Pigmentary Retinopathy and Chronic Subretinal Fluid Associated with Pseudoxanthoma Elasticum and Angioid Streaks

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Intravitreal triamcinolone for intraocular inflammation and associated macular edema

Triamcinolone acetonide (TA) is a corticosteroid that has many uses in the treatment of ocular diseases because of its potent anti-inflammatory and anti-permeability actions. Intraocular inflammation broadly referred to as uveitis can result from several causes, including the immune system and after ophthalmic surgery. One of the most common reasons for vision loss with uveitis is macular edema. TA has been used for many years as an intravitreal injection for the treatment of ocular diseases. Several case control studies have been reported showing the efficacy of TA in the treatment of intraocular inflammation and associated macular edema caused by Behcet’s disease, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia and white dot syndromes. It has also been shown efficacious in cases of pars planitis and idiopathic posterior uveitis. Some authors have reported its use in postoperative cystoid macular edema. Many of the studies on the use of TA in controlling intraocular inflammation and concomitant macular edema showed its effect to be transient in many patients requiring reinjection. Complications can arise from intravitreal injection of TA including elevated intraocular pressure and cataract. Rarely, it can be associated with infectious and non-infectious endophthalmitis. TA may be useful as an adjuvant in the treatment of uveitis and its associated macular edema, especially in patients resistant or intolerant to standard treatment

Use of triamcinolone during vitrectomy surgery to visualize membranes and vitreous

Triamcinolone is a corticosteroid that is used to treat many ophthalmic diseases. Recently, its use has been advocated to aid in visualization of transparent tissue in ophthalmic surgery. It can be used in anterior segment surgery to help manage vitreous loss during complicated cataract surgery. It has been used to visualize the posterior cortical vitreous during pars plana vitrectomy. In addition, it can be useful in the visualization and peeling of the internal limiting membrane. Triamcinolone has been advocated in surgical repair of proliferative vitreoretinopathy both for its visualizing properties and its anti-inflammatory properties. Overall, triamcinolone use in surgery is safe with low incidence of complications including elevated intraocular pressure, cataract and endophthalmitis

The Use of Tutoplast as an Adjunct in Scleral Buckle Procedure in Patients with Extremely Thin Sclera

Extremely thin sclera often necessitates abortion of scleral buckle procedures. In patients in whom a scleral buckle is desired, previous techniques have included the use of cyanoacrylate glue and continuing with surgery or placing donor tissue over the areas of thin sclera, but this can delay surgery. This was a retrospective review of three patients with thin sclera encountered during scleral buckling procedures. All patients had Tutoplast Pericardial Graft placed over the areas of thin sclera which allowed the scleral buckle to be sutured onto the Tutoplast rather than the thin sclera. Tutoplast Pericardial Graft is a useful adjunct in scleral buckle procedures with extremely thin sclera, and a scleral buckle can be safely placed over it and lead to successful retinal reattachment

Ophthalmol Ther

There is little understanding of long-term treatment persistence in patients receiving anti-vascular endothelial growth factor (anti-VEGF) injections for diabetic macular edema (DME), particularly relating to treatment intervals. The aim of this study was to investigate the association between treatment interval and discontinuation rate after 24 months of unilateral anti-VEGF treatment in patients with DME under routine clinical care in the USA. This was a non-interventional, retrospective cohort study to review the health insurance claims of adults with DME linked with the IBM MarketScan Commercial and Medicare Supplemental databases, who were continuously enrolled in a health plan for at least 6 months prior to their first anti-VEGF treatment and for a duration of at least 24 months between July 2011 and June 2017. Patients were grouped on the basis of the injection interval they achieved at 24 months of treatment. Discontinuation rate beyond 24 months and its association with treatment intervals at 24 months was estimated using the Kaplan-Meier method and Cox proportional hazards models. The overall discontinuation rate among the 1702 eligible patients from 24 to 60 months after treatment initiation was 30%. At 60 months, patients were more likely to remain on treatment in shorter (75.3% [4-week interval group]) versus longer treatment interval groups (62.1% [> 12-week interval group], difference = 13.2%, [95% confidence interval (CI) 1.06, 2.06], p = 0.01). Patients on a > 12-week interval were twice as likely to discontinue treatment compared with those on an 8-week interval (hazard ratio = 2.01 [95% CI 1.43, 2.82], p < 0.001). Patients with DME on longer anti-VEGF treatment intervals at 24 months consistently had higher discontinuation rates in the following years than those on shorter treatment intervals

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

The Use of Antivascular Endothelial Growth Factor Agents in the Perioperative Period in Diabetic Vitrectomy

Pars plana vitrectomy is an established surgical method for the treatment of proliferative diabetic retinopathy and its complications. Anti-vascular endothelial growth factor agents suppress vascular proliferation and may be used as pharmacological adjuvants to reduce the incidence of postoperative hemorrhage in the vitreous cavity and to facilitate the surgical approach. We conducted an electronic search to identify prospective randomized controlled trials looking at the use of —perioperative vascular endothelial growth factor suppression in diabetic patients undergoing vitrectomy. We found six prospective randomized trials with only one being double-masked. We present a summary of the findings. Four studies suggest that the use of perioperative, anti-vascular endothelial growth factor agents facilitate vitrectomy surgery, but only one study supports their use to reduce the chances of early postoperative vitreous bleeding. Two studies did not find a significant benefit for their use before surgery to reduce the recurrence of vitreous hemorrhage in proliferative diabetic retinopathy. More randomized double blinded studies with a larger number of patients are needed to establish a clear recommendation regarding the use of these agents. Those studies should factor in the use of endo-tamponade with gas or silicone oil following vitrectomy