Philip J. Banerjee

Bilateral macular hole from a handheld laser pointer

In March, 2012, a 15-year-old boy presented to our vitreoretinal department with a 3 week history of reduced vision in both eyes. He reported an acute drop in central vision, immediately after looking directly at a powerful laser pointer while lighting a cigarette. His vision had deteriorated further over the following 3 weeks, before seeking medical advice. The device had been purchased online, and had an emission power of 1000 mW and a wavelength of 474 nm (reading from the label of the device). On clinical examination, his visual acuity was 6/18 in both eyes. Fundus examination showed bilateral macular holes with irregular scalloped edges (fi gure, appendix). Optical coherence tomography (OCT) confi rmed the diagnosis (fi gure). Surgical treatment with vitrectomy, internal limiting membrane peeling, and gas tamponade was off ered, but the patient declined. At fi nal follow up, in March, 2012, the vision remained the same. The patient was discharged on the understanding that he would contact our department should he change his mind about surgery. Although the use of handheld laser devices has become common in everyday life, their potential as an ocular hazard has not been adequately described. In recent years high-power laser pointers, identical in appearance to those used in lecture theatres, have become easily obtainable at low cost via the internet. These devices have become popular among young people for their novel application in lighting cigarettes, popping balloons, and burning holes in objects. Laser pointers with an output power of less than 5 mW are regarded as harmless to the human eye because of the limited exposure aided by innate ocular protective mechanisms (blink refl ex and aversion response). Devices with an output power of more than 150 mW are capable of causing severe ocular damage. Retinal damage from high-power lasers has been reported mostly in the setting of military, industrial, or hospital use. The severity of damage is directly dependent on the laser type, wavelength, duration of exposure, and spot size. Diff erent ocular structures absorb light of varying wavelengths, with photochemical retinal damage (photocoagulation and photodisruption) more likely to be caused by blue light. Previous reports describe varying retinal pathology caused by handheld lasers. Wyrsch et al reported a 15-year-old boy who sustained a submacular haemorrhage after using a handheld green laser pointer with an output power of 150 mW. Similar fi ndings were recently published by Alsulaiman et al after the use of handheld lasers with 750 mW output power at 450 nm wavelength. Outer retinal disruption, epiretinal membrane with subretinal fl uid, and unilateral macular holes were also presented in this series; macular holes were associated with a shorter ocular-laser exposure distance. In our case, although the patient reported that the bilateral injury occurred when he was attempting to light a cigarette with simultaneous foveal exposure, it is more likely that each eye was separately exposed to the full beam while his gaze was at the output aperture. We are unaware of other reports of bilateral macular holes caused by the use of a handheld laser pointer. The device was obtained from the internet at low cost and was identical in appearance to low-power laser pointers. We suggest that these devices be classifi ed as seriously hazardous for vision and urge government action to raise public and physician awareness.

Ozurdex® (a slow-release dexamethasone implant) in proliferative vitreoretinopathy: study protocol for a randomised controlled trial

BackgroundProliferative vitreoretinopathy (PVR) is the commonest cause of late anatomical failure in rhegmatogenous retinal detachment. Visual and anatomical outcomes remain poor despite advances in vitreoretinal surgical techniques with reported primary failure rates of up to nearly 50%. Numerous adjunctive medications have been evaluated in clinical trials with no agent gaining widespread acceptance and use.This study was designed to investigate the benefits of using a slow-release dexamethasone implant delivered intra-operatively in patients undergoing vitrectomy surgery for retinal detachment with established PVR.Methods/designFor the study, 140 patients requiring vitrectomy surgery with silicone oil for retinal detachment with established PVR will be randomised to receive either standard treatment or study treatment in a 1:1 treatment allocation ratio. Both groups will receive the standard surgical treatment appropriate for their eye condition and routine peri-operative treatment and care, differing only in the addition of the supplementary adjunctive agent in the treatment group. The investigated primary outcome measure is stable retinal reattachment with removal of silicone oil without additional vitreoretinal surgical intervention at 6 months.DiscussionThis is the first randomised controlled clinical trial to investigate the use of an adjunctive slow-release dexamethasone implant in patients undergoing vitrectomy surgery for retinal detachments with proliferative vitreoretinopathy.Trial registrationEudraCT No:2011-004498-96.

