Christina Y. Weng

Self-Induced Laser Maculopathy in an Adolescent Boy Utilizing a Mirror

Laser maculopathy is a rare complication that can occur when a beam of laser light is focused directly on the macula. This report describes the first published case of self-induced laser pointer maculopathy that was secondary to laser beam reflection from a mirror. The patient demonstrated both visual and anatomic recovery during the follow-up period. In addition, the issue of discrepancy between the labeled and actual power of laser pointers is addressed.

Adjunct Intravitreous Triamcinolone Acetonide in the Treatment of Diabetic Macular Edema with Anti-VEGF Agents

Aims. To compare visual and anatomic outcomes of adjunct intravitreous (IVT) triamcinolone acetonide to antivascular endothelial growth factor (VEGF) injections to IVT anti-VEGF injections alone for center-involving diabetic macular edema (DME) in treatment-naïve eyes. Methods. Retrospective study of treatment-naïve eyes with center-involving DME. The primary outcome was the change in best corrected visual acuity (BCVA) in eyes receiving only IVT anti-VEGF (group 1) and eyes receiving IVT anti-VEGF and adjunct IVT-TA (group 2). Results. Included were 192 eyes. The mean change in BCVA was +3.5 letters in group 1 compared to −3.5 letters in group 2 (p = 0.048). Final macular thickness improved by −94 μm in group 1 versus −68 μm in group 2 (p = 0.26). In group 1, 5/150 eyes compared to 9/42 eyes in group 2 (3.3% versus 21%, p = 0.0005) had a IOP >10 mmHg increase. Six of 126 phakic eyes in group 1 versus 12/33 phakic eyes in group 2 underwent cataract surgery (4.7% versus 36.3%, p = 0.00009). Conclusions. IVT-TA results in no additional benefit in eyes treated with anti-VEGF agents for DME.

Subthreshold Micropulse Laser Photocoagulation in the Management of Central Serous Chorioretinopathy.

Central serous chorioretinopathy (CSCR) is a condition characterized by a serous neurosensory detachment, with or without retinal pigment epithelial (RPE) detachment, and is typically associated with one or more leakage points in the choriocapillaris that lead to fluid accumulation in the subretinal space. It is primarily seen in young healthy males in the fourth or fifth decades of life, but can also affect elderly patients. Although there is no clear racial predilection, it is thought to be more common in whites, Asians, and Hispanics. CSCR classically presents unilaterally and is characterized by blurred vision; other symptoms include metamorphopsia, relative central scotoma, micropsia, mild dyschromatopsia, and reduced contrast sensitivity. A diagnosis of CSCR can be made using a combination of clinical history, ophthalmoscopic examination, enhanced-depth imaging optical coherence tomography (OCT), fluorescein angiography (FA), and indocyanine green angiography (ICGA). Biomicroscopic examination typically reveals the presence of a serous detachment of the neurosensory retina in the posterior pole. Enhanced-depth imaging OCT may assist in confirming the location and quantity of subretinal fluid, as well as demonstrating a thickening of the underlying choroid which is a hallmark finding in CSCR. FA often shows a single focal area of leakage at the level of the RPE, although multiple foci can be observed, especially in atypical or recurrent cases. Although it seems that the choroid, RPE, and hormonal factors all play a role in the pathogenesis of CSCR, its etiology remains unknown.

Visual and anatomical outcomes of macular epiretinal membrane peeling after previous rhegmatogenous retinal detachment repair.

