Patrick Oellers

Surgery for proliferative diabetic retinopathy: New tips and tricks

Over the recent years, retina specialists have enjoyed significant improvements in the surgical management of proliferative diabetic retinopathy including improved preoperative planning, vitreoretinal instrumentation and new surgical maneuvers. In this review, we present new tips and tricks such as preoperative pharmacotherapy approaches including pegaptanib injection and biodegradable dexamethasone implantation, bimanual vitrectomy techniques and the concept of mixing small gauges as well as valved cannulas and intraoperative optical coherence tomography. With advanced surgical planning and sophisticated operative maneuvers tailored to the individual patient, excellent outcomes can be achieved even in severe cases of diabetic tractional detachment.

SMALL-GAUGE VALVED VERSUS NONVALVED CANNULA PARS PLANA VITRECTOMY FOR RETINAL DETACHMENT REPAIR.

Purpose: To compare functional and anatomical outcomes and complication rates between valved versus traditional nonvalved small-gauge cannula vitrectomy for retinal detachment repair. Methods: Retrospective case series of 163 eyes undergoing small-gauge valved versus nonvalved vitrectomy with intraoperative perfluoro-n-octane for retinal detachment repair at a single academic institution. Results: There were 104 eyes in the valved cannula group and 59 eyes in the nonvalved cannula group. The valved group had lower baseline Grade C proliferative vitreoretinopathy (35 vs. 53%, P = 0.031) and combined rhegmatogenous retinal detachment/tractional retinal detachment (3 vs. 12%, P = 0.037), but both groups had otherwise comparable preoperative characteristics. Final postoperative best-corrected visual acuity was 1.01 logarithm of the minimum angle of resolution (Snellen 20/205) and 1.27 (Snellen 20/372) (P = 0.131) in valved and nonvalved cannula eyes, respectively. Single surgery success was equivalent between the valved and nonvalved groups (88 vs. 86%; P = 1.00). Final anatomical success was higher in the valved versus nonvalved group (98 vs. 90%; P = 0.027). Complication rates were not statistically different, including Postoperative Day 1 intraocular pressure, Postoperative Day 1 anterior chamber fibrin, retained subretinal/intraocular perfluoro-n-octane, and epiretinal membrane peeling. Conclusion: Valved cannulas, with their improved fluidics, are an important addition to pars plana vitrectomy with similar functional and anatomical success without increased complication rates compared with traditional nonvalved cannulas.

Spontaneous resolution of subfoveal perfluorocarbon

Perfluorocarbon liquids (PFCL) have transformed the surgical approach to complex retinal detachments, but their use can be complicated by subretinal retention. Migration of peripherally located subretinal PFCL towards the fovea is well established, but spontaneous resolution of subfoveal PFCL without surgical evacuation or displacement has rarely been described. We present a case of a large single retained subfoveal PFCL droplet following vitrectomy with membrane peeling, inferior relaxing retinectomy, and silicone oil tamponade that demonstrated spontaneous resolution 3 weeks postoperatively, with subsequent anatomic and visual improvement. No residual subretinal PFCL was noted, and we hypothesize that the PFCL droplet spontaneously extruded through a transient hole created in the thinned retina overlying the droplet, which subsequently closed spontaneously. Further understanding of the mechanisms of PFCL migration and resolution may facilitate improved treatments for this complication.

Role of aflibercept for macular edema following branch retinal vein occlusion: comparison of clinical trials

For years, the standard of care for branch-retinal-vein-occlusion-associated macular edema was initial observation followed by grid-pattern laser photocoagulation for persistent edema. Newer pharmacologic options have revolutionized the management of branch-retinal-vein-occlusion-associated macular edema, and the visual outcomes of these eyes are better than ever. However, a variety of available treatment options including intravitreal corticosteroids and intravitreal anti-vascular endothelial growth factor agents have established novel challenges with regard to appropriate drug selection. This review summarizes the available clinical studies with special emphasis on the comparison of intravitreal aflibercept with ranibizumab, bevacizumab, and steroid agents.

Retained Intraocular Perfluoro-n-octane After Valved Cannula Pars Plana Vitrectomy for Retinal Detachment

BACKGROUND AND OBJECTIVE To investigate cases of retained intraocular perfluoro-n-octane (PFO) after pars plana vitrectomy (PPV) for retinal detachment (RD). PATIENTS AND METHODS Retrospective, noncomparative case series of six eyes with retained intraocular PFO after RD repair. Clinical data were supplemented with an experimental silicone eye model. RESULTS A cluster of six cases of retained intraocular PFO after PPV for RD repair were noted shortly after transitioning to valved cannulas. PFO was noted in the anterior chamber (AC) and/or vitreous and removed with AC paracentesis, AC wash-out, and/or PPV. A silicone eye model demonstrated that PFO levels are maintained anterior to cannula insertion with valved cannulas only. CONCLUSION The authors hypothesize that anterior PFO fill using valved cannulas can lead to sequestration within the AC, zonules, ciliary sulcus, ciliary teeth, and/or capsular bag. They suggest vigilance in not overfilling PFO, particularly when transitioning to use of valved cannulas, to minimize the risk of intraocular retention.