Neurotrophic Corneal Ulceration After Retinal Detachment Surgery With Retinectomy and Endolaser: A Case Series

IMPORTANCE Trigeminal nerve lesions at differing levels can result in complete or partial corneal anesthesia and ensuing epithelial breakdown. Disease progression can lead to corneal ulceration, melt, and perforation. To our knowledge, neurotrophic corneal ulceration has not previously been reported after retinal detachment surgery and argon endolaser. OBSERVATION Herein, we report a series of 5 cases of patients without diabetes who developed neuropathic corneal ulceration presumed secondary to long ciliary nerve compromise. This occurred within 5 to 10 weeks following vitrectomy surgery with endolaser and silicone oil tamponade for retinal detachment. CONCLUSIONS AND RELEVANCE Clinicians should be mindful of the long ciliary nerves intraoperatively and, where possible, avoid heavy confluent treatment at these sites without compromising the need for adequate retinopexy. Where corneal anesthesia occurs, it is important to recognize this early and treat promptly to minimize the risk for ulceration and visual loss.

Triamcinolone during pars plana vitrectomy for open globe trauma: a pilot randomised controlled clinical trial

Purpose To investigate the feasibility of conducting a randomised controlled trial in patients undergoing pars plana vitrectomy surgery following open globe trauma (OGT). Additionally, to investigate the treatment effect and toxicity of intensive anti-inflammatory agents. Methods A 2-year, pilot, single-centre prospective, participant and surgeon-masked randomised controlled trial (RCT). Forty patients requiring vitrectomy surgery following OGT were randomised to either standard (control) or study treatment (adjuncts) in a 1:1 allocation ratio. Perioperatively, the adjunct group received intravitreal and subtenons triamcinolone acetonide, oral flurbiprofen and guttae prednisolone acetate 1%. The control group received standard care. Primary outcome was anatomical success at 6 months. Secondary outcomes included final visual acuity, occurrence of proliferative vitreoretinopathy, intraocular pressure rise, number of operations and recruitment rate. Results 40 patients were recruited within 21 months. Primary outcome assessment showed similar results in anatomical success with 50% (10/20) in the adjunct group compared with 47% (9/19) in the standard group (OR 1.11, 95% CI 0.316 to 3.904). Visual outcomes were better in the adjunct group with a final median visual acuity of 31 Early Treatment Diabetic Retinopathy Study (ETDRS) letters compared with 25 ETDRS letters in the standard group. A higher proportion of patients gained 10, 20 and 30 ETDRS letters in the adjunct group (80%, 65% and 50%, respectively) compared with the standard group (52.6%, 52.6% and 42.1%). Fewer adjunct patients (15%, n=3) had poor visual outcomes (Zero ETDRS letters) compared with 42.1%, (n=8). Conclusions An RCT in this population is deliverable and estimated recruitment rates are realistic. Results and patient discussions determined that the definitive study should have vision as a primary outcome. This pilot study is supportive of there being a positive treatment effect of intensive anti-inflammatory agents in OGT. Trial registration number European Clinical Trials Database 2007-005138-35; Results.

Grading in ectopia lentis (GEL): a novel classification system

Ectopia lentis (EL) can be caused by trauma or associated with ophthalmic and systemic disorders such as Marfan syndrome (OMIM154700), pseudoexfoliation or isolated EL (OMIM129600). It is therefore managed and researched by a wide range of physicians and scientists. To date, there is no validated method of classifying the clinical features of this condition. A novel grading in ectopia lentis (GEL) classification system was created to encompass the possibilities of lens movement. This was assessed on anterior segment images from our hospital database of patients with EL of any aetiology. All pupils were pharmacologically dilated with a combination of tropicamide (1%) and phenylephrine (2.5%) drops. Primarily, subluxation (Sub) was defined as movement of the lens within coronal plane behind the iris, while dislocation (D) was defined as complete movement either anteriorly (DA) into the anterior chamber or posteriorly (DP) into the vitreous cavity. Subluxation was categorised by direction and …

