H. Matthew Wheatley

A novel approach for posterior chamber intraocular lens placement or rescue via a sutureless scleral fixation technique.

The approach to intraocular lens (IOL) implantation in an eye with insufficient capsular support continues to present a unique surgical challenge. A report from the American Academy of Ophthalmology Ophthalmic Technology Assessment group reviewed the standard approaches to this surgical problem (anterior chamber IOL, scleral sutured posterior chamber IOL [PCIOL], and iris fixated PCIOL) and did not identify compelling data to recommend one technique over another. However, each approach has well-known liabilities. Anterior chamber IOL placement may increase the risk of developing glaucoma, intraocular inflammation, and corneal decompensation. Suture degradation and breakage with subsequent IOL dislocation may occur in cases of suture fixation to both the iris and the sclera. In an effort to create a minimally invasive approach that could improve surgical outcomes, we developed a technique that allows for ciliary sulcus–based scleral fixation of a PCIOL without the use of sutures scleral flaps or fibrin glue. This approach may modify the incidence of complications secondary to anterior chamber IOL placement and the risk of IOL malposition secondary to suture rupture. We significantly modified an anterior segment technique in a manner that takes advantage of the surgical instrumentation and skill set of the posterior segment surgeon. Through these modifications, we have been able to achieve a reliable and reproducible surgical procedure that can be performed both for the rescue of a dislocated IOL and for the implantation of a secondary IOL. The technique allows for permanent scleral fixation of the polypropylene haptics of a three-piece IOL directly into the sclera, thus obviating the need for suturing and achieving a position in the ciliary sulcus.

One-year outcomes of eyes treated with a sutureless scleral fixation technique for intraocular lens placement or rescue.

Purpose: To report the 1 year results of a novel surgical technique for sutureless scleral fixation of a 3-piece intraocular lens. Methods: Retrospective consecutive series of patients who underwent sutureless scleral fixation of a three-piece intraocular lens. All patients were required to have at least 1 year of follow-up to be included in the series. Outcomes data were obtained and treated with simple statistical analyses. Results: A total of 24 patients were included in the study population. The average age was 75 years (range, 44–87). Short-term complications were few and included vitreous hemorrhage (n = 2), elevated intraocular pressure (n = 1), and hypotony (n = 1). Long-term complications included intraocular lens dislocation (n = 3) and cystoid macular edema (n = 1). Mean visual acuity improved from logMAR 1.30 (Snellen 20/399) to 0.52 (Snellen 20/66) at 1 year. Conclusion: This novel technique for sutureless scleral fixation of a three-piece intraocular lens was well-tolerated 1 year after surgery.

Post-Marketing Survey of Adverse Events Following Ocriplasmin

BACKGROUND AND OBJECTIVE To study the post-marketing safety profile of ocriplasmin (Jetrea; ThromboGenics, Iselin, NJ) as experienced by retinal physicians in the United States. STUDY DESIGN/MATERIALS AND METHODS Two thousand four hundred sixty-five retinal physicians were surveyed regarding their frequency of use of ocriplasmin and reports of ocular adverse events. RESULTS There were 270 respondents (11%) who reported treating 1,056 eyes with ocriplasmin. The reports of adverse events (AE) were as follows: acute decline in visual acuity (16.95%), development of submacular fluid or serous retinal detachment (10.23%), dyschromatopsia (9.09%), progression of vitreomacular traction to macular hole (8.71%), development of retinal detachment (2.65%), development of retinal tear (1.99%), development of afferent pupillary defect (1.80%), electroretinography abnormalities (0.57%), crystalline lens instability (0.38%), and vasculitis (0.28%). CONCLUSION Although the frequency of some ocular AEs reported in this study are comparable to those reported in the phase 3 registration trials, additional phase 4 safety studies are warranted to better understand the pathophysiology and clinical relevance of ocular AEs of ocriplasmin.

Frequency and characteristics of intraocular inflammation after aflibercept injection.

Purpose: To report the frequency and characteristics of intraocular inflammation after intravitreal aflibercept injection. Methods: A single-center retrospective study was performed in patients who received intravitreal aflibercept from November 2011 through June 2013. Results: There were 28 cases of intraocular inflammation after a total of 5,905 aflibercept injections among 1,660 patients. The mean baseline acuity was 20/57, which decreased to 20/179 at diagnosis (P < 0.0001) but recovered to 20/59 at Month 1, 20/57 at Month 3, and 20/52 at Month 6 (P = not significant). Vitreous culture and injection of antibiotics were performed in eight cases, and all were culture negative; the remainder received only topical corticosteroids. Conclusion: The frequency of inflammation after aflibercept was 0.47% per injection. Visual acuity and inflammation returned to baseline within 1 month in most cases with topical corticosteroid treatment.

Age-Related Hyperplasia of the Nonpigmented Ciliary Body Epithelium (Fuchs Adenoma) Simulating a Ciliary Body Malignant Neoplasm

4. Jakobiec FA, Buckman G, Zimmerman LE, et al. Metastatic melanoma within and to the conjunctiva. Ophthalmology. 1989;96(7):999-1005. 5. Kiratli H, Shields CL, Shields JA, De Potter P. Metastatic tumours to the conjunctiva: report of ten cases. Br J Ophthalmol. 1996;80(1):5-8. 6. Kwapiszeski BR, Savitt ML. Conjunctival metastasis from a cutaneous melanoma as the initial sign of dissemination. Am J Ophthalmol. 1997;123(2): 266-268. 7. Shields JA, Shields CL, Eagle RC Jr, Raber I. Conjunctival metastasis as initial sign of disseminated cutaneous melanoma. Ophthalmology. 2004;111 (10):1933-1934. 8. Gausas RE, Daly T, Fogt F. D2-40 expression demonstrates lymphatic vessel characteristics in the dural portion of the optic nerve sheath. Ophthal Plast Reconstr Surg. 2007;23(1):32-36.

