Mohammed Ali Khan

Clinical management of proliferative vitreoretinopathy: an update.

Background: Proliferative vitreoretinopathy (PVR) remains the most significant obstacle to successful retinal reattachment surgery. Preclinical studies continue to add insights into the complex molecular events leading to PVR development, helping to identify new targets for potential prophylactic or therapeutic agents. This article reviews the recent evidence supporting surgical and medical treatments for PVR. Methods: PUBMED was used for literature search. Clinical studies regarding surgical management of PVR from January 1, 2000 to August 1, 2014 were included. Clinical studies regarding medical management of PVR from January 1, 2000 to August 1, 2014 were included if the design of study was a randomized controlled trial. Results: Many recent studies have evaluated surgical and medical strategies for the treatment and prevention of PVR. Newer vitreoretinal surgery technology (23- and 25-gauge vitrectomy) and tamponade agents (heavy silicone oils) have been studied. Medical therapies evaluated include antiinflammatory agents, low molecular weight heparin, 5-fluorouracil, 13-cis-retinoic acid, and daunorubicin, amongst others. Conclusion: Surgical management with pars plana vitrectomy, with or without scleral buckle or inferior retinectomy, remains an effective treatment for PVR-related detachments. Consensus regarding a preferred surgical strategy remains controversial. Many medical therapies have been studied but fail to demonstrate a statistically significant benefit in clinical trials. Further studies to clarify the efficacy of available and novel treatment options are warranted.

Scleral fixation of posterior chamber intraocular lenses using gore-tex suture with concurrent 23-gauge pars plana vitrectomy.

In the absence of capsular support, options for intraocular lens (IOL) placement include anterior chamber intraocular lenses, iris-fixated posterior chamber intraocular lenses (PCIOLs), and scleral-fixated PCIOLs. In a 2003 Ophthalmic Technology Assessment report for the American Academy of Ophthalmology, Wagoner et al supported the effective use of these varying fixation techniques in the appropriate clinical setting, without clear superiority of one method. The choice of surgical technique depends on many factors, including comorbid ocular conditions and anatomical considerations. For surgeons treating patients with history of trauma or complicated cataract surgery, vitrectomy is often required along with IOL placement. Herein, we describe an effective technique for ab externo scleral fixation of PCIOLs using GoreTex (W.L. Gore & Associates, Newark, DE) suture, initially described by Slade et al, modified to include concurrent 23-gauge pars plana vitrectomy.

Outcomes of anti-vascular endothelial growth factor therapy in the management of choroidal neovascularization associated with choroidal osteoma.

Purpose: To investigate the efficacy of serial anti–vascular endothelial growth factor injections for choroidal neovascularization associated with choroidal osteoma. Methods: In this retrospective interventional case series, eyes with choroidal osteoma and associated choroidal neovascularization were treated with intravitreal ranibizumab or bevacizumab with or without photodynamic therapy consolidation. Resolution of subretinal fluid on optical coherence tomography and best-corrected visual acuity were assessed. Results: Eight eyes in eight patients were treated with monthly intravitreal anti–vascular endothelial growth factor injections with or without photodynamic therapy. Resolution of subretinal fluid on optical coherence tomography was achieved in 7 of 8 eyes (87%) with a mean of 12.3 ± 12.6 injections (range, 1–40). Four eyes (50%) experienced at least 1 recurrence of exudation at a mean interval of 10 months (median, 7.5; range, 5–21 months), necessitating further therapy. The mean Snellen visual acuity improvement was 1 ± 4 lines (range, loss 3 to gain 7 lines) at a mean of 32-months follow-up. Conclusion: Serial anti–vascular endothelial growth factor therapy alone or with photodynamic therapy consolidation for choroidal neovascularization due to choroidal osteoma resulted in anatomical improvement and modest visual gain.

Combined 27-Gauge Pars Plana Vitrectomy and Scleral Fixation of an Akreos AO60 Intraocular Lens Using Gore-Tex Suture.

