Kyle V. Marra

Angiogenic and Inflammatory Vitreous Biomarkers Associated With Increasing Levels of Retinal Ischemia.

PURPOSE To characterize the angiogenic and inflammatory vitreous biomarker profiles in a spectrum of ischemic retinopathies, including neovascular glaucoma. METHODS This institutional review board-approved study retrospectively analyzed 80 undiluted vitreous samples obtained during pars vitrectomy. The specimens were frozen (-80°C) and sent for concentration analysis of 34 proteins by Bio-Plex Pro assays. Specimens were divided into four groups: patients undergoing epiretinal membrane (ERM) peeling and/or macular hole (MH) surgery with no history of diabetes (non-DM group), patients undergoing ERM peeling, and/or MH surgery with a history of diabetes (DM group), patients with proliferative diabetic retinopathy (PDR group), and patients with neovascular glaucoma (NVG group). Parametric and nonparametric analyses of demographics and cytokine levels were performed using SPSS. RESULTS There were no significant differences in demographics among cohorts. Numerous proteins were significantly elevated between non-DM and DM (G-CSF, sCD40L, Endoglin, IL-6, placental growth factor [PlGF], VEGF-D), DM and PDR (leptin, IL-8, PlGF, VEGF-A), and PDR and NVG (G-CSF, leptin, TIE-2, sCD40L, EGF, HB-EGF, IL-6, IL-8, PlGF, TNF-α). Only PlGF was significantly elevated between each successive cohort. The most potent drivers of NVG were PlGF, VEGF-A, IL-6, and IL-8. CONCLUSIONS While the role of angioproliferative growth factors is well documented in ischemic retinopathy, our study delineates the importance of inflammatory and previously underreported angiogenic proteins. It also demonstrates a significant incremental increase in certain factors with increasing levels of ischemia. Both of these findings may guide the development of future therapies for ischemic retinopathies.

Reversible vision loss and outer retinal abnormalities after intravitreal ocriplasmin injection.

PURPOSE Ocriplasmin is a truncated form of the human serine protease plasmin, which was recently approved for the nonsurgical treatment of symptomatic vitreomacular adhesions. According to its FDA label, approximately 8% of subjects experienced acute transient vision loss during the first week after injection with no alternative explanation for the change. This report focuses on a recent case of recovered vision loss over a 3-month period after the injection. METHODS A comprehensive ophthalmic examination was performed before the injection, during the day of the injection, and at 2 days, 2 weeks, 1 month, and 4 months after the injection. This examination included a full ophthalmic workup and imaging with spectral domain optical coherence tomography. A case of a 55-year-old woman who experienced acute severe vision loss 2 days after the treatment with ocriplasmin was reported. RESULTS Distinct alterations, as seen with spectral domain optical coherence tomography, were observed in the ellipsoid zone of photoreceptors. These changes together with patients visual acuity gradually recovered over a 3-month period after the injection. CONCLUSION Further investigation may be warranted to fully elucidate the precise molecular mechanisms involved in patients with unexplained vision loss after ocriplasmin injection.

Surgical outcomes after epiretinal membrane peeling combined with cataract surgery

Objective To compare functional and anatomical outcomes after idiopathic epiretinal membrane (ERM) peeling combined with phacoemulsification and intraocular lens implantation versus ERM peeling alone. Methods A retrospective, non-randomised comparative case series study was conducted of 81 eyes from 79 patients who underwent ERM peeling at the Beth Israel Deaconess Medical Center between 2001 and 2010. Eyes that underwent combined surgery for ERM and cataracts (group 1) were compared with those that had ERM peeling alone (group 2) with respect to best-corrected visual acuity at 6 months and 1 year after surgery, postoperative central macular thickness (CMT) as measured on optical coherence tomography, and rates of complications, including elevated intraocular pressure (IOP), ERM recurrence and need for reoperation. Results Mean logMAR visual acuity improved significantly in both groups at 6 months (p<0.001) and 1 year (p<0.001) after surgery. There was no statistical difference between the two groups in visual acuity improvement at 6 months (p=0.108) or 1 year (p=0.094). Mean CMT of both groups also significantly decreased after surgery (p=0.002), with no statistical difference in CMT reduction between the two groups, but a trend toward less CMT reduction in group 1 (p=0.061). The rates of complications, including IOP elevation, ERM recurrence and frequency of reoperation, were similar in the two groups, with non-statistical trends toward greater ERM recurrence (p=0.084) and need for reoperation (p=0.096) in those that had combined surgery. Conclusions Combined surgery for ERMs and cataracts may potentially be as effective as membrane peeling alone with respect to visual and anatomical outcomes. Further studies are necessary to determine if there may be greater ERM recurrence or need for reoperation after combined surgery.