Characteristics and vitreoretinal management of retinal detachment in eyes with Boston keratoprosthesis

Purpose To review the incidence and features of vitreoretinal complications of a permanent Boston keratoprosthesis and to report the use and outcomes of 23-gauge vitrectomy to manage vitreoretinal pathology. Design Retrospective non-comparative, interventional case series. Subject, Participants 27 eyes of 27 patients managed with a Boston keratoprosthesis at Moorfields Eye Hospital over a 3-year period. Methods All eyes that underwent pars plana vitrectomy (PPV) and had at least 6 months follow-up were analysed with a specific focus on the anatomical and histological characteristics of retinal detachment and outcomes of surgery. Main outcome measures Anatomical success and characteristics of retinal detachment over the follow-up period. Results 27 patients underwent Boston keratoprosthesis implantation over the study period. Of these, six (22%) required PPV for retinal detachment which demonstrated a specific pattern of serous elevation with subsequent severe anterior proliferative vitreoretinopathy (PVR). The mean follow-up period was 9 months (range 6–14 months). At final follow-up, visual acuity ranged from perception of light to 6/18, and five of six cases had attached retinae under the silicone oil. Histological analysis of a subretinal membrane demonstrated a predominantly glial/retinal pigment epithelium fibrocellular tissue, consistent with PVR. Conclusions The study showed that retinal detachment complicated by PVR, as demonstrated by the clinical and histological characteristics of this condition, is common in patients undergoing Boston keratoprosthesis. We also showed that 23-gauge vitrectomy can be effectively performed in patients with a permanent prosthesis. Visual acuity often remains poor, despite successful anatomical results.

Long-Term Survival Rates of Patients Undergoing Vitrectomy for Proliferative Diabetic Retinopathy

ABSTRACT Purpose: Reported 5-year survival rates in patients undergoing vitreous surgery for proliferative diabetic retinopathy (PDR) range from 68–95%. Studies relating survival rates to medical baseline characteristics predate the millennium. This study aimed to update data on life expectancy of patients undergoing vitrectomy for PDR and identify baseline factors which may influence survival. Methods: A retrospective cohort study of consecutive patients who underwent their first pars-plana vitrectomy for PDR between April 2004 and May 2005 was performed. Survival status on 1 May 2012 was the primary endpoint. The Kaplan-Meier life table method was used to determine survival rates. Univariate and multiple variable Cox proportional hazards regressions were used to identify risk factors for mortality. Results: A total of 148 patients were included in the study, with a mean age of 54 years (range 20–80 years) at time of surgery. The 3-, 5- and 7-year survival rates were 94%, 86% and 77%, respectively (95% confidence interval, CI, 88–97%, 79–91% and 68–84%, respectively). Renal failure was the most common cause of death. The presence of limb ulcers at baseline was the most important prognostic indicator for mortality, with a hazard ratio of 3.13 (95% CI 1.46–6.71, p = 0.003) and a survival rate at 5 years reduced to 79%. Conclusion: The 5-year survival rate remains comparable to those reported 20 years ago despite a lowering in threshold for vitrectomy and increased health awareness. Limb ulcers are strongly associated with increasing mortality. Clinicians should remain mindful of the systemic associations of diabetes particularly in advanced retinal disease.