Combined 27-Gauge Pars Plana Vitrectomy and Scleral Fixation of an Akreos AO60 Intraocular Lens Using Gore-Tex Suture Scleral fixation of a posterior chamber intraocular lens (IOL) is an effective management strategy in selected patients with aphakia and poor capsular support, with outcomes commensurate to iris-fixated and anterior chamber IOL placement. In response to concerns regarding suture breakage or erosion with the commonly used polypropylene (PROLENE; Ethicon Inc, Somerville, NJ), surgical techniques using sutureless scleral fixation or alternative suture materials have been described. In 2014, our institution described a technique for combined 23gauge pars plana vitrectomy (PPV) and scleral fixation of IOLs using Gore-Tex (W.L. Gore & Associates, Newark, DE) suture material. In a recent series reporting outcomes of this technique, transient hypotony was the most common postoperative complication encountered, occurring in 9.4% of eyes. Temporary wound leakage through 23-gauge sclerotomy sites was posited as the etiology of the transient hypotony, and use of smaller gauge instruments was suggested to potentially reduce this risk. Here, we describe a modified technique enabling 4-point scleral fixation of an Akreos AO60 IOL (Bausch & Lomb, Rochester, NY) using Gore-Tex suture through a 27-gauge vitrectomy platform. Methods

En Face Optical Coherence Tomography Imaging of Deep Capillary Plexus Abnormalities in Paracentral Acute Middle Maculopathy.

The authors describe a case of para-central acute middle maculopathy (PAMM) in a 75-year-old man who had recently undergone cardiac catheterization. Imaging with simultaneous en face optical coherence tomography (OCT) and OCT angiography (OCTA) revealed signal abnormalities localized to the deep capillary plexus. This case highlights the ability of OCTA to image and localize retinal disease by vascular distribution, previously difficult with conventional fluorescein angiography, and lends evidence to the belief that PAMM is caused by vascular injury to the intermediate and deep capillary plexus.

Clinical management of vitreomacular traction.

Purpose of review To describe recent evidence regarding the clinical management of vitreomacular traction (VMT). Recent findings Recent studies have reported favorable outcomes in patients with VMT managed with observation, pharmacologic vitreolysis with ocriplasmin, and intravitreal perfluoropropane gas. Subgroup analysis has identified features associated with spontaneous release of VMT as well as features associated with successful pharmacologic release of VMT with ocriplasmin. Summary Observation may be an appropriate initial recommendation for patients with mild VMT. When treatment is necessary, pharmacologic vitreolysis with ocriplasmin is an effective nonsurgical therapeutic option. Careful patient selection improves success rates with ocriplasmin. Further study is necessary to establish the efficacy of intravitreal perfluoropropane gas for VMT as well as the efficacy of ocriplasmin in patients with VMT and concurrent retinal disease. As these treatments are more widely used, prospective data will continue to clarify their risk/benefit profile.

Legal Blindness From Severe Optic Nerve Head Drusen.

A man in his late 40s presented for evaluation of progressive visual acuity and visual field loss in both eyes over a 10-year period. Best-corrected visual acuity was 20/200 OD and counting fingers OS. No afferent pupillary defect was present. Goldmann perimetry revealed severe field constriction in each eye. A diagnosis of optic nerve head drusen was made based on clinical examination (Figure). Given a history of progressive visual loss, magnetic resonance imaging was completed to rule out compressive optic neuropathy. Low-vision aids were recommended to maximize visual potential. Two years after presentation, visual acuity and Goldmann perimetry remained stable.

Contemporary Management of Rhegmatogenous Retinal Detachment Due to Giant Retinal Tears: A Consecutive Case Series

BACKGROUND AND OBJECTIVE To investigate outcomes of contemporary surgical techniques for repair of rhegmatogenous retinal detachments (RRD) associated with giant retinal tears (GRT). PATIENTS AND METHODS Retrospective, consecutive case series including 58 eyes of 58 patients. Mean age was 52 years (range: 16 to 83 years). All patients underwent 23-gauge pars plana vitrectomy with use of perfluorocarbon liquid and intravitreal tamponade (28 with silicone oil, 25 with octafluoropropane gas, and five with sulfur hexafluoride gas). Scleral buckle (SB) was placed in 30 eyes (52%). RESULTS At a mean follow-up of 17 months, mean visual acuity improved from 20/500 preoperatively to 20/88 at final follow-up. Fifty-one patients (88%) had single-surgery anatomic success, and all patients achieved final retinal reattachment. Use of SB (P = 1.0), silicone oil (P = .1), or 360° endophotocoagulation (P = .7) did not correlate with higher rates of successful repair. CONCLUSION Contemporary vitreoretinal surgery techniques achieve high rates of primary anatomic success in GRT-related RRDs.

