Chris S. Bergstrom

Intraoperative Microscope-Mounted Spectral Domain Optical Coherence Tomography for Evaluation of Retinal Anatomy during Macular Surgery

OBJECTIVE To evaluate the use of microscope mounted spectral domain optical coherence tomography (SD-OCT) to detect changes in retinal anatomy during macular surgery. DESIGN Retrospective, observational case series. PARTICIPANTS We included 25 eyes of 24 consecutive patients who underwent SD-OCT during macular surgery. METHODS A retrospective review of operative techniques, outcomes, and imaging for all patients who underwent intraoperative microscope mounted SD-OCT during surgery for macular hole or epiretinal membrane (ERM) from April 2009 to April 2010 was performed. Qualitative and quantitative characteristics of intraoperative and postoperative changes in retinal anatomy were studied. MAIN OUTCOME MEASURES Intraoperative change in macular hole dimensions and retinal thickness in patients with ERM owing to surgical manipulation measured using SD-OCT. RESULTS Intraoperative SD-OCT from 13 eyes of 13 patients undergoing surgery for macular hole was reviewed. Two cases had images of suboptimal quality and were excluded. The remaining 11 eyes were subjected to quantitative analysis, which revealed stability of macular hole height and central hole diameter after internal limiting membrane (ILM) peeling, but an increase in the diameter of subretinal fluid under the macula in ten of 11 eyes (average 87% wider). Intraoperative imaging from 12 eyes of 11 patients undergoing surgery for ERM was analyzed. Quantitative analysis revealed an average increase of retinal thickness after ILM peel of <2%. Ten of 12 eyes developed a new subretinal hyporeflectance, which likely represents shallow detachment of the macula, after uncomplicated membrane peel. CONCLUSIONS Use of intraoperative SD-OCT has provided new insight into the changes to retinal anatomy during macular surgery and may prove to be a useful tool for vitreoretinal surgery. Further study is warranted to determine whether intraoperative changes such as the creation of shallow retinal detachments during uncomplicated macular surgery affects visual recovery. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Topical Ketorolac in Vitreoretinal Surgery: A Prospective, Randomized, Placebo-Controlled, Double-Masked Trial

OBJECTIVE To evaluate the effects of topical ketorolac in patients undergoing vitreoretinal surgery. METHODS One hundred nine patients undergoing vitrectomies were randomized to receive either topical ketorolac tromethamine, 0.4%, or placebo. Patients were instructed to begin taking the study medication 3 days preoperatively (4 times daily) and to continue taking it 4 weeks postoperatively. MAIN OUTCOME MEASURES Intraoperative pupil diameter, postoperative day 1 pain and inflammation, 1-month postoperative retinal thickness, and preoperative and 1-month postoperative best-corrected visual acuities. RESULTS The difference in mean pupil diameters between patients using ketorolac and those taking placebo was 0.06 mm (P = .39). Patients taking ketorolac and those taking placebo had mean pain scores (scale, 1-10) of 0.24 (SD, 0.6) and 1.06 (SD, 2) (P = .03) and mean inflammation grades (grade, 0-4) of 0.59 (SD, 0.7) and 1.16 (SD, 0.9) (P < .001), respectively. Ketorolac reduced central subfield thickness by 8%, but this was not statistically significant. At 1 month, mean visual acuities improved to 0.40 logMAR units (mean Snellen, 20/50; SD, 0.28 logMAR units) in the ketorolac group from 0.83 logMAR units (20/150(+2); SD, 0.60 logMAR units) at baseline and to 0.67 logMAR units (20/100(+1); SD, 0.46 logMAR units) in the placebo group from 0.92 logMAR units (20/150(-2); SD, 0.62 logMAR units) at baseline (P = .001). CONCLUSIONS Topical ketorolac was well tolerated and safe, reduced postoperative pain and inflammation, and improved visual recovery in this prospective, double-masked trial. APPLICATION TO CLINICAL PRACTICE Topical ketorolac may benefit patients undergoing vitreoretinal surgery. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00576329.

Long-term results of primary transpupillary thermal therapy for the treatment of choroidal malignant melanoma

