Jeremy D. Wolfe

RESOLUTION OF SUBRETINAL FLUID AND OUTER RETINAL CHANGES IN PATIENTS TREATED WITH OCRIPLASMIN.

Purpose: To evaluate the aftermarket efficacy of ocriplasmin for vitreomacular adhesion (VMA) and identify the frequency and duration of structural changes on optical coherence tomography. Methods: The authors conducted a retrospective case series of 36 eyes treated with ocriplasmin for symptomatic VMA at a single center between February 2013 and September 2013. Eyes were evaluated for release of VMA at 1 month postinjection, preinjection adhesion size, postinjection closure of macular hole, presence of subretinal fluid after release of adhesion, size of subretinal fluid, outer retinal structural change, and visual acuity at 1 month, 6 months, and 1 year. Results: Fifteen eyes (42%) had complete release of VMA at 1 month postinjection, and 78% of eyes had closure of the macular hole. Eyes that did not have an epiretinal membrane that had a smaller initial adhesion size and a smaller macular hole size were more likely to have complete release of VMA. Subretinal fluid was present after release in 73.3% of treated eyes, and ellipsoid zone changes were present in 66.7% of treated eyes. At the end of 1 year, complete resolution of subretinal fluid occurred in 87% of treated eyes with only trace subretinal fluid remaining in 2 eyes. Complete resolution of ellipsoid zone changes was found in all eyes. Best-corrected visual acuity improved throughout the first year after treatment. Conclusion: Ocriplasmin is effective in the treatment of patients with symptomatic VMA. Results can be improved with patient selection based on specific criteria. Subretinal fluid and ellipsoid zone changes are common after treatment but mostly resolve over 1 year.

Central serous chorioretinopathy in patients receiving exogenous testosterone therapy.

Purpose: To report an association between central serous chorioretinopathy (CSCR) and exogenous testosterone therapy. Methods: This is a retrospective case series from two institutions. Patients who presented with fluorescein angiography and optical coherence tomography findings consistent with CSCR were included. All patients were concurrently being treated with exogenous testosterone therapy and lacked other known risk factors for CSCR. Results: Nine patients presented with CSCR after beginning exogenous testosterone therapy. Two patients stopped therapy with resolution of symptoms and subretinal fluid. Conclusion: Exogenous testosterone may be an independent risk factor for the development of CSCR.

Hybrid 25- and 27-Gauge Vitrectomy for Complex Vitreoretinal Surgery.

BACKGROUND AND OBJECTIVE The authors report the technique of using the 27-gauge (G) vitreous cutter through 25-G valved cannulas to allow hybrid instrumentation of both gauges. PATIENTS AND METHODS Vitrectomy is initiated with standard placement of 25-G valved cannulas, followed by insertion of a 27-G vitreous cutter through the 25-G cannulas. RESULTS The hybrid procedure emphasizes the advantages of both platforms: The 25-G cutter is more efficient for core vitrectomy and is more rigid to facilitate peripheral vitrectomy; the 25-G platform enjoys a wider armamentarium of instrumentation options; and the smaller profile of the 27-G cutter can be maneuvered more easily into tight surgical planes to act analogous to vertical scissors, with the added benefits of aspiration and spatula-like features. The authors illustrate this technique in three cases: diabetic tractional retinal detachment with dense plaques, posterior stage 4B retinopathy of prematurity, and sutureless scleral fixation of an intraocular lens. CONCLUSIONS Hybrid use of the 25-G and 27-G platforms offers greater versatility for the management of complex vitreoretinal conditions.

Multimodal Imaging Of West Nile Virus Chorioretinitis

Purpose: To report the results of multimodal imaging of West Nile virus chorioretinitis. Methods: Three patients with West Nile virus chorioretinitis were evaluated by color fundus photography, fluorescein angiography, enhanced depth optical coherence tomography, indocyanine green angiography, and fundus autofluorescence. Results: Imaging results demonstrate outer retinal and retinal pigment epithelial involvement with inner retinal sparing. Conclusion: Multiple fundus imaging modalities used during the diagnosis of West Nile chorioretinitis are consistent with outer retinal and pigment epithelial changes, suggesting outer retina and retinal pigment epithelium as the primary sites of ocular involvement.

