Nicola Recchimurzo

Triamcinolone-assisted Pars Plana Vitrectomy for Proliferative Vitreoretinopathy

Purpose To determine whether triamcinolone acetonide (TAAC) staining facilitates posterior hyaloid and epiretinal membrane (ERM) removal in patients undergoing pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) with proliferative vitreoretinopathy (PVR). Methods Ten consecutive pseudophakic patients (10 eyes) underwent PPV for RRD with PVR. After a core PPV, a few drops of a commercially available TAAC aqueous suspension (40 mg/mL) with vehicle were injected into the mid vitreous cavity to visualize the posterior hyaloid, thus allowing a complete posterior hyaloidectomy. Next, 0.1 to 0.2 mL of TAAC was applied on the retinal surface to visualize and peel the ERMs. The tamponading agent was silicone oil (1,300 cs) in eight eyes and perfluropropane (C3F8 14%) in two eyes. The minimal follow-up period in all patients was 4 months. Results In all patients, intraoperative staining with TAAC consistently improved direct visualization and delineation of the posterior hyaloid and ERMs and facilitated their removal. No adverse reaction related to the use of TAAC was observed immediately postoperatively or 4 months after surgery. Conclusions Intravitreal TAAC may be an important adjuvant tool in the delineation of posterior hyaloid and ERMs, allowing for a more complete and safer ERM removal in the surgical management of PVR complicating RRD. It is well tolerated with all its vehicle if used at low concentration and rapidly removed during surgery.

Intravitreal bevacizumab for treatment‐naïve subfoveal occult choroidal neovascularization in age‐related macular degeneration

Purpose:  This study aimed to evaluate the efficacy of multiple injections of intravitreal bevacizumab for treatment‐naïve subfoveal occult choroidal neovascularization (CNV) in age‐related macular degeneration (AMD).

Ocular Toxicity in Metastatic Melanoma Patients Treated With Mitogen-Activated Protein Kinase Kinase Inhibitors: A Case Series

PURPOSE To report the clinical features and management of mitogen-activated protein kinase kinase inhibitor-associated ocular side effects in 4 patients with advanced melanoma and a review of literature. DESIGN Interventional case series. METHODS Four patients with advanced cutaneous melanoma were treated with a mitogen-activated protein kinase kinase (MEK) inhibitor as single therapy or together with a v-raf murine sarcoma viral oncogene homolog B1 (BRAF) inhibitor. All patients underwent ophthalmologic examinations at regular intervals or as needed, including visual acuity, intraocular pressure, external eye examination, and funduscopy. When pathologic findings were found, patients underwent visual field examination, optical coherence tomography (OCT), and/or fluorescein angiography. Ocular toxicity was assessed and handled according to the Common Terminology Criteria for Adverse Events. RESULTS Ocular adverse events appeared early in the treatment. In 3 patients OCT revealed subfoveal neuroretinal elevation, often asymptomatic, also after discontinuation and re-starting of MEK inhibitor. Vascular injury appeared in 2 patients, in 1 case associated with a visual field defect reduced after discontinuation of the drug and use of systemic therapy. In 1 case an inflammatory reaction was observed in the anterior chamber. Visual symptoms were usually mild and short-lived. CONCLUSIONS MEK inhibitor as a single agent or in combination with BRAF inhibitor induces transient retinopathy with time-dependent recurrence and usually mild visual symptoms. Vascular injuries can be observed and their management is essential in clinical practice. It is important to investigate all previous ocular disorders, systemic conditions, and pharmacologic interactions of MEK inhibitor that could facilitate the onset of associated ocular effects.

Intravitreal dexamethasone implant for macular edema following uncomplicated phacoemulsification

Purpose To retrospectively study the efficacy of a single 0.7-mg dexamethasone intravitreal implant in eyes with refractory macular edema secondary to uncomplicated phacoemulsification and intraocular lens implant. Methods In 11 eyes of 11 consecutive patients with persistent refractory macular edema, secondary uncomplicated cataract extraction, and intraocular lens implant, the injection of 0.7-mg dexamethasone implant was performed at the Clinica Oculistica, University of Bari, Italy. Best-corrected visual acuity (BCVA), central retinal thickness measured by spectral-domain optical coherence tomography, and intraocular pressure (IOP) was evaluated at baseline, 1 month, and 6 months. Results After a mean follow-up of 6.27 ± 0.47 months, BCVA was significantly increased from 20/40 to 20/22 (p<0.0001), mean central retinal thickness decreased significantly from 462 ± 100 to 276 ± 8 μm (p<0.0001), and IOP did not change significantly (p = 0.053). In no case were postoperative complications observed. Conclusions A single injection of 0.7-mg dexamethasone intravitreal implant was effective in the treatment of persistent refractory macular edema secondary to uneventful phacoemulsification and in-bag lens implant.

