Devon H. Ghodasra

Worldwide Argus II implantation: recommendations to optimize patient outcomes.

BackgroundA position paper based on the collective experiences of Argus II Retinal Prosthesis System investigators to review strategies to optimize outcomes in patients with retinitis pigmentosa undergoing retinal prosthesis implantation.MethodsRetinal surgeons, device programmers, and rehabilitation specialists from Europe, Canada, Middle East, and the United States were convened to the first international Argus II Investigator Meeting held in Ann Arbor, MI in March 2015. The recommendations from the collective experiences were collected. Factors associated with successful outcomes were determined.ResultsFactors leading to successful outcomes begin with appropriate patient selection, expectation counseling, and preoperative retinal assessment. Challenges to surgical implantation include presence of staphyloma and inadequate Tenon’s capsule or conjunctiva. Modified surgical technique may reduce risks of complications such as hypotony and conjunctival erosion. Rehabilitation efforts and correlation with validated outcome measures following implantation are critical.ConclusionsBringing together Argus II investigators allowed the identification of strategies to optimize patient outcomes. Establishing an on-line collaborative network will foster coordinated research efforts to advance outcome assessment and rehabilitation strategies.

Safety and Feasibility of Quantitative Multiplexed Cytokine Analysis From Office-Based Vitreous Aspiration.

Purpose The goals of this study were to evaluate the safety of office-based vitreous sampling, and determine the utility of these samples with multiplex cytokine analysis. Methods Vitreous samples were collected from office-based needle aspiration and the rate of adverse events during follow-up was reviewed. The vitreous cytokine concentrations in a subset of patients with diabetic macular edema (DME) were analyzed using a 42 plex-cytokine bead array. These results were compared with vitreous cytokine concentrations in proliferative diabetic retinopathy (PDR) and controls (macular hole, epiretinal membrane, symptomatic vitreous floaters) from pars plana vitrectomy. Results An adequate volume of vitreous fluid (100–200 μL) was obtained in 52 (88%) of 59 office-based sampling attempts. The average length of follow-up was 300 days (range, 42–926 days). There were no complications, including cataract, retinal tear or detachment, and endophthalmitis. Two patients (3%) had posterior vitreous detachments within 3 months. Vitreous cytokine concentrations were measured in 44 patients: 14 controls, 13 with DME, and 17 with PDR. The concentration of ADAM11, CXCL-10, IL-8, and PDGF-A were higher in PDR compared with controls and DME. The concentration of IL-6 was higher in PDR compared with controls, but not compared with DME. Conclusions Office-based vitreous aspiration is safe and yields high-quality samples for multiplex vitreous cytokine analysis. Significant elevations of vitreous cytokines were found in PDR compared with DME and controls, including the novel finding of elevated ADAM11. As such, office-based aspiration is a safe and effective means to identify vitreous factors associated with vitreoretinal disease.

Posterior Polar Annular Choroidal Dystrophy

A young boy with a history of a ruptured left globe presented for evaluationofretinalatrophyintherighteye.Hehadnoocularconcerns, and there was no family history of eye disease. His visual acuity was 20/40ODby Snellen testing, and he had no light perceptionOS. He hadanormalanterior segment in therighteyeandenophthalmiaand phthisis in the lefteye.The findingsondilated fundusexaminationof the patient’s right eye are shown in the Figure. An ultrasonogram showedcomplex retinaldetachment in thepatient’s lefteye.Electroretinographicrod,combinedrod-cone,andconeresponsesoftheright eyewere highly reduced. The 32-Hz flicker response in the right eye showedahighlyreducedamplitudeanddelayedpeakimplicittime.The findingsonophthalmologicexaminationwereconsistentwithposterior polar annular choroidal dystrophy. Fundus examination findings of the patient’s mother showed no abnormalities in either eye. At a 6-monthfollowupappointment,thepatient’svisualacuityandappearance of his right funduswere unchanged.

CILIOCHOROIDAL EFFUSION and ACUTE MACULAR NEURORETINOPATHY ASSOCIATED with CERVICAL TRACTION THERAPY

Purpose: To report an unusual case of ciliochoroidal effusion and presumed acute macular neuroretinopathy associated with cervical traction therapy for the treatment of cervical spinal stenosis. Methods: Case report. Results: A 75-year-old man reported sudden onset of a wedge-shaped paracentral scotoma in the right eye. Fundus examination showed a ciliochoroidal effusion in the right eye. Optical coherence tomography revealed intraretinal fluid in both eyes without leakage on fluorescein angiography. B-scan ultrasonography and anterior segment ultrasound biomicroscopy of the right eye showed peripheral ciliochoroidal effusion. He had recently started intensive cervical traction therapy for the treatment of cervical spinal stenosis. There was spontaneous resolution of the choroidal effusion and intraretinal fluid after stopping cervical traction treatments. Optical coherence tomography imaging after resolution of the intraretinal fluid revealed thinning of the outer nuclear layer and attenuation of the ellipsoid and interdigitation zones corresponding to a persistent paracentral scotoma, consistent with acute macular neuroretinopathy. Conclusion: This is the first report of adverse ocular effects of cervical traction. We postulate that venous and arterial compromise during cervical traction therapy resulted in both ciliochoroidal effusion and a watershed infarct in the outer retina.

