Shelley Day

Preclinical evaluation and intraoperative human retinal imaging with a high-resolution microscope-integrated spectral domain optical coherence tomography device

Purpose: The authors have recently developed a high-resolution microscope-integrated spectral domain optical coherence tomography (MIOCT) device designed to enable OCT acquisition simultaneous with surgical maneuvers. The purpose of this report is to describe translation of this device from preclinical testing into human intraoperative imaging. Methods: Before human imaging, surgical conditions were fully simulated for extensive preclinical MIOCT evaluation in a custom model eye system. Microscope-integrated spectral domain OCT images were then acquired in normal human volunteers and during vitreoretinal surgery in patients who consented to participate in a prospective institutional review board–approved study. Microscope-integrated spectral domain OCT images were obtained before and at pauses in surgical maneuvers and were compared based on predetermined diagnostic criteria to images obtained with a high-resolution spectral domain research handheld OCT system (HHOCT; Bioptigen, Inc) at the same time point. Cohorts of five consecutive patients were imaged. Successful end points were predefined, including ≥80% correlation in identification of pathology between MIOCT and HHOCT in ≥80% of the patients. Results: Microscope-integrated spectral domain OCT was favorably evaluated by study surgeons and scrub nurses, all of whom responded that they would consider participating in human intraoperative imaging trials. The preclinical evaluation identified significant improvements that were made before MIOCT use during human surgery. The MIOCT transition into clinical human research was smooth. Microscope-integrated spectral domain OCT imaging in normal human volunteers demonstrated high resolution comparable to tabletop scanners. In the operating room, after an initial learning curve, surgeons successfully acquired human macular MIOCT images before and after surgical maneuvers. Microscope-integrated spectral domain OCT imaging confirmed preoperative diagnoses, such as full-thickness macular hole and vitreomacular traction, and demonstrated postsurgical changes in retinal morphology. Two cohorts of five patients were imaged. In the second cohort, the predefined end points were exceeded with ≥80% correlation between microscope-mounted OCT and HHOCT imaging in 100% of the patients. Conclusion: This report describes high-resolution MIOCT imaging using the prototype device in human eyes during vitreoretinal surgery, with successful achievement of predefined end points for imaging. Further refinements and investigations will be directed toward fully integrating MIOCT with vitreoretinal and other ocular surgery to image surgical maneuvers in real time.

Retinopathy of prematurity malpractice claims: The ophthalmic mutual insurance company experience

OBJECTIVE To examine the causes of retinopathy of prematurity (ROP) malpractice claims filed with the Ophthalmic Mutual Insurance Company. METHODS All closed ROP malpractice claims were reviewed. RESULTS Eight cases involved failure of transfer of care on patient discharge from the hospital, 3 cases demonstrated inappropriately long periods between follow-up examinations, 1 case was due to failure of outpatient referral from screening to the treating ophthalmologist, and 1 case concerned unsupervised resident provision of ROP care. CONCLUSIONS Many preventable factors can be addressed to improve ROP care. It is essential to ensure that ophthalmologists, neonatologists, pediatricians, and families are updated on current guidelines for ROP screening and treatment and to facilitate follow-up appointments before patient discharge from the hospital. Doing so can help avoid future malpractice claims and patient harm.

Association of vitamin D deficiency and age-related macular degeneration in medicare beneficiaries

Several studies have found an association between vitamin D deficiency and age-related macular degeneration (AMD).1-4 Vitamin D has been shown to have immunomodulatory and antiangiogenic properties, suggesting a biologically plausible role in the pathogenesis of AMD.5 This study examines the possible association of vitamin D deficiency and subsequent incidence of first diagnosis of nonneovascular and neovascular AMD in a cohort of Medicare beneficiaries. To our knowledge, this is the first study to evaluate incidence rather than prevalence of AMD in a large sample of vitamin D–deficient patients.