A phase III, multi-centre, double-masked randomised controlled trial of adjunctive intraocular and peri-ocular steroid (triamcinolone acetonide) versus standard treatment in eyes undergoing vitreoretinal surgery for open globe trauma (ASCOT): statistical analysis plan

BackgroundOpen globe ocular trauma complicated by intraocular scarring (proliferative vitreoretinopathy) is a relatively rare, blinding, but potentially treatable condition for which, at present, surgery is often unsatisfactory and visual results frequently poor. To date, no pharmacological adjuncts to surgery have been proven to be effective. The aim of the Adjunctive Steroid Combination in Ocular Trauma (ASCOT) randomised controlled trial is to determine whether adjunctive steroid (triamcinolone acetonide), given at the time of surgery, can improve the outcome of vitreoretinal surgery in patients with open globe ocular trauma. This article presents the statistical analysis plan for the main publication as approved and signed off by the Trial Steering Committee prior to the first data extraction for the Data Monitoring Committee meeting report.Methods/designASCOT is a pragmatic, multi-centre, parallel-group, double-masked randomised controlled trial. The aim of the study is to recruit from 20–25 centres in the United Kingdom and randomise 300 eyes (from 300 patients) into two treatment arms. Both groups will receive standard surgical treatment and care; the intervention arm will additionally receive a pre-operative steroid combination (triamcinolone acetonide) into the vitreous cavity consisting of 4 mg/0.1 ml and 40 mg/1 ml sub-Tenon’s. Participants will be followed for 6 months post-surgery. The primary outcome is the proportion of patients achieving a clinically meaning improvement in visual acuity in the study eye at 6 months after initial surgery, defined as a 10 letter score improvement in the ETDRS (the standard scale to test visual acuity).Trial registrationISRCTN30012492. Registered on 5 September 2014.EudraCT2014-002193-37. Registered on 5 September 2014.

IV.F. Pharmacotherapy of Proliferative Vitreoretinopathy

Proliferative vitreoretinopathy (PVR) is the most common cause of late anatomic failure in retinal detachment surgery, with a reported incidence of 5–11 % of all rhegmatogenous retinal detachments [1]. PVR can be considered an exaggerated wound healing response in specialized tissue, resulting in the formation of complex fibrocellular membranes on both surfaces of the retina and the posterior vitreous cortex. Contraction of these membranes then distorts the normal retinal architecture with resultant visually detrimental sequelae and/or traction retinal detachment, with re-opening of preexisting retinal breaks or the formation of new ones. Based on the premise that the primary pathology was centered in the vitreous, PVR was previously referred to as massive vitreous retraction syndrome (MVR) or massive preretinal retraction syndrome (MPR). However, to acknowledge the role of periretinal membrane formation and pigment epithelial cell proliferation, PVR later became known as massive periretinal proliferation (MPP) [2]. A unifying classification system was established in 1983 by the Retina Society Terminology Committee [1] coining the phrase proliferative vitreoretinopathy (PVR), which was later updated in 1991 to the current classification system in clinical practice today [3].

Pars Plana Vitrectomy for Vitreomacular Traction Syndrome: Analysing the Preoperative Prognostic Factors

ABSTRACT Purpose: To identify the prognostic factors affecting the surgical outcomes in patients with vitreomacular traction syndrome undergoing pars plana vitrectomy. Methods: This was a retrospective clinical study of 67 eyes of 67 patients with vitreomacular traction syndrome who underwent pars plana vitrectomy. Demographic, clinical, and optical coherence tomography (OCT) characteristics were collected and analyzed. Univariate and multivariate linear regression analysis were used to examine the effect of parameters on change in best-corrected visual acuity (BCVA). Results: At a mean follow-up period of 15.9±12 months (mean±SD), the BCVA improved from 0.7±0.3 LogMAR (mean±SD) to 0.5±0.3. Seven patients developed full-thickness macular hole intraoperatively and tamponade (air, 20% SF6 or 12% C3F8) was used in 41 patients. Retinal breaks were identified intraoperatively in four patients. Regression analysis demonstrated that the preoperative BCVA was the only parameter affecting the postoperative visual outcome. Conclusion: In the present study, the preoperative BCVA plays a predictive role in the surgical outcome of patients with VMT undergoing pars plana vitrectomy. No other preoperative OCT characteristics demonstrated prognostic potential. Further prospective studies are needed in order to examine the role of several factors that could potentially facilitate preoperative patient counselling.