Evaluation of corneal damage by combined phacoemulsification and passive efflux of silicone oil in vitrectomized eyes

Purpose: To evaluate the effect on the corneal endothelium of phacoemulsification combined with passive silicone oil removal and intraocular lens (IOL) implantation under topical anesthesia after pars plana vitrectomy. Setting: Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy. Methods: This retrospective study evaluated the corneal endothelium in 17 consecutive patients (17 eyes) who had phacoemulsification with transpupillary passive silicone oil washout (1300 centistokes) through a posterior capsulorhexis and single clear corneal incision and foldable acrylic IOL implantation. The findings were compared with those in a control group of 17 patients (17 eyes) who had phacoemulsification with acrylic IOL implantation through a single clear corneal incision. All procedures were performed by the same surgeon using topical anesthesia. The preoperative and postoperative endothelial cell densities, coefficient of variation (CV), and percentage of hexagonal cells at the corneal center and peripheral temporal position, evaluated by noncontact specular microscopy, were compared between the 2 groups. The central corneal thickness and occurrence of keratopathy were also noted. Results: The mean phacoemulsification and total ultrasound times did not differ significantly between the 2 groups. At 6 months, the mean endothelial cell loss was 284.50 cell/mm2 ± 462.3 (SD) (11.2%) in the study group and 200.15 ± 117.9 cell/mm2 (8.3%) in the control group (P=.87, unpaired t test). There were no significant between‐group differences in the increase in the mean CV and the percentage of hexagonal cells. The mean pachymetry remained at preoperative values, with no difference between groups. Keratopathy was not observed in any patient. Conclusions: Passive silicone oil efflux caused significant endothelial cell loss and changes in endothelial morphology. Nevertheless, these modifications were well tolerated and minimally different from the results of trauma caused by standard phacoemulsification with posterior chamber IOL implantation.

Diathermy of leaking sclerotomies after 23-gauge transconjunctival pars plana vitrectomy: a prospective study.

Purpose: To evaluate the efficacy of bipolar diathermy in ensuring closure of leaking sclerotomies after complete 23-gauge transconjunctival sutureless vitrectomy. Methods: In this prospective, interventional case series, in 136 eyes of 136 patients with at least one leaking sclerotomy at the end of a complete 23-gauge transconjunctival sutureless vitrectomy, external bipolar wet-field diathermy was applied to leaking sclerotomies, including the conjunctiva and sclera. Intraoperative wound closure, and postoperatively, at 6 hours, 1 day and 3 days, sclerotomies leakage, intraocular pressure, hypotony, and hypotony-related complications were evaluated. Results: Intraoperative closure was achieved in 231 of 238 leaking sclerotomies (97%) that received diathermy. One of these with postoperative leakage needed suture. Compared with baseline (14.4 ± 2.8 mmHg), mean intraocular pressure was lower at 6 hours (13.2 ± 3.8 mmHg, Tukey–Kramer P < 0.001) and not different at 24 hours or 72 hours. Hypotony (intraocular pressure <5 mmHg) was observed in 6 eyes (4.5%) at 6 hours, in 2 (1.5%) at 24 hours, and in none at 3 days. Logistic regression analysis showed that, 6 hours postoperatively, hypotony was related to younger age (⩽50 years) at surgery (P = 0.031). No hypotony-related complications were recorded. Conclusion: Bipolar wet-field diathermy of sutureless sclerotomies is an effective method for ensuring a leaking sclerotomies closure.

Cauterization for the prevention of leaking sclerotomies after 23-gauge transconjunctival pars plana vitrectomy: an easy way to obtain sclerotomy closure.

M icroincisional vitrectomy surgery is becoming increasingly popular based on several reported advantages of sutureless vitrectomy over the traditional techniques. However, potential disadvantages of this technique are an increased incidence of wound leaks, vitreous incarceration, hypotony, choroidal detachment, retinal detachment, endophthalmitis, and subconjunctival migration of gas and oil. Even with recent modifications of incision techniques, such as two-step or slit-shaped scleral tunnel incisions, it may be difficult to ensure perfect selfsealing of every entry site, especially in particular cases, such as myopia, thin sclera, and reoperation. In case of leaking sclerotomies, many authors place a single transconjunctival and transscleral absorbable suture. Chieh et al recently reported, in a retrospective case series of 118 eyes undergoing 23-gauge vitrectomy surgery, that 38% of eyes required suture closure of at least 1 sclerotomy port. The data from the Preferences and Trends (PAT) of the American Society of Retina Specialists (ASRS) survey support these numbers: 93% of the members of the ASRS who perform 23-gauge surgery suture at least 1 of the sclerotomies. Suture application leads to some undesirable effects, such as astigmatism and foreign body sensation, and sometimes it could be difficult to place because of chemosis or bleeding. To avoid these complications, alternative techniques to avoid entry site leakage were proposed: use of tissue glue, polyethylene glycol–based hydrogel bandage, or releasable suture technique. All of the mentioned techniques add cost and further procedures. We describe a new simple method to obtain a complete watertight sclerotomy closure. Description of Technique

Intravitreal dexamethasone implant for refractory macular edema secondary to vitrectomy for macular pucker.

