidences of zonular dialysis (1.3% vs. 0.6%) and dropped nuclear fragments (0.6% vs. 0.2%) were higher in the prior PPV group (P \u3c 0.0001). The mean time interval between PPV and cataract surgery was 399 days. CONCLUSIONS: We found a significant improvement in VA with postvitrectomy cataract surgery. However, compared with eyes without prior PPV, there was a worse mean postoperative vision of 0.2 logMAR units, a higher rate of zonular dialysis and dropped nuclear fragments, and a similar rate of posterior capsule rupture

IMPG2-associated unilateral adult onset vitelliform macular dystrophy

Purpose: To present a case of unilateral IMPG2-associated adult onset vitelliform macular dystrophy (AVMD). Observations: A 68 year-old female presented with best corrected visual acuity (BCVA) of 20/20 and 20/40 for the right and left eye respectively. The patient had a left subfoveal yellow lesion on dilated fundus examination. Optical coherence tomography showed hyper-reflective material accumulation below the fovea in the left eye only. The patient was followed for 10 years with stable BCVA, and evolution of the subretinal vitelliform lesion to a “vitelliruptive” stage. The right eye did not develop vitelliform lesion. Genetic testing identified a heterozygous likely disease-causing variant in IMPG2; c.3423–7_3423-4del. Conclusions and importance: This is the first report of unilateral AVMD associated with IMPG2, expanding the phenotypic spectrum of IMPG2 retinopathy. We provide further evidence that IMPG2 variants can cause both autosomal recessive rod-cone dystrophy and autosomal dominant AVMD, with implications for patient counselling

Primary care physicians’ knowledge of the ophthalmic effects of diabetes

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