Novel grid combined with peripheral distortion correction for ultra-widefield image grading of age-related macular degeneration

Purpose Eyes with age-related macular degeneration (AMD) often harbor pathological changes in the retinal periphery and perimacular region. These extramacular changes have not been well classified, but may be phenotypically and functionally relevant. The purpose of this study was to demonstrate a novel grid to systematically study peripheral retinal abnormalities in AMD using geometric distortion-corrected ultra-widefield (UWF) imaging. Methods This is a cross-sectional observational case series. Consecutive patients with AMD without any other coexisting vitreoretinal disease and control patients over age 50 without AMD or any other vitreoretinal disease were imaged using Optos 200 Tx. Captured 200° UWF images were corrected for peripheral geometric distortion using Optos transformation software. A newly developed grid to study perimacular and peripheral abnormalities in AMD was then projected onto the images. Results Peripheral and perimacular changes such as drusen, retinal pigment epithelium changes and atrophy were found in patients with AMD. The presented grid in conjunction with geometric distortion-corrected UWF images allowed for systematic study of these peripheral changes in AMD. Conclusion We present a novel grid to study peripheral and posterior pole changes in AMD. The grid is unique in that it adds a perimacular zone, which may be important in characterizing certain phenotypes in AMD. Our UWF images were corrected for geometric peripheral distortion to accurately reflect the anatomical dimensions of the retina. This grid offers a reliable and reproducible foundation for the exploration of peripheral retinal pathology associated with AMD.

Imaging the Deep Choroidal Vasculature Using Spectral Domain and Swept Source Optical Coherence Tomography Angiography

Purpose: To evaluate the deeper choroidal vasculature in eyes with various ocular disorders using spectral domain (SD) optical coherence tomography angiography (OCTA) and swept source (SS) OCTA. Methods: Patients underwent OCTA imaging with either SD-OCTA (Zeiss Cirrus Angioplex or Optovue AngioVue) or SS-OCTA (Topcon Triton). Retinal pigment epithelium (RPE) integrity, structural visualization of deep choroidal vessels on en face imaging, and OCTA of deep choroidal blood flow signal were analyzed. Choroidal blood flow was deemed present if deeper choroidal vessels appeared bright after appropriate segmentation. Results: Structural visualization of choroidal vessels was feasible in all eyes by en face imaging. In both SD-OCTA and SS-OCTA, choroidal blood flow signal was present in all eyes with overlying RPE atrophy (100% of eyes with RPE atrophy, 28.6% of all imaged eyes, P < .001). Conclusions: While choroidal vessels can be visualized anatomically in all eyes by en face imaging, choroidal blood flow detection in deep choroidal vessel is largely restricted to areas with overlying RPE atrophy. Intact RPE acts as a barrier for reliable detection of choroidal flow using current OCTA technology, inhibiting evaluation of flow in deeper choroidal vessels in most eyes.

Saturday Night Retinopathy After Intranasal Heroin

Purpose: To describe the clinical features of a case of Saturday night retinopathy (SNR) following intranasal heroin use. Methods: Ophthalmological examination, including optical coherence tomography and fluorescein angiogram, was performed. Serial images were obtained at follow-up visits at 1 week and 1 month. Results: The visual acuity was no light perception vision and there was an afferent pupillary defect in the affected eye. There was also evidence of complete ophthalmoplegia, globe proptosis, conjunctival chemosis, and corneal epitheliopathy and funduscopic evidence of ophthalmic artery occlusion. Follow-up imaging showed choroidal and retinal nonperfusion. Magnetic resonance imaging demonstrated edematous extraocular muscles and a bilateral hippocampal ischemia. Conclusions: This is the first case of SNR following intranasal heroin use and opioid-associated hippocampal ischemia. As physicians witness the impacts of the country’s opioid epidemic, it is important to recognize SNR as a cause of acute visual loss.

Hemorrhagic choroidal melanoma

Purpose To demonstrate the clinical pathologic correlation in a hemorrhagic choroidal melanoma. Observations A 52 year old patient presented with a large choroidal mass associated with vitreous and retinal hemorrhage. The eye was enucleated and histopathology demonstrated epithelioid-type MART1 positive tumor cells consistent with choroidal melanoma. The tumor had broken through Bruchs membrane, which led to localized vascular compression with bleeding into the subretinal space, retina and vitreous. Conclusions and importance Choroidal melanoma rarely presents with hemorrhage. Tumor rupture through Bruchs membrane may result in a tourniquet effect on the tumor vasculature leading to massive hemorrhage, as in this case. A high level of clinical suspicion is required to make the diagnosis.

Overloaded Dysfunctional RPE Leads to Delayed Absorption of Subretinal Fluid After Retinal Detachment Repair

Persistent subretinal fluid (SRF) can impair visual recovery after vitrectomy or scleral buckling surgery for rhegmatogenous retinal detachment. Several hypotheses have been proposed for delayed absorption of SRF, but the etiology has not been clearly identified. The authors present a patient with persistent SRF after vitrectomy for retinal detachment who developed central serous chorioretinopathy (CSCR) during the postoperative period in the nonoperative eye. Thus, subclinical retinal pigment epithelial (RPE) dysfunction was likely present in the operative eye, and when overloaded with SRF after retinal detachment repair, this manifested as delayed absorption. This may be the first evidence for overloaded, dysfunctional RPE as the etiology for persistent SRF following otherwise uncomplicated retinal detachment repair. The authors propose that RPE dysfunction can manifest as CSCR or, when overloaded with SRF after RD repair, it can also manifest as delayed absorption of SRF. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:852-855.].