Mark E. Seamone

Letter to the Editor: Imaging Characteristics and Natural History of Macular Pseudo-Folds Mimicking Full-Thickness Postoperative Macular Folds Following Retinal Detachment Repair

Dear Editor, We read with interest the article written by Sheng et al.1 that was published in the June 2017 issue of your journal. The authors present three cases in which partialthickness retinal folds were observed following the repair of rhegmatogenous retinal detachment (RRD) by way of pars plana vitrectomy (PPV) and gas tamponade. In all cases, inner retinal folds or wrinkling can be appreciated at the 1-month postoperative visit on spectral-domain optical coherence tomography (SD-OCT). Distortion, in Cases 1 and 2, causes internal limiting membrane (ILM)-to-ILM apposition of inner retinal folds. Outer retinal folds are also noted, with base-tobase photoreceptor apposition. In follow-up images, although the outer retinal folds appear to have resolved in all cases, inner retinal folds remain present, although less prominent. Inner and outer retinal folds following PPV for RRD were first described by Benson et al. and dell’Omo et al., respectively.2,3 Other studies have since reported the longitudinal follow-up of inner retinal folds and outer retinal folds by OCT.4 Both tend to resolve spontaneously with good visual outcomes, although inner retinal folds may persist longer.4 As such, observation has been typically recommended for partial-thickness retinal folds following PPV for RRD. This is in contrast to fullthickness retinal folds with base-to-base photoreceptor apposition following PPV for RRD. It is in these circumstances that many, including Sheng et al.1, advocate for the surgical management of retinal folds. Sheng et al.1 suggest employing the term “pseudofolds” when discussing partial thickness folds involving either the outer retina or inner retina. In an analogous situation, the term “pseudohole” is used for the scenario where there is the clinical appearance of a full-thickness macular hole, however, the OCT demonstrates no loss of tissue. Instead, epiretinal membrane is present and has created distortion of the anatomy, giving the appearance of a hole clinically.5 The word “pseudo” is Greek for “false.” However, the folds in question are in fact true folds in the retina, as demonstrated via SD-OCT. Hence, we do not feel that “pseudo-folds” is the most precise descriptor for this pathology. We believe that the established terms in the literature (“partial thickness folds”, or more specifically “inner retinal folds” or “outer retinal folds”) may be more appropriate. The term “pseudo-fold” may be more suitable in the scenario of an epiretinal membrane that gives the appearance of a retinal fold clinically, in which there are no actual folds of the retina observed on OCT. R. Rishi Gupta MD, FRCSC Douglas S.M. Iaboni, MSc Netan Choudhry MD, FRCSC Mark E. Seamone MSc, MD Dalhousie University, Halifax, Nova Scotia

Surgical Repair of a Persistent Full-Thickness Macular Fold With Base-to-Base Photoreceptor Apposition Secondary to Hypotony From Trabeculectomy Surgery and Postoperative Laser Suturelysis

Purpose: To report the successful repair of a persistent full-thickness retinal fold secondary to hypotony from trabeculectomy surgery. Results: Laser suturelysis was performed on a patient to relieve an elevated intraocular pressure posttrabeculectomy surgery. This resulted in chronic hypotony, a full-thickness retinal fold, and a decline in visual acuity to “count fingers.” The patient underwent a pars plana vitrectomy with internal limiting membrane peeling, subretinal injection of balanced saline solution, fluid-air exchange, injection of F-Decalin, peripheral retinotomy, endolaser photocoagulation, and vitreous substitution with 15% C3F8 gas. Anatomic improvement was documented via multimodal imaging. Six months postoperatively best-corrected visual acuity (BCVA) returned to 20/30. Conclusions: We describe a surgical approach to full-thickness retinal folds and review the management options previously reported in the setting of hypotony. We provide support for the active management of appositional full-thickness retinal folds involving the fovea and demonstrate that surgical correction can significantly improve BCVA even after 4 months of hypotony.

Spectral domain optical coherence tomography interpretation

Lonial, S., Petrucci, M.T., Orlowski, R.Z., Zamagni, E., Morgan, G., Dimopoulos, M.A., Durie, B.G., Anderson, K.C., Sonneveld, P., San Miguel, J., Cavo, M., Rajkumar, S.V. & Moreau, P. (2015) Revised international staging system for multiple myeloma: a report from International Myeloma Working Group. Journal of Clinical Oncology, 33, 2863–2869. Palumbo, A., Chanan-Khan, A., Weisel, K., Nooka, A.K., Masszi, T., Beksac, M., Spicka, I., Hungria, V., Munder, M., Mateos, M.V., Mark, T.M., Qi, M., Schecter, J., Amin, H., Qin, X., Deraedt, W., Ahmadi, T., Spencer, A. & Sonneveld, P. (2016) Daratumumab, bortezomib, and dexamethasone for multiple myeloma. New England Journal of Medicine, 375, 754–766. Plesner, T., Arkenau, H.T., Gimsing, P., Krejcik, J., Lemech, C., Minnema, M.C., Lassen, U., Laubach, J.P., Palumbo, A., Lisby, S., Basse, L., Wang, J., Sasser, A.K., Guckert, M.E., de Boer, C., Khokhar, N.Z., Yeh, H., Clemens, P.L., Ahmadi, T., Lokhorst, H.M. & Richardson, P.G. (2016) Phase 1/2 study of daratumumab, lenalidomide, and dexamethasone for relapsed multiple myeloma. Blood, 128, 1821– 1828. Walker, I., Coady, A., Neat, M., Ladon, D., Benjamin, R., El-Najjar, I., Kazmi, M., Schey, S. & Streetly, M. (2016) Is the revised international staging system for myeloma valid in a real world population? British Journal of Haematology, 180, 451.