EFFICACY AND SAFETY OF TREATMENT OPTIONS FOR VITREOMACULAR TRACTION: A Case Series and Meta-Analysis.

Purpose: To evaluate treatment options for vitreomacular traction (VMT). Methods: A retrospective, consecutive case series and a literature search with Boolean search logic. A random-effects meta-analysis was conducted to combine the rates of VMT resolution per treatment. Patients from studies analyzed were placed into cohorts based on the treatment received. Results: Case series: Zero of 10 control, 3 of 7 intravitreal ocriplasmin (IVO, P = 0.10), 7 of 8 intravitreal expansile gas (pneumatic vitreolysis, PV, P < 0.01), and 10 of 10 pars plana vitrectomy (P < 0.01)–treated eyes experienced VMT release (VMTr) at Day 28. No patients developed retinal tears or detachment. One PV-treated (12.5%) eye developed a macular hole. Meta-analysis: Twenty-three of 131 prospective or retrospective and consecutive articles were included. Sixty-three eyes were treated with PV, 726 eyes were treated with intravitreal ocriplasmin, and 253 eyes were characterized as the control group (saline injection). The weighted rate of VMT resolution for the control group was 0.09 (95% confidence interval [CI]: 0.06–0.13), PV was 0.84 (95% CI: 0.76–0.92), and intravitreal ocriplasmin was 0.26 (95% CI: 0.23–0.29). Conclusion: Our analysis found that PV releases VMT in most patients and suggest that PV may be as effective or superior to nonsurgical options for VMTr at Day 28 with a similar risk profile.

Endoscopic pars plana vitrectomy for the management of severe ocular trauma.

Major advances in vitreoretinal instrumentation have been made in the past several decades, including the introduction of smaller-gauge systems, chandelier lighting, and wide-angle viewing systems. The use of endoscopy in ophthalmology surprisingly predates all of these recent technologies. Thorpe first described the use of an ophthalmic endoscope in 1934, where he combined a Galilean telescope and a light source with a 6.5 mm diameter shaft for forceps. An eyepiece was attached to the proximal end for direct monocular visualization, and 8 mm scleral incisions were made to introduce this instrument into the globe. The proposed indication was for nonmagnetic intraocular foreign bodies (IOFB). Further advances in ophthalmic endoscopy were not reported until 4 decades later in 1978, when Norris and Cleasby developed a 1.7 mm diameter rigid endoscope for intraocular and orbital surgery. Although documentation was limited, they were able to expand the indications to the management of vitreous hemorrhage and retinal detachment. These advances were also complemented by the interval advent of pars plana vitrectomy. Subsequently in 1990, flexible endoscopes were described by Volkov et al, and in the same year, Eguchi and Araie introduced a flexible 20 G videoendoscope using charge-coupled device camera technology for remote video projection of real-time images, akin to the current modern ophthalmic endoscope. The intraocular endoscope has been significantly refined since its initial conceptions to provide improved size, visualization, and maneuverability. Its most prominent application in ophthalmology has become

Care of Older Adults: Role of Primary Care Physicians in the Treatment of Cataracts and Macular Degeneration.

This article aims to facilitate optimal management of cataracts and age‐related macular degeneration (AMD) by providing information on indications, risk factors, referral guidelines, and treatments and to describe techniques to maximize quality of life (QOL) for people with irreversible vision loss. A review of PubMed and other online databases was performed for peer‐reviewed English‐language articles from 1980 through August 2012 on visual impairment in elderly adults. Search terms included vision loss, visual impairment, blind, low vision, QOL combined with age‐related, elderly, and aging. Articles were selected that discussed vision loss in elderly adults, effects of vision impairment on QOL, and care strategies to manage vision loss in older adults. The ability of primary care physicians (PCPs) to identify early signs of cataracts and AMD in individuals at risk of vision loss is critical to early diagnosis and management of these common age‐related eye diseases. PCPs can help preserve vision by issuing aptly timed referrals and encouraging behavioral modifications that reduce risk factors. With knowledge of referral guidelines for soliciting low‐vision rehabilitation services, visual aids, and community support resources, PCPs can considerably increase the QOL of individuals with uncorrectable vision loss. By offering appropriately timed referrals, promoting behavioral modifications, and allocating low‐vision care resources, PCPs may play a critical role in preserving visual health and enhancing the QOL for the elderly population.