Headache or eye pain as the presenting feature of uveal melanoma.

retreatment led to a significant, gradual increase in mean CST (P 1⁄4 0.03). Therefore, for the second year of the SAVE trial, the protocol was modified:Both cohortswere evaluatedmonthlywith PRN retreatment. Of the 79 patients who completed 1 year, 77 completed 20months and 64 completed 24 months (cohort A, n1⁄4 33; cohort B, n1⁄4 31). Patient attrition was precipitated by cessation of production of 2.0 mg ranibizumab after release of the HARBOR trial results. During the second year of the SAVE trial, mean PRN retreatments were 11.2 (range, 5e12) and 11 (range, 6e12) for cohorts A and B, respectively. Highlighting the recalcitrant nature of the choroidal neovascular complexes in these patients, a majority of patients, 25/33 (76%) and 19/31 (61%) of cohorts A and B, respectively, received all possible PRN injections. Upon switching cohort B from PRN retreatment every 6 weeks to every 4 weeks, mean SD OCT CST decreased to a comparable level as had been observed in cohort A (Fig 1; available at http://aaojournal.org); at month 24, CST was 73 and 66 mm for cohorts A and B, respectively. During the second year, mean ETDRS BCVA gains remained stable and similar between cohorts (Fig 2; available at http://aaojournal.org); at month 24, BCVA gains were þ3.6 and þ2.9 letters for cohorts A and B, respectively. The ocular and systemic safety of 2.0 mg intravitreal ranibizumab observed in SAVE was consistent with previous trials of ranibizumab including the 2.0 mg cohort in HARBOR. Other trials have also assessed the potential role of higher doses of anti-VEGF medications in AMD management. The phase III HARBOR trial found no difference in visual or anatomic outcomes in patients randomized to 2.0 versus 0.5 mg ranibizumab. Critically, however, HARBOR included only treatment-naïve neovascular AMD eyes. Supporting the concept that a higher dose of anti-VEGF medication may be more valuable in neovascular AMD patients with an incomplete anatomic response to conventional therapy, Fung et al reported a group of 7 recalcitrant neovascular AMD eyes treated with 2.0 mg ranibizumab who experienced visual gain and anatomic improvement. The burden of neovascular AMD eyes with recalcitrant fluid despite adequate anti-VEGF therapy is a common clinical challenge. Many alternative treatment approaches have been considered and continue to be investigated, such as radiation therapy and extended-release formulations and devices, as well as pharmaceuticals directed at alternative molecular targets. As a part of this multidimensional approach to delivering optimal visual benefit, a higher dose of ranibizumab merits further study as a management tool for patients with recalcitrant neovascular AMD.

COTTON-WOOL SPOTS AFTER USE OF MACITENTAN FOR PULMONARY ARTERIAL HYPERTENSION.

Purpose: To report a case of transient, bilateral cotton spots after initiation of macitentan, an endothelin receptor antagonist used for the treatment of pulmonary arterial hypertension. Methods: Case report. Results: A 76-year-old woman with WHO Class IIIb pulmonary arterial hypertension was referred for evaluation of bilateral cotton-wool spots 1 week after starting macitentan therapy. The patient was asymptomatic and visual acuity was 20/25 in each eye. Fluorescein angiography and optical coherence tomography were completed. Given lack of symptoms and alternative treatment options, the patient was observed closely. The cotton-wool spots resolved 8 weeks after presentation and visual acuity remained stable at 20/25. Throughout the observation period, average mean arterial pressure was within normal limits at 84.8. Conclusion: In patients using endothelin receptor antagonists, medication side effect should be considered in the differential diagnosis of cotton-wool spots.