Purpose: To report outcomes and prognostic factors after epiretinal membrane peeling in patients with previous rhegmatogenous retinal detachment repair. Methods: A consecutive case series. Best-corrected visual acuity and optical coherence tomography characteristics were analyzed before and after epiretinal membrane surgery. Results: Fifty-three eyes were analyzed. Best-corrected visual acuity improved by a mean of 10 letters at 1 month (N = 45; P = 0.001), 15 at 3 months (N = 42; P < 0.001), 11 at 6 months (N = 35; P = 0.001), and 16 at 12 months (N = 33; P < 0.001). The mean optical coherence tomography central foveal thickness decreased by 141 (N = 22; P < 0.001), 185 (N = 24; P < 0.001), 180 (N = 17; P = 0.001), and 151 &mgr;m (N = 9; P = 0.017) at 1, 3, 6, and 12 months, respectively. Better preoperative best-corrected visual acuity correlated with better best-corrected visual acuity at all follow-up visits (P ⩽ 0.001). Intact preoperative inner segment/outer segment junction and external limiting membrane line, but not the change in central foveal thickness or location of fluid, correlated with better postoperative best-corrected visual acuity through 6 months. Conclusion: Epiretinal membrane peeling after previous rhegmatogenous retinal detachment repair resulted in significant improvements in visual acuity and optical coherence tomography thickness, even in eyes with previous macula-involving rhegmatogenous retinal detachment. Better preoperative visual acuity and intact outer retinal layers by optical coherence tomography were the main prognostic factors for visual outcomes.

Ocriplasmin and its role in the management of vitreoretinal interface disorders.

The vitreous gel has an outer cortex consisting primarily of type II collagen that is attached to the internal limiting membrane (ILM) consisting primarily of type IV collagen. The vitreous plays a central role in many common and potentially blinding diseases such as diabetic retinopathy, proliferative vitreoretinopathy, and vitreomacular interface disorders; the latter will be the focus here. The development of a posterior vitreous detachment is a natural process that occurs typically after the age of 50 years. However, sometimes the posterior hyaloid face does not detach completely and there are focal areas that remain attached to the macula. This is a condition known as vitreomacular adhesion (VMA). In a recent noncomparative case series of 106 eyes with symptomatic idiopathic VMA, spontaneous release of VMA occurred in 34% of eyes during the mean study follow-up period of 23 months. In the cases where VMA does not resolve on its own, traction on the retina may develop, leading to subsequent anatomic distortion; although the terminology is not universally accepted, this anatomic distortion on OCT in the setting of VMA is referred to as vitreomacular traction (VMT). If left untreated, VMT can sometimes progress into a sight-threatening condition where patients can experience decreased visual acuity, metamorphopsia, and scotomas; full-thickness macular holes can also form as a result of VMT. In a retrospective analysis of 53 consecutive symptomatic eyes with untreated VMT, Hikichi et al found that 64% of eyes experienced a decrease in visual acuity of Z2 Snellen lines after a

Retinal imaging in perimacular degenerative retinoschisis

Macula-threatening degenerative retinoschisis is a rare clinical problem. In the current report, imaging of three patients with asymptomatic and nonprogressive retinoschisis is presented. The visual and anatomic findings have remained stable during follow-up.

When and How to Incorporate Steroids for Persistent Diabetic Macular Edema: A Discussion of Real-World Treatment Optimization Strategies

In the United States, diabetic macular edema (DME) is the leading cause of vision loss among people with diabetic retinopathy. Despite the availability of different therapies for DME, up to half of patients with DME show some persistent edema after anti-vascular endothelial growth factor (VEGF) treatment alone, leaving these patients at high risk for vision loss. However, dosing in a similar fashion to that of pivotal anti-VEGF trials is difficult because of real-life challenges faced in clinical practice. This is particularly true for DME, in that the frequency and burden of anti-VEGF injections are a major challenge to patient care. Research evaluating anti-VEGF therapies has shaped the treatment paradigms for patients with DME, and similar benefits have also been noted in clinical trials evaluating the use of intravitreal steroids. Treatment with a long-term intravitreal corticosteroid, which requires fewer injections than treatment with most short-acting therapies, has been found to reduce inflammation and improve vision in a percentage of patients. This roundtable discussion, which took place during the 2018 annual meeting of the Vit-Buckle Society, reviews the current treatment paradigms for DME and evaluates how to customize and optimize treatment strategies geared toward individualized patient care. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:S5-S15.].