Retinal Prostheses: Clinical Outcomes and Potential Complications

In vitro experiments and animal studies first established the biocompatibility of retinal prostheses for the treatment of retinal degenerations such as retinitis pigmentosa. Early human studies further confirmed the feasibility of implantation. The clinical trial of the most studied retinal implant, the Argus II Retinal Prosthesis, has shown good long-term safety and reliability. The clinical outcomes of the Argus II clinical trial are reviewed. The most common complications arising from retinal prosthesis implantation are discussed. These include conjunctival erosion or dehiscence, hypotony, endophthalmitis, and retinal tear or detachment. Nonserious adverse events include macular thickening, epiretinal membranes, elevated intraocular pressure, and uveitis. For each complication, the signs and symptoms of presentation are reviewed. Critical components of the ocular examination to facilitate early diagnosis are identified. The risk of potential complications may be reduced with certain preoperative and intraoperative strategies. Strategies for management of complications associated with retinal implantation are reviewed. Retinal prosthesis implantation has the potential to improve the lives of patients with retinal degenerations. Outcomes from initial clinical trials have been promising but have also identified potential complications unique to the process of retinal implantation. Early diagnosis and appropriate management of complications can preserve the full potential of retinal prostheses.

Visual recovery after surgical repair of chronic macular detachment associated with peripheral retinoschisis

Purpose To report 2 cases of chronic macular detachment associated with peripheral retinoschisis in which surgical repair resulted in significant visual recovery. Observations A 44-year-old man and 60-year-old woman were evaluated for chronic macular detachment, with a duration of 5 years and 6 months, respectively. In each case, optical coherence tomography was used to establish a diagnosis of full-thickness macular detachment resulting from peripheral retinoschisis and to confirm or identify the pathogenic outer layer breaks. After surgical repair with pars plana vitrectomy, endolaser photocoagulation of outer layer breaks, and gas tamponade, both patients had significant improvement in vision. The best-corrected visual acuity improved from 20/50- to 20/20 at one year post-operatively in the first patient and from 20/1250 to 20/200 at 8 months post-operatively in the second. Conclusion and importance In cases of chronic schisis-detachment involving the macula, surgical intervention can sometimes result in unexpected levels of visual recovery.

POSTOPERATIVE ENDOPHTHALMITIS CAUSED by BOSEA thiooxidans

Purpose: To report an unusual case of postcataract endophthalmitis secondary to Bosea thiooxidans. Methods: Case report. Results: An 86-year-old man presented with postoperative endophthalmitis 3 weeks after uncomplicated cataract surgery. He complained of a headache and blurry vision but denied having eye pain. Slit-lamp examination demonstrated leukocytes with a fibrinous membrane in the anterior segment and vitritis. A diagnosis of acute postoperative endophthalmitis was made, and the patient was treated with intravitreal antibiotics. Culture of vitreous tap revealed Bosea thiooxidans, a gram-negative rod found in soil and water systems. Conclusion: To our knowledge, this report is the first to describe Bosea thiooxidans endophthalmitis and one of a few reports of human infection with this microbial agent.

Fungal Endophthalmitis Associated With DSAEK and Thermal Sclerostomy.

An 85-year-old man with remote thermal sclerostomy and Descemets stripping automated endothelial keratoplasty (DSAEK) in the right eye presented urgently for pain and blurred vision in that eye. Examination revealed bleb purulence and vitreous cellular aggregates concerning for endophthalmitis. Microscopy of a vitreous sample revealed yeast and pseudohyphae. He developed corneal infiltrates consistent with fungal infection. Therapy included topical, intravitreal, and systemic antifungals voriconazole and amphotericin. Fungal pathogens have very rarely been reported to cause bleb-associated endophthalmitis and should be considered in addition to bacterial pathogens. Vitreous aspiration should be performed in all cases of bleb-related endophthalmitis and include fungal studies. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:691-693.].

Bilateral BRVO in a patient with recurrent prostate cancer

Bilateral cases of branch retinal vein occlusions (BRVO) are infrequent and often related to systemic disease. A 72-year-old man with biochemical recurrence of prostate cancer was referred for decreased vision in his left eye. Fundus examination and fluorescein angiography disclosed bilateral BRVO with patches of peripheral non-perfusion and macular oedema in the left eye. A systemic work up revealed elevated fibrinogen and reduced free protein S antigen, consistent with an underlying hypercoagulable state. Cancer is a well-known cause of hypercoagulability. We report the first case of bilateral BRVO related to biochemical recurrence of prostate cancer and a proven coagulation derangement.