Purpose: To study the efficacy of a single 0.7 mg dexamethasone intravitreal implant in vitrectomized eyes with refractory macular edema secondary to combined cataract extraction and macular pucker removal. Methods: In 8 eyes of 8 consecutive patients with refractory macular edema secondary to combined cataract extraction and 25-gauge vitrectomy with internal limiting membrane peeling for macular pucker removal, the injection of the 0.7 mg dexamethasone implant was performed. Best-corrected visual acuity, central retinal thickness measured by spectral domain optical coherence tomography, and intraocular pressure were evaluated at baseline, 1 month, and 6 months. Results: After a mean follow-up of 6.75 ± 0.71 months, best-corrected visual acuity was significantly increased (P < 0.0001) from 20/50 to 20/23 (P < 0.0001), mean central retinal thickness decreased significantly from 439 ± 45 &mgr;m to 296 ± 49 &mgr;m (P < 0.0001), and intraocular pressure changed significantly (P = 0.02) from 14.63 ± 1.19 to 16 ± 0.93. In no case postoperative hypotony or other complication was observed. Conclusion: A single injection of the 0.7 mg dexamethasone intravitreal implant resulted effective in the treatment of refractory macular edema secondary to combined cataract extraction and vitrectomy for macular pucker removal allowing a stable visual acuity recovery.

Phacoemulsification with transpupillary silicone oil removal and lens implantation through a corneal incision using topical anesthesia

Purpose: To evaluate phacoemulsification combined with transpupillary silicone oil removal and foldable intraocular lens (IOL) implantation through a single corneal incision and planned posterior capsulorhexis after pars plana vitrectomy using topical anesthesia. Setting: Department of Ophthalmology, University of Bari, Bari, Italy. Methods: This noncomparative nonrandomized noncontrolled interventional case series comprised 34 consecutive patients (34 eyes). The mean age of the 25 men and 9 women was 54.4 years ± 13.3 (SD). A mean of 8.2 ± 9.4 months after silicone oil injection, patients had phacoemulsification with transpupillary silicone oil removal and foldable acrylic IOL implantation through a single corneal incision and a planned posterior capsulorhexis under topical anesthesia. Patients were operated on by the same surgeon. Visual acuity, the frequency of retinal redetachment, secondary cataract and vitreous hemorrhage formation, subjective pain and discomfort, the duration of surgery, and intraocular pressure (IOP) were noted. The mean follow‐up was 9.4 ± 5.1 months (range 4 to 21 months). Results: Vision improved or stabilized in 88.2% of eyes. Retinal redetachment occurred in 4 eyes (11.8%) and transient vitreous hemorrhage in 1 (2.9%). All patients reported minimal discomfort during the procedure. The mean duration of surgery was 17 ± 4 minutes. There was no significant intraoperative or postoperative IOP variation. Conclusions: Combined phacoemulsification, transpupillary silicone oil removal, and IOL implantation through a single corneal incision under topical anesthesia was safe and effective. In general, the visual outcomes were good with improvement in visual acuity.

Bilateral Ischemic Retinal Vasculitis in Metastatic Cutaneous Melanoma Patient Treated with Dabrafenib and Trametinib: A Case Report

In the last few years, about two-thirds of metastatic melanoma have revealed gene target mutations, which involve v-Raf murine sarcoma viral oncogene homolog B1 (BRAF) or neuroblastoma RAS viral oncogene homolog (NRAS), both along the mitogen-activated protein kinase (MAPK) cell pathway. Biologic targeted agents, such as including BRAF inhibitors and mitogen-activated protein kinase kinase (MEK) inhibitors, have revolutionized the treatment for metastatic melanoma. These drugs administered as a single therapy or in combination, have tripled the median overall survival of patients who reported related ocular adverse events. In two clinical trials on oral Dabrafenib (BRAF inhibitor) (75 or 150 mg twice daily) and Trametinib (MEK inhibitor) (1, 1.5, or 2 mg daily) in combination, rare cases of reversible undefined chorioretinopathy events were reported. This combination regimen has since been approved by the US Food and Drug Administration (2014). The most serious ocular effect of inhibition of the MAPK signaling pathway is retinal vein occlusion but the most common ocular side-effect of Dabrafenib and Trametinib as single treatment is uveitis (including iritis, vitritis), which tends to develop overweeks or months of drug exposure. Usually, uveitis is easilymanagedwith temporary dose interruption, topical and/or systemic steroid therapy without serious sequelae. One case report described a severe bilateral uveitis with vitritis, early patchy choroidal hyperfluorescence and optic disk leakage on fluorescein angiography, resolved after drugs discontinuation without sequelae. Another report described a severe bilateral panuveitis with choroidal thickening, chorioretinal folds, and multiple serous retinal detachments resolved after starting topical corticosteroid treatment and dabrafenib discontinuation. We present here a case of bilateral ischemic retinal vasculitis developed over months of combined therapy.