The Emergence of Telemedicine in Retina.

The word ‘‘teleophthalmology’’ is derived from the Greek root tele meaning ‘‘distance’’ and ophthalmology referring to the branch of medicine involving the structure, function, and pathology of the eye. Teleophthalmology is a subgroup of telemedicine, which involves the investigation, monitoring, and treatment of patients’ medical problems when a barrier exists between the patient and physician. Telemedicine has been effectively used in multiple areas such as monitoring chronic heart failure and multiple respiratory conditions. It has also proven therapeutic in computer-based smoking cessation programs, telepsychiatry, and home care for diabetes, heart disease, and chronic obstructive pulmonary disease. The first application of telemedicine to ophthalmology occurred in 1987 on the space shuttle Columbia at the Johnson Space Center in Houston, TX. In an effort to monitor retinal vessels during space flight, the National Aeronautics and Space Administration (NASA) developed a system to transmit real-time retinal images from space to Earth via portable video funduscopy. This NASA-developed process of image acquisition, storage, display, and transmission became the foundation upon which the future of teleophthalmology was based. There is now, more than ever, a significant need for teleophthalmology. Diabetic retinopathy (DR) is currently a leading cause of newly diagnosed blindness in working-aged adults in the United States. The International Diabetes Federation estimates that 8.3% of adults worldwide (approximately 382 million people) have diabetes, and this number is estimated to rise to 592 million in the next 2 decades. As the American Diabetes Association and the American Academy of Ophthalmology

The Evolution of Pars Plana Vitrectomy to 27-G Microincision Vitrectomy Surgery

The pars plana vitrectomy (PPV) has undergone extensive transformation since its origination approximately 45 years ago. Perhaps the most drastic changes that have led to the advent of modern-day vitrectomy have occurred predominantly within the last 2 decades; these have drastically improved the prognosis for many retinal diseases. The PPV procedure represents the core of vitreoretinal surgical management and is the basis of repair for a multitude of pathologies including retinal detachment, macular hole, vitreomacular traction, epiretinal membrane (ERM), vitreous biopsy, intraocular foreign body, endophthalmitis, vitreous hemorrhage, intraocular lens (IOL) exchange, and retrieval of dropped lens nucleus. The evolution of surgical techniques and instrumentation in PPV has allowed present-day retinal surgeons to perform vision-saving procedures in a less invasive and less risky way. Modern PPV was first developed in 1970 by Machemer during a period when vitreous opacities, retinal detachments, and vitreoretinal scarring posed a great challenge to ophthalmologists. His invention, known as the vitreous infusion suction cutter, was developed after early cataract surgeons had successfully shown that removal of vitreous was safe and well-tolerated. The vitreous infusion suction cutter was a 17-G (1.42 mm diameter) single-port instrument with combined infusion, suction, and cutting abilities that entered the vitreous cavity through a 2.3-mm sclerotomy. Initially, there was an external source of illumination, but the integration of intraocular fiberoptic illumination soon took place in 1974. Techniques were practiced on eyes considered nonoperable at the time, which consisted mainly of diabetic patients with vitreous hemorrhage and tractional bands with or without retinal detachment. By 1974, bimanual techniques involving scissors and

Intravitreal Steroid Implants in the Management of Retinal Disease and Uveitis.

Steroids have been successfully used for the treatment of noninfectious intermediate uveitis, posterior uveitis, and panuveitis as well as for the treatment of a number of retinal diseases, including diabetic macular edema (DME), macular edema (ME) due to retinal vein occlusion (RVO), cystoid macular edema (CME) due to Irvine-Gass syndrome, retinitis pigmentosa (RP), and radiation retinopathy. The ideal steroid for treating uveitis and retinal disease would penetrate the blood-retinal barrier, have a long duration of action after a single administration while avoiding systemic and intraocular side effects, and be affordable to health care payers (patients, insurance companies, government entities). Topical, systemic, periocular, and intravitreal (IVT) steroids are available, but fall short of the ideal described above.