Background/aims: This is a long-term follow-up report investigating primary transpupillary thermal therapy (TTT) for choroidal melanoma. Methods: Retrospective case series of 135 patients harbouring choroidal melanoma treated with primary TTT. Patient demographics, tumour characteristics, treatment responses and complications, visual acuity outcomes and mortality data were captured and reported. A statistical analysis was performed for predictors of treatment failure. Results: Successful tumour regression was achieved in 76% of patients. Of the 32 patients who failed, 12 had enucleation, and 20 had irradiation. Metastatic disease has occurred in three patients, and two patients have died (3/135, or 2%). Multivariate analysis determined that tumour diameter, tumour thickness greater than 3 mm and tumours exhibiting high-risk characteristics were significant predictors of failure. Patient age, gender, number of treatments and proximity of the tumour to the disc or fovea were not predictive of failure. Kaplan–Meier cumulative probability predicted a 19% 5-year treatment failure and 33% 10-year treatment failure. Treatment failure occurred as late as 99 months. Final visual acuity was 20/40 or better in 50% of patients; 32% had a final visual acuity of 20/200 or worse. Thirty-two per cent of patients developed one or more complications as a result of the TTT, the most concerning of which was intra- or extrascleral extension of tumour (occurring in 11 patients). Conclusions: Though not as successful as radiation therapy, TTT successfully induced regression in 76% of patients. TTT may still have a role in our treatment paradigm but should probably be reserved for specific cases, such as monocular patients with tumours near critical visual structures, surgically unstable patients or patients with advanced diabetic retinopathy. All patients considering TTT as monotherapy for choroidal melanoma must be selected, counselled and followed appropriately.

Combination intravitreal triamcinolone injection and cryotherapy for exudative retinal detachments in severe Coats disease.

Intravitreal triamcinolone injection effectively reduces subretinal fluid in pediatric patients with exudative retinal detachments in severe Coats disease. However, when combined with cryotherapy, a large percentage of patients develop rhegmatogenous retinal detachments with proliferative vitreoretinopathy.

Incidence of Postvitrectomy Macular Edema Using Optical Coherence Tomography

OBJECTIVE To evaluate the incidence, effect on visual recovery, and predisposing risk factors of postvitrectomy macular edema (ME). DESIGN Prospective cohort study. PARTICIPANTS One-hundred nine eyes undergoing nonemergent vitrectomy surgery. METHODS Eyes were evaluated for postoperative day 1 inflammation, 1-month retinal thickness using optical coherence tomography, and preoperative and 1-month postoperative best-corrected visual acuity (BCVA). Macular edema was defined as central subfield thickness > or =272 microm. MAIN OUTCOME MEASURES Retinal thickness, inflammation, and BCVA. RESULTS Incidence of ME on optical coherence tomography was 47% (95% confidence interval [CI], 37%-56%). Mean 1-month visual acuity improved 3.3 lines (0.33 logarithm of minimum angle of resolution [logMAR] units) to 20/80(+1) (0.58+/-0.46 logMAR units) from 20/150(-2) (0.91+/-0.63 logMAR units) before surgery (P<0.001). Mean 1-month center point thickness (CPT), central subfield (CSF), and total macular volume were 265+/-107 microm, 288+/-94 microm, and 7.8+/-1.2 mm(3), respectively. Severity of postoperative inflammation predicted retinal thickness at 1 month (P<0.05). Intraoperative epinephrine use was associated with increased postoperative inflammation (P = 0.02). Eyes with greater reduction in CSF (or CPT) from baseline experienced more rapid visual recovery (r = -0.36; 95% CI, -0.61 to -0.06; P = 0.02). CONCLUSIONS Postvitrectomy ME is common and delays visual recovery. Degree of postoperative inflammation is an important risk factor for ME and, in this series, was increased in the setting of intraocular epinephrine. Efforts to reduce or prevent inflammation after vitrectomy should be beneficial and therefore are encouraged.

Vogt-Koyanagi-Harada-like syndrome after CTLA-4 inhibition with ipilimumab for metastatic melanoma.

Cytotoxic T-lymphocyte-associated antigen is a naturally occurring inhibitor of T-cell costimulation. Monoclonal antibody inhibition of cytotoxic T-lymphocyte-associated antigen with ipilimumab blocks this negative regulator of costimulation, promoting T-cell activation and survival, and leads to melanoma regression. Findings of the Vogt-Koyanagi-Harada (VKH) syndrome, an uveomeningitic syndrome that features neurological, auditory, ophthalmologic, and cutaneous involvement because of autoimmune targeting of melanocytic antigen, have rarely been described in association with melanoma immunotherapy. We describe a case of VKH-like syndrome in a 45-year-old HLA-A02-positive patient with metastatic melanoma treated with ipilimumab. Disruption of immune tolerance by ipilimumab led to melanoma remission while also inciting systemic and ophthalmic autoimmunity toward melanocytic antigen. These observations provide insight into the pathophysiology of the VKH syndrome, and the balance between tumor-associated tolerance and autoimmunity.