Incidence and clinical features of post-injection endophthalmitis according to diagnosis

Purpose To compare the incidence and clinical features of endophthalmitis after intravitreal antivascular endothelial growth factor (VEGF) therapy for diabetic eye disease, neovascular age-related macular degeneration (AMD) and retinal vein occlusion (RVO). Methods Multicentre, retrospective, consecutive case–control study. All patients treated with intravitreal bevacizumab, ranibizumab or aflibercept for diabetic eye disease, neovascular AMD or RVO between 1 January 2009 and 30 September 2013 at three retina practices were included in this study. The total number of anti-VEGF injections administered for the three indications was calculated using billing records. Endophthalmitis cases were identified using both endophthalmitis log sheets and billing records. Patient charts were reviewed to confirm that endophthalmitis was directly related to anti-VEGF injection and to record clinical features and culture results. Results During the study period, a total of 353 978 intravitreal anti-VEGF injections were performed. Presumed infectious endophthalmitis occurred in 119 of 296 017 injections performed for neovascular AMD (1/2487, 0.040%), 12 of 24 541 for diabetic eye disease (1/2045, 0.049%) and 4 of 32 418 for RVO (1/8104, 0.012%). χ2 analysis found endophthalmitis rates to be higher in diabetic eye disease compared with RVO (p=0.010) and higher in neovascular AMD compared with RVO (p=0.014), while diabetic eye disease and neovascular AMD (p=0.517) had similar rates. The average age of the overall neovascular AMD patient population (81.9 years) was significantly older than the diabetic eye disease (64.7 years, p<0.001) and RVO (73.4 years, p<0.001) populations. Conclusions Endophthalmitis rates appear to be lower in eyes with RVO compared with diabetic eye disease and neovascular AMD, possibly due to impaired immunity in diabetics and waning immunity in the generally older AMD population.

Sutureless Intrascleral Fixation of Secondary Intraocular Lens Using 27-Gauge Vitrectomy System

Transconjunctival sutureless intrascleral fixation is an important surgical option for secondary intraocular lens (IOL) implantation. In this report, the authors describe the technique of using a 27-gauge platform to perform pars plana vitrectomy, lensectomy, and sutureless scleral IOL fixation in a patient with crystalline lens dislocation secondary to Marfans syndrome. Case report and detailed description of the surgical technique are discussed.

Short-term Efficacy of Intravitreal Dexamethasone Implant in Vitrectomized Eyes with Recalcitrant Diabetic Macular Edema and Prior Anti-VEGF Therapy

Purpose: To determine the efficacy of an intravitreal dexamethasone implant (IDI) for diabetic macular edema (DME) in vitrectomized eyes. Methods: This interventional retrospective consecutive case series included vitrectomized eyes undergoing IDI placement for treatment of recalcitrant DME between June 2011 and June 2014. All patients had previously received anti-VEGF therapy (ranibizumab or bevacizumab). Primary endpoints were changes in visual acuity (VA) and central retinal thickness (CRT) from baseline values one month after device implantation. Secondary endpoints were VA and CRT changes at 3 months. Results: A total of 8 eyes of 8 patients met the inclusion criteria. One month after IDI placement, there was a significant (p = 0.01) improvement in VA from 0.79 ± 0.52 logMAR (20/123 Snellen equivalent) to 0.64 ± 0.55 logMAR (20/88), meanwhile CRT improved from 455.75 ± 123.19 to 295.00 ± 90.39 μm (p = 0.02). These findings persisted at 3 months. Conclusion: In vitrectomized eyes previously treated with anti-VEGF agents for recalcitrant DME, implantation of the IDI appears to be efficacious in improving VA and CRT at 1-month with the observed benefits persisting for at least for 3 months.

