Robert W. Wong

Iron toxicity as a potential factor in AMD.

While it has been known for years that iron overload is associated with retinal degeneration in the context of ocular siderosis, intraocular hemorrhage, and the hereditary diseases aceruloplasminemia and pantothenate kinase associated neurodegeneration, recent evidence suggests that age-related macular degeneration (AMD) may also be exacerbated by retinal iron overload. In the retina, iron is necessary for normal cellular function. Iron overload, however, can cause retinal toxicity through the generation of oxygen free radicals. Histopathology of eyes with macular degeneration has shown elevated levels of iron in the retinal pigment epithelium, Bruch membrane, and within drusen, some of which was chelatable in vitro with deferoxamine. In this review, the authors summarize the evidence that iron overload may contribute to AMD pathogenesis. It is hoped that continued investigation of the role of iron and iron associated proteins in the retina will uncover clues to AMD pathogenesis and lead to new preventative or therapeutic options.

INTRAVITREAL SULFUR HEXAFLUORIDE INJECTION FOR THE TREATMENT OF VITREOMACULAR TRACTION SYNDROME.

Purpose: Vitreomacular traction (VMT) syndrome can cause symptomatic metamorphopsia and decreased visual acuity. Although it is typically treated with vitrectomy or intravitreal ocriplasmin injection, these procedures can be invasive and costly. The purpose of this retrospective, consecutive case series was to evaluate the efficacy of intravitreal expansile sulfur hexafluoride gas injection for the treatment of symptomatic VMT syndrome. Methods: Nine eyes of 9 patients with symptomatic VMT syndrome on spectral domain optical coherence tomography received an intravitreal injection of 0.3 mL of 100% sulfur hexafluoride. The primary outcome was the number of eyes with release of VMT on spectral domain optical coherence tomography at 1 month after treatment. Secondary outcomes included change in visual acuity and central subfield thickness 1 month after treatment. Results: Five patients (55.6%) had release of VMT on spectral domain optical coherence tomography by 1 month after injection. Two patients who had Stage I macular holes before injection had closure of the macular holes. Mean visual acuity at 1 month improved slightly after injection by 0.09 logMAR units, although this change was not statistically significant (P = 0.15). Central subfield thickness on spectral domain optical coherence tomography decreased by an average of 35.3 microns after injection (P = 0.004). All eyes with release of VMT had pretreatment vitreomacular adhesion of less than 521 microns and none had epiretinal membranes. One patient (11.1%) developed a peripheral retinal hole at 1 month after injection. Conclusion: Intravitreal injection of expansile sulfur hexafluoride gas is a low-cost and minimally invasive alternative for the treatment of symptomatic VMT syndrome. Further study is warranted.

Complications associated with clear corneal cataract wounds during vitrectomy

Purpose:The purpose of this study was to report the intraoperative surgical complications that occurred during vitrectomy surgery associated with clear corneal incisions from previous cataract surgery. Methods:Retrospective, multicenter, case series, and chart review of five patients. Results:Five patients, 3 men and 2 women, with a median age of 75 years (range, 59-78 years), were followed up for a median of 7.5 months (range, 6 months to 5 years). In each eye, the patient had previously undergone cataract surgery and intraocular lens implantation through a clear corneal wound. Each patient developed a surgical complication during the subsequent vitrectomy related to leakage through the clear corneal wound. Vitrectomy was performed for retained lens fragments (three), macular hole (one), and repair of combined rhegmatogenous/tractional diabetic retinal detachment (one). Twenty-gauge vitrectomy was performed in 3 cases; 23-gauge in 1 case; and a combined 25- and 20-gauge vitrectomy was used in 1 case. Median time between cataract surgery and vitrectomy was 8 days (range, 0-14 days). Median preoperative visual acuity was 20/200 (20/50 to hand motions), and median postoperative visual acuity was hand motions (20/40 to light perception). In all five eyes, the clear corneal wound was found to leak extensively with minimal manipulation of the sclera at the pars plana. Leakage through clear corneal wounds occurred during marking of the sclerotomy site (Case 1), during placement of a 23-gauge infusion cannula (Case 2), during lens fragmentation (Case 3), during retinotomy and retinectomy (Case 4), and during scleral depression (Case 4). Four eyes developed choroidal detachment associated with hypotony caused by leakage through the clear corneal wound. Three of these eyes developed hemorrhagic choroidal detachment with subretinal and/or vitreous hemorrhage. One eye developed iris incarceration and anterior subluxation of a sulcus-placed intraocular lens associated with leakage through the clear corneal wound. In all five cases, extra sutures were placed to secure the clear corneal incision, and the cases were able to be completed. Two eyes underwent repeat vitrectomy to address complications associated with hemorrhagic choroidal detachments. Median final visual acuity was 20/400 (range, 20/40 to hand motions). The retina remained attached in all cases at the latest follow-up visit. Conclusion:Intraoperative complications related to clear corneal incisions can occur during pars plana vitrectomy. We recommend that cataract surgeons encountering complications during surgery should secure clear corneal wounds in anticipation of eventual vitrectomy surgery. It is incumbent on the retinal surgeon to carefully inspect the corneal wound at the start of the vitrectomy procedure and to close it with sutures if it appears to leak with minimal manipulation. This should help to minimize additional intraoperative and/or long-term complications.

Necrotizing Herpetic Retinitis

Department of Ophthalmology, California Pacific Medical Center, San Francisco, California, The Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, California, Austin Retina Associates, Austin, Texas, and Centre for Ophthalmology, University Tuebingen, Schleichstrasse 12, Tuebingen, Germany

Posterior scleritis in patients with systemic lupus erythematosus.