Primitive Neuroectodermal Tumor/Ewing Sarcoma of the Retina

An 11-year-old boy underwent enucleation of his left eye for an intraocular tumor. Examination showed a small, round blue cell tumor arising in the peripheral retina near the ciliary body. Immunohistochemical stain results were positive for neuron-specific enolase, synaptophysin, cluster of differentiation 99 (CD99), Friend leukemia integration 1, and CD56. Ultrastructural findings included occasional intracytoplasmic dense core granules. Polymerase chain reaction of the tumor showed a Ewing sarcoma/Friend leukemia integration gene fusion product. The tumor was classified as a primitive neuroectodermal tumor/Ewing sarcoma of the retina and should be distinguished from retinoblastoma. To our knowledge, this is the first case of primary primitive neuroectodermal tumor of the retina.

Fundus autofluorescence features in the inflammatory maculopathies

Purpose To describe the fundus autofluorescence (FAF) features of the inflammatory maculopathies and develop a quantification method for FAF analysis. Methods This is a retrospective, consecutive case series of patients with inflammatory maculopathies from two tertiary centers. The clinical findings, demographics, and FAF imaging characteristics were reviewed. Foveal autofluorescence (AF) was analyzed. Median and standard deviation (SD) of foveal AF intensity were measured. Results Thirty eyes of 15 patients were evaluated with both qualitative and quantitative FAF analysis. In acute macular neuroretinopathy, the active phase showed foveal hypoautofluorescence, which became hypoautofluorescent with resolution. In acute posterior multifocal placoid pigment epitheliopathy, multiple lesions with hypoautofluorescent centers with hyperautofluorescent borders were observed in active disease and became hypoautofluorescent with disease convalescence. In multifocal choroiditis and punctate inner choroiditis, the active hyperautofluorescent lesions progressed to inactive, hypoautofluorescent scars. Active serpiginous choroiditis showed hyperautofluorescent borders adjacent to a helicoid-shaped, hypoautofluorescent scar. Active unilateral acute idiopathic maculopathy (UAIM) showed a complex pattern of hypo- and hyperautoflourescence in the macula. The median foveal AF was the greatest in acute macular neuroretinopathy and UAIM among the maculopathies, while the greatest SD of foveal AF intensity was observed in UAIM. Conclusion The active phase of the majority of inflammatory maculopathies was characterized by hyperautofluorescent lesions. Increased SD of foveal AF correlated with a mixture of hypo-and hyperautoflourescence. Median and SD may be useful metrics in foveal AF and quantifiable values that may be assessed over time as a disease process evolves. Improvements in quantification methods of FAF imaging may allow us to objectively evaluate posterior uveitis.

Residual triamcinolone acetonide sequestered in the fovea after macular hole repair.

Purpose: To report the macular hole closure rate and visual outcomes of patients with residual triamcinolone acetonide in the fovea after macular hole repair. Methods: We reviewed the medical records of consecutive patients who underwent macular hole surgery at our institution between 2005 and 2008. Only patients with visible triamcinolone in the fovea in the first postoperative month were included. Results: Six patients with Stage III or IV macular holes were included. All patients underwent pars plana vitrectomy, internal limiting membrane peeling, and gas tamponade. Triamcinolone acetonide was used to visualize the vitreous in every patient, and diluted indocyanine green was used to stain the internal limiting membrane in five patients. The median preoperative best-corrected visual acuity was 20/200, which improved to a median of 20/40 at the last follow-up. Five patients eventually developed retinal pigment epithelial alterations. Anatomic hole closure was achieved in every patient. The mean follow-up was 23 months (range, 3-36 months). Conclusion: Residual triamcinolone sequestered in the fovea after macular hole surgery did not affect hole closure or prevent improvement in visual acuity. It is unclear whether the retinal pigment epithelial alterations in our patients represent toxicity or are unrelated to the triamcinolone exposure.

Intraocular T-cell Lymphoma: Clinical Presentation, Diagnosis, Treatment, and Outcome

ABSTRACT Purpose: To report on the clinical data of seven patients with T-cell intraocular lymphoma (IOL).Methods: Retrospective case series.Results: Seven immunocompetent patients, 12 eyes, 6 women, with T-cell-IOL were included from five countries. Mean age was 53.5 years (range: 25–82). Four patients had systemic-ocular lymphoma, two had CNS-ocular lymphoma, and one had systemic-CNS- ocular lymphoma. Vitritis was the most frequent clinical sign, followed by anterior uveitis and serous retinal detachment. Cytopathologic examination was performed on all ocular specimens (vitreous in six and iris mass biopsy in one patient). Adjunctive diagnostic procedures included immunohistochemistry, molecular tests, and cytokine profiling of vitreous samples. Treatment modalities included systemic chemotherapy (five patients), intravitreal methotrexate (three patients), globe radiotherapy, and intrathecal chemotherapy. Mean survival from diagnosis was 21.7 months (range: 2–69). Two patients are still alive.Conclusions: T-cell IOL has variable clinical manifestations and prognosis. Systemic involvement, SRD, and vitreoretinal involvement were frequently observed.