Massive Subretinal Gas After Vitrectomy Surgery: Mechanism And Management

PURPOSE To describe the complication of subretinal gas after pars plana vitrectomy for rhegmatogenous retinal detachment, as well as its management. METHODS The presence of subretinal gas was noted on postoperative Day 1 after pars plana vitrectomy for a chronic rhegmatogenous retinal detachment. Resolution of subretinal gas was facilitated by an infusion line and external sclerotomy to expand the vitreous cavity. Residual subretinal gas was removed through a posterior retinotomy after fluid-air exchange. RESULTS This technique resulted in the successful evacuation of subretinal gas, allowing for chorioretinal adhesion and reattachment of the retina. CONCLUSION Subretinal gas can rarely occur after pars plana vitrectomy for rhegmatogenous retinal detachment. This complication can be successfully managed by way of external drainage, followed by evacuation of residual gas through fluid-air exchange and posterior retinotomy.

Torpedo Maculopathy Presenting With Fovea Plana in a 21-Year-Old Female

Purpose: To report a case of torpedo maculopathy presenting with fovea plana in a 21-year-old female patient. Methods: Multimodal imaging including fluorescein angiography, fundus autofluorescence, and spectral domain optical coherence tomography (OCT) was used to characterize pathology. Results: A well-circumscribed ellipsoidal hypopigmented lesion was observed inferotemporal to the fovea OS. Fluorescein angiography and fundus autofluorescence revealed hyperfluorescence and focal hypoautofluorescence, respectively, corresponding to the hypopigmented lesion. Spectral domain optical coherence tomography imaging of the lesion revealed attenuation of the ellipsoid zone and retinal pigment epithelium with a hyporeflective subretinal cleft. En face OCT imaging demonstrated an area of subretinal hyporeflectivity at the subretinal cleft. Spectral domain optical coherence tomography revealed the absence of a foveal pit. Conclusion: We have described a novel case presentation of fovea plana alongside torpedo maculopathy. The significance of this association remains unclear. Further study into these conditions is necessary to help better determine factors responsible for visual symptoms or lack thereof and circumstances that promote their development.

VEGF-A is increased in exogenous endophthalmitis

OBJECTIVE Exogenous endophthalmitis is an ophthalmologic emergency defined by panocular inflammation. Vascular endothelial growth factor A (VEGF-A) contributes to inflammation by promoting chemotaxis of monocytes and granulocytes and by increasing vascular permeability. The purpose of this article is to determine if VEGF-A is elevated in the vitreous samples obtained from individuals with exogenous endophthalmitis. METHODS Vitreous samples from individuals with exogenous endophthalmitis (n = 18) were analyzed via Luminex assay and enzyme-linked immunosorbent assay for the cytokines VEGF-A, tumor necrosis factor (TNF), interleukin 6 (IL-6), IL-8 (chemokine [CXCL]-8), IL-1β, IL-10, IL-12p70, IL-33, interferon (IFN)-γ, IFN-α, IFN-β, chemokine ligand (CCL)-3, IL-2, IL-5, IL-15, CXCL-10, CCL-2, IL-1Ra, CCL-5, IL-17, and CCL-11. Vitreous samples obtained at the time of macular hole surgery served as controls (n = 8). RESULTS Concentrations of VEGF-A were significantly elevated in vitreous samples from individuals with exogenous endophthalmitis compared with macular hole (p < 0.001). VEGF-A was significantly upregulated in individuals with exogenous endophthalmitis after cataract surgery (p = 0.001), vitrectomy (p = 0.024), and intravitreal injection (p = 0.012). VEGF-A concentrations were similar in both culture-positive and culture-negative populations (p > 0.05). In a linear regression model, levels of VEGF-A correlated significantly with the chemokine CXCL-8 (p = 0.028). CONCLUSIONS We demonstrate that VEGF-A is potently upregulated in exogenous endophthalmitis. This observation provides a foundation for future studies of targeted VEGF-A blockade in the management of endophthalmitis.

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A Ghostly OCT.

1. Sproule DM, Kaufmann P. Mitochondrial encephalopathy, lactic acidosis, and strokelike episodes: basic concepts, clinical phenotype, and therapeutic management of MELAS syndrome. Ann N Y Acad Sci. 2008;1142:133-58. 2. Daruich A, Matet A, Borruat FX. Macular dystrophy associated with the mitochondrial DNA A3243G mutation: pericentral pigment deposits or atrophy? Report of two cases and review of the literature. BMC Ophthalmol. 2014;14:77.