VITAMIN D DEFICIENCY IN NEOVASCULAR VERSUS NONNEOVASCULAR AGE-RELATED MACULAR DEGENERATION

Purpose: To compare 25-hydroxyvitamin D (25OHD) levels in patients with neovascular age-related macular degeneration (NVAMD) with patients with nonneovascular age-related macular degeneration and control patients. Methods: Medical records of all patients diagnosed with age-related macular degeneration and tested for serum 25OHD level at a single medical center were reviewed. Control patients were selected from patients diagnosed with pseudophakia but without age-related macular degeneration. The lowest 25OHD level available for each patient was recorded. Results: Two hundred sixteen patients with nonneovascular age-related macular degeneration, 146 with NVAMD, and 100 non–age-related macular degeneration control patients were included. The levels of 25OHD (mean ± SD) were significantly lower in NVAMD patients (26.1 ± 14.4 ng/mL) versus nonneovascular age-related macular degeneration (31.5 ± 18.2 ng/mL, P = 0.003) and control (29.4 ± 10.1 ng/mL, P = 0.049) patients. The prevalence of vitamin D insufficiency (<30 ng/mL 25OHD), deficiency (<20 ng/mL), and severe deficiency (<10 ng/mL) were highest in the NVAMD group. The highest quintile of 25OHD was associated with a 0.35 (95% confidence interval, 0.18–0.68) odds ratio for NVAMD. Conclusion: This is the largest study to compare 25OHD levels in patients with the different clinical forms of age-related macular degeneration. Mean 25OHD levels were lower and vitamin D deficiency was more prevalent in NVAMD patients. These associations suggest that further research is necessary regarding vitamin D deficiency as a potentially modifiable risk factor for the development of NVAMD.

Interactive image-guided endoscopic dacryocystorhinostomy

The authors describe dacryocystorhinostomy performed with CT guidance. A 53-year-old man with a history of cocaine abuse was referred for bilateral nasolacrimal duct obstruction. Nasal speculum examination revealed an oronasal fistula and obliteration of the inferior nasal septum. Bilaterally, the inferior and middle turbinates were contracted, forming thick scar tissue conglomerates. The loss of normal anatomic landmarks and extensive contracted scar tissue precluded standard dacryocystorhinostomy approaches. Endoscopic dacryocystorhinostomy was therefore undertaken using CT-guided navigation. The location of the superior nasolacrimal duct was identified and subsequently exposed. Dissection was continued superiorly, marsupializing the lacrimal sac. Silicon stents were placed and tied intranasally. Right and left sides were managed similarly. Several months later, following stent removal, the patient was without epiphora. This case demonstrates that CT guidance can be a useful adjunct to standard dacryocystorhinostomy techniques, allowing otherwise challenging surgical cases to be managed effectively and safely.

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.

Spontaneous resolution of a traumatic cataract caused by an intralenticular foreign body

A 49-year-old man presented with an intralenticular metal foreign body incurred while he was sawing wood. The metal chard had violated the lens capsule and was lodged in the cortex of the lens. It was removed using a lens-preservation technique during open-globe repair. Subsequently, a dense posterior cortical cataract developed, which spontaneously resolved over the ensuing months. The cataract had a cruciate configuration with wave-like disruption of the stromal lamellae. To our knowledge, this is the first case of spontaneous resolution of a cataract after capsule violation by an intralenticular foreign body. The unique appearance of the cataract and its unusual resolution led to a new theory of lens injury by shockwave.

Incomplete Retinal Vascularization After Ranibizumab Treatment of Retinopathy of Prematurity.

A former 24-week-old premature infant was treated with intravitreal ranibizumab (Lucentis; Genentech, South San Francisco, CA) in one eye and conventional laser in the other eye for aggressive posterior retinopathy of prematurity in both eyes. Fluorescein angiography performed at 149 weeks of age showed persistent avascularity of the temporal peripheral retina in the ranibizumab-treated eye. This case report confirms the need for long-term follow-up of patients treated with ranibizumab monotherapy. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:75-78.].

Chapter 153 – Circumscribed Choroidal Hemangioma

Abstract Circumscribed choroidal hemangiomas are benign vascular tumors that can produce retinal exudation and fluid leakage.

BILATERAL CHOROIDAL EXCAVATION IN JUVENILE LOCALIZED SCLERODERMA.

Purpose: To describe a case of bilateral choroidal excavation in a patient with juvenile localized scleroderma. Methods: Case report. Results: An asymptomatic 12-year-old boy with localized scleroderma presented for examination and was found to have bilateral areas of choroidal excavation temporal to the fovea. Conclusion: Previous reports of ocular complications of localized scleroderma have primarily described adnexal and anterior segment changes. This is the second report of choroidal changes in a patient with localized scleroderma, and the first in a pediatric patient.