PURPOSE To describe three cases of posterior scleritis associated with systemic lupus erythematosus. METHODS Retrospective chart review including ophthalmic examination, fundus photography, optical coherence tomography, angiography, ultrasonography, and/or magnetic resonance imaging. RESULTS Three patients presented with blurred vision, red eye, and/or eye pain in one or both eyes. The diagnosis of posterior scleritis was confirmed in each patient using B-scan ultrasonography. One patient presented with giant nodular scleritis. In two patients, posterior scleritis was the presenting sign of systemic lupus erythematosus. Two patients received systemic corticosteroids together with noncorticosteroid immunosuppressive medications. One patient received topical and periocular injections of corticosteroids. All three patients showed prompt resolution of their posterior scleritis in response to treatment. CONCLUSION While uncommon, posterior scleritis may occur in patients with systemic lupus erythematosus and, in some instances, may be the presenting sign of the disease. Prompt diagnosis and treatment was associated with good visual outcomes in our patients.

Reported Complications Following Laser Vitreolysis

Importance Use of laser vitreolysis for symptomatic floaters has increased in recent years, but prospective studies are not available and the complication profile is poorly understood. Objective To analyze cases of complications following laser vitreolysis as voluntarily reported to the American Society of Retina Specialists Research and Safety in Therapeutics (ASRS ReST) Committee, an independent task force formed to monitor device-related and drug-related safety events. Design, Setting, and Participants A retrospective assessment was performed of all cases of complications following laser vitreolysis that were voluntarily reported by practitioners throughout the United States to the ASRS ReST Committee from the first report on September 19, 2016, through March 16, 2017, the date of data analysis and manuscript writing. Main Outcomes and Measures Complications reported to the ASRS ReST Committee following laser vitreolysis were analyzed by type to gain an understanding of the spectrum of potential complications. Results A total of 16 complications following laser vitreolysis were reported in 15 patients by 7 US vitreoretinal specialists during the study period. Complications included elevated intraocular pressure leading to glaucoma; cataracts, including posterior capsule defects requiring cataract surgery; retinal tear; retinal detachment; retinal hemorrhages; scotomas; and an increased number of floaters. Conclusions and Relevance This report presents a spectrum of complications reported to the ASRS ReST Committee across 6 months. The rate of complications cannot be determined because the denominator of total cases is unknown. Also, these findings cannot determine whether there is a causal association between these complications and laser vitreolysis. Prospective studies are warranted to better understand the efficacy of this procedure and the frequency of attendant complications. Until then, practitioners should be aware of the profile of potential complications to properly inform patients during the consent process. The ASRS ReST Committee will continue to monitor device-related and drug-related adverse events and encourages active surveillance and reporting by all physicians.

Angioid streaks and optic nerve head drusen in hyperphosphatemic familial tumoral calcinosis.

PURPOSE To describe a patient with angioid streaks and optic nerve head drusen associated with familial tumoral calcinosis (FTC). DESIGN Retrospective, observational case report. METHODS The patients records were reviewed. RESULTS After receiving blunt trauma to the head, the patient presented with loss of vision in the left eye. Fundus examination revealed bilateral angioid streaks, optic nerve head drusen, and choroidal ruptures associated with subretinal hemorrhages. Subsequent physical, laboratory, and radiologic examinations revealed periarticular calcification, elevated serum phosphate levels, and normal calcium levels, consistent with FTC. CONCLUSIONS FTC should be considered in the differential diagnosis for patients presenting with angioid streaks and optic nerve head drusen.

Surgically induced necrotizing scleritis and optic neuropathy after pars plana vitrectomy as presenting signs of churg-strauss syndrome.

PURPOSE To report a case of surgically induced necrotizing scleritis and optic neuropathy after pars plana vitrectomy as presenting signs of Churg-Strauss syndrome. METHOD Case report. RESULTS A 59-year-old Asian man underwent a 20-gauge pars plana vitrectomy to remove a posteriorly dislocated intraocular lens. During follow-up, he developed unilateral necrotizing scleritis and optic neuropathy. Systemic evaluation and laboratory investigations revealed findings consistent with Churg-Strauss syndrome. Systemic corticosteroids therapy produced dramatic improvement in visual symptoms. CONCLUSION Churg-Strauss syndrome should be considered in any patient who develops surgically induced necrotizing scleritis and/or optic neuropathy after pars plana vitrectomy. Prompt and aggressive treatment with systemic corticosteroids can result in marked improvement.

Immediate Vitrectomy Following Inadvertent Intravitreal Injection of Depo-Medrol

Purpose: To report a case of an iatrogenic intraocular injection of Depo-Medrol where prompt vitrectomy was performed leading to a good visual and anatomical outcome. Methods: Retrospective case report and review of the literature. Results: A 61-year-old man received an injection of Depo-Medrol for the treatment of trigeminal neuralgia that was inadvertently injected into the globe of the left eye leading to sudden and severe vision loss. Prompt vitrectomy was performed within 4 hours. Electroretinogram revealed that b-wave amplitudes in scotopic and photopic conditions were decreased by 25%. Following subsequent cataract surgery, the patient’s visual acuity improved to 20/20 vision. Conclusions: The toxic effects of Depo-Medrol may be dependent on the temporal and spatial contact of the preservative with the retina where prolonged exposure may cause widespread retinal damage hindering visual rehabilitation. Immediate vitrectomy may be crucial to preserve the anatomy and function of the retina.

Nonleaking cystoid macular edema in Cohen syndrome

An 11-year-old girl with a history of neutropenia, developmental delay, hypotonia, and intellectual disability was diagnosed with Cohen syndrome after genetic testing discovered homozygous mutation in the VPS13B gene. She was referred to a retinal specialist with a chief complaint of decreased peripheral vision. On examination, decreased visual acuity, pigmentary changes, and nonleaking cystoid macular edema were present in both eyes.