A novel approach for rescuing and scleral fixating a posterior dislocated intraocular lens/bag complex without conjunctival opening.

A Novel Approach For Rescuing And Scleral Fixating a Posterior Dislocated Intraocular Lens/Bag Complex Without Conjunctival Opening Eyes in which a posterior chamber intraocular lens (IOL) completely dislocates into the posterior segment, while remaining completely within the capsular bag, present a unique surgical challenge. Traditionally, there have been two techniques to fix this problem. One method involves removing the lens/bag complex and replacing it with a secondary IOL. Alternatively, the second method entails explanting the lens from the bag complex, followed by a repositioning of the dislocated lens. A report from the American Academy of Ophthalmology Ophthalmic Technology Assessment group reviewed the standard approaches to secondary IOL placement in the absence of adequate capsular support (anterior chamber IOL, scleral sutured posterior chamber IOL, and iris fixated posterior chamber IOL) and did not identify compelling data to recommend one technique over another. We present a novel procedure that allows for suture fixation of the lens/bag complex without the need for manipulating the conjunctiva. Our approach uses a number of anterior segment techniques that have been previously described. We have combined those techniques with an approach that takes advantage of the surgical instrumentation and the skill set of the posterior segment surgeon. Through these modifications, we have been able to achieve a reliable and reproducible operation that allows for rescue of a posteriorly dislocated lens/bag complex with permanent scleral fixation in the ciliary sulcus. Technique

ONE-YEAR OUTCOMES OF A NOVEL TECHNIQUE FOR RESCUING AND SCLERAL FIXATING A POSTERIOR DISLOCATED INTRAOCULAR LENS-BAG COMPLEX WITHOUT CONJUNCTIVAL OPENING (HOFFMAN POCKETS).

Purpose: To present the 1-year follow-up of a novel surgical technique that allows for suture fixation of a posteriorly dislocated lens–bag complex without the need for conjunctival incision. Methods: A retrospective chart review of 19 patients who underwent posterior chamber intraocular lens rescue using the novel surgical technique was performed. Data were collected 1 year after surgery for all patients. Results: Average preoperative vision was 20/500, whereas 3 months and 12 months postoperatively, the vision was 20/65 and 20/54, respectively. Three of 15 eyes had decentration of the sutured intraocular lens, 2 of which required additional surgical repair. Conclusion: Outcome data at 1 year support this novel technique as a viable option for the surgical repair of a dislocated lens–capsular bag complex.

Incidence of steroid-induced ocular hypertension after vitreoretinal surgery with difluprednate versus prednisolone acetate.

Purpose: To identify changes in intraocular pressure (IOP) after vitreoretinal surgical procedures in eyes that received either difluprednate ophthalmic emulsion 0.05% (DP) or prednisolone acetate ophthalmic suspension 1% (PA). Methods: A retrospective chart review compared a consecutive series of 100 patients who received DP with 100 patients who received PA after vitreoretinal surgery. Data were collected for a 3-month period from the time of surgery. Results: A significantly higher number of patients treated with DP (35%, n = 35) developed increased IOP (>21 mmHg with a change from baseline of >10 mmHg) compared with those receiving PA (22%, n = 22) (P = 0.042). The mean maximum IOP in the DP cohort (26.7 mmHg) was significantly higher than that in the PA cohort (22.8 mmHg) (P = 0.0027). Additionally, the rise in IOP from baseline was significantly higher in the DP-treated cohort (9.0 mmHg) than that in the PA-treated cohort (6.0 mmHg) (P = 0.027). Conclusion: Eyes treated with DP after vitreoretinal surgery were at increased risk for developing clinically significant increases in IOP compared with those receiving PA.

Recurrent Vitreous Hemorrhage Secondary to Sulcus Positioning of a One-Piece Acrylic Intraocular Lens Haptic: Report of 3 Cases and Management With Retrocapsular Haptic Repositioning:

Three pseudophakic patients presented with recurrent, unilateral vitreous hemorrhage, one of which also had uveitis, glaucoma, and hyphema, consistent with “uveitis–glaucoma–hyphema (UGH)-Plus” syndrome. Arcuate transillumination defects secondary to inadvertent placement of 1 intraocular lens (IOL) haptic in the sulcus were identified in each case. The second haptic and optic were located in the capsular bag. The IOLs were all single-piece foldable acrylic lenses with square-edge haptic design. Surgical repositioning of the malpositioned haptic from the sulcus to the retrocapsular space resulted in the resolution of the recurrent vitreous hemorrhage. This series highlights the fact that recurrent vitreous hemorrhage secondary to iris chafing, with or without UGH, may occur in cases where a square-edge IOL haptic is placed in the sulcus. Vitrectomy with repositioning of the malpositioned IOL is a simple alternative to IOL exchange in these cases.