Vitrectomy After ocriplasmin for VitreOmacular adhesion Or Macular hole (VAVOOM) study

Background/aims To describe the results of pars plana vitrectomy (PPV) for persistent symptomatic vitreomacular traction (VMT) with or without macular hole (MH) after intravitreal ocriplasmin injection. Methods Multicentre retrospective study of eyes that received intravitreal ocriplasmin between January 2013 and January 2014 for symptomatic VMT with or without MH, and then went on to PPV (ocriplasmin-treated group) for persistent pathology, compared with a control group of patients with symptomatic VMT with or without MH who were offered ocriplasmin injection but proceeded directly to PPV (PPV-only group). Intraoperative characteristics, visual acuity (VA) outcomes and spectral-domain optical coherence tomography images were reviewed for the two groups. Primary outcome measure was VA after PPV. Results 51 eyes of 51 patients underwent PPV after receiving ocriplasmin, and 22 eyes of 22 patients proceeded directly to PPV. Although VA was significantly better at all time points in the PPV-only compared with the ocriplasmin-treated group, at 3 and 6 months after PPV both groups had similar amount of visual improvement. Both groups had similar rates of pathology resolution; 50/51 (98%) eyes in the ocriplasmin group and 22/22 (100%) eyes in the PPV-only group had release of VMT and/or MH closure after PPV. The two groups had similar PPV-related complication rates. Conclusions Eyes with persistent symptomatic VMT and/or MH have similarly high rates of pathology resolution as well as similar VA gains regardless of whether they received ocriplasmin prior to PPV.

WIDEFIELD FLUORESCEIN ANGIOGRAPHY IN PATIENTS WITHOUT PERIPHERAL DISEASE: A Study of Normal Peripheral Findings.

Purpose: Widefield photography and angiography provide access up to 200-degrees of the retinal periphery. The range of normal peripheral findings has not been characterized, yet is relevant to studies addressing putative peripheral retinal vascular pathology. Methods: This study was an observational retrospective cohort study. Adult patients with epiretinal membrane or choroidal nevi who underwent imaging with Optos 200 MA/200Tx were included. Dye transit times, peripheral arteriovenous shunting, presence of vessels crossing the horizontal raphe, right angle vessels, terminal networks, absence of capillary detail, ground glass hyperfluorescence, peripheral drusen, and microaneurysms were evaluated. Results: Fifty-eight eyes of 31 patients met inclusion criteria. Mean peripheral arterial filling time was 8.65 ± 2.54 seconds (range 3–15 seconds). One or more peripheral anomalies were noted in all patients (P < 0.01). The prevalences of findings were: arteriovenous shunting (0.00%), vessels crossing the horizontal raphe (44.83%), right angle vessels (70.69%), terminal networks (77.59%), absence of capillary detail (98.28%), ground glass hyperfluorescence (87.93%), drusen (34.48%), and microaneurysms (41.38%). Conclusion: There was a high prevalence of peripheral vascular anatomic variations in eyes expected to have normal peripheral retinal vasculature. These findings may provide a reference for future studies addressing putative pathologic peripheral angiographic findings.

Electroretinographic Effects of Omega-3 Fatty Acid Supplementation on Dry Age-Related Macular Degeneration

OBJECTIVES To evaluate the effects of high-dose oral omega-3 fatty acid supplementation on electroretinography and omega-3 index in patients with dry age-related macular degeneration. DESIGN Single institution, prospective, nonrandomized, noncomparative interventional case series comprising 34 eyes of 17 patients older than 50 years of age with early to intermediate age-related macular degeneration. Patients received oral supplementation with 4 g of omega-3 fatty acids daily (840 mg eicosapentaenoic acid/2520 mg docosahexaenoic acid) for 6 months. The main outcome measures included Early Treatment Diabetic Retinopathy Study best-corrected visual acuity, change in N1 and P1 peak amplitudes on multifocal electroretinographic testing, and change in serum omega-3 index. RESULTS Mean baseline Early Treatment Diabetic Retinopathy Study best-corrected visual acuity letter score was 77 letters (Snellen equivalent of 20/32). There were no statistically significant changes in visual acuity (P = .12) or retinal function by multifocal electroretinographic testing. Serum omega-3 index increased by an average of 7.6% during the course of the study (P < .001). Study limitations included the relatively short duration of the study and small number of participants. CONCLUSIONS Short-term supplementation with high doses of omega-3 fatty acids does not result in any measurable changes in visual acuity or retinal function by multifocal electroretinographic testing. Dietary supplementation with 4 g of omega-3 fatty acids results in a significant increase in serum omega-3 index in patients with dry age-related macular degeneration and may provide a useful clinical measure for future studies. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01258335.