PERIODONTAL DISEASE AND AGE-RELATED MACULAR DEGENERATION: Results From the National Health and Nutrition Examination Survey III.

Purpose: To study the association between periodontal disease (PD) and age-related macular degeneration (AMD). Methods: For this cross-sectional analysis, 8,208 adults aged 40 years or older with retinal photographs graded for AMD were used from the National Health and Nutrition Examination Survey III. National Health and Nutrition Examination Survey III standardized dental measurements of PD status (defined as loss of >3 mm of attachment between the gum and tooth in at least 10% of sites measured). Participants were stratified into 60 years or younger and older than 60 years of age groups. Association between PD and AMD was assessed while controlling for sex, race, education, poverty income ratio, smoking, hypertension, body mass index, cardiovascular disease, and C-reactive protein. Results: In this population, a total of 52.30% had PD, and the prevalence of AMD was 11.45%. Logistic regression model controlled for confounders and stratified by age 60 years or younger versus older than 60 years showed PD to be independently associated with an increased risk for AMD (odds ratio = 1.96, 95% confidence interval = 1.22–3.14, P = 0.006) for those aged 60 years or younger but not for subjects older than 60 years (odds ratio = 1.32, confidence interval = 0.93–1.90, P = 0.120). Conclusion: In this population-based study, PD is independently associated with AMD in those aged 60 years or younger.

Fully automated, deep learning segmentation of oxygen-induced retinopathy images

Oxygen-induced retinopathy (OIR) is a widely used model to study ischemia-driven neovascularization (NV) in the retina and to serve in proof-of-concept studies in evaluating antiangiogenic drugs for ocular, as well as nonocular, diseases. The primary parameters that are analyzed in this mouse model include the percentage of retina with vaso-obliteration (VO) and NV areas. However, quantification of these two key variables comes with a great challenge due to the requirement of human experts to read the images. Human readers are costly, time-consuming, and subject to bias. Using recent advances in machine learning and computer vision, we trained deep learning neural networks using over a thousand segmentations to fully automate segmentation in OIR images. While determining the percentage area of VO, our algorithm achieved a similar range of correlation coefficients to that of expert inter-human correlation coefficients. In addition, our algorithm achieved a higher range of correlation coefficients compared with inter-expert correlation coefficients for quantification of the percentage area of neovascular tufts. In summary, we have created an open-source, fully automated pipeline for the quantification of key values of OIR images using deep learning neural networks.

Scleral Buckling in the Treatment of Retinal Detachment Due to Retinal Dialysis

BACKGROUND AND OBJECTIVE To describe clinical features and outcomes of scleral buckle surgery as treatment for patients with rhegmatogenous retinal detachment caused by retinal dialysis. PATIENTS AND METHODS Nonrandomized, consecutive case series. All patients underwent encircling scleral buckle for retinal detachment secondary to retinal dialysis. Visual acuity (VA) and retinal attachment status were recorded for the postoperative period. RESULTS The study included 16 eyes of 15 patients with mean age 25.8 years; 80% were male, and 75% of the cases were associated with trauma. Dialyses were most commonly found inferotemporally (63%). Mean preoperative VA was 20/103 and mean postoperative VA was 20/62. VA improved in nine cases, and eight cases had a VA of 20/40 or better at the last follow-up. Due to retinal re-detachment, two patients (13%) required additional surgery with vitrectomy. CONCLUSIONS Retinal dialysis is an uncommon etiology for retinal detachment and is often associated with trauma and younger age. Scleral buckling can be an effective strategy in the initial management of these patients.

Authors’ response: surgical outcomes after epiretinal membrane peeling combined with cataract surgery

We appreciate the comments by Drs Kahn and Rahman and agree that interpreting retrospective data must always be approached with caution.1 Indeed, properly controlled randomised prospective studies remain the gold standard for evaluating medical treatments. However, retrospective case series often provide important insights into therapies that are less commonly performed, or subject to variability in operator or technique, as is the case when comparing surgical methods. Retrospective studies also generate important preliminary data to help guide the design of future randomised trials. Our study was devised to compare simultaneous combined phacoemulsification, PCIOL placement, pars plana vitrectomy and epiretinal membrane (ERM) peeling, with vitrectomy and membrane peeling alone.2 Patients in the membrane peeling alone group were either phakic or pseudophakic at the time of surgery. The inherent limitation of evaluating combined surgeries …