Yewlin E. Chee

Achieving Target Refraction after Cataract Surgery

PURPOSE To evaluate the difference between target and actual refraction after phacoemulsification and intraocular lens implantation at an academic teaching institutions Comprehensive Ophthalmology Service. DESIGN Retrospective study. PARTICIPANTS We examined 1275 eye surgeries for this study. METHODS All consecutive cataract surgeries were included if they were performed by an attending or resident surgeon from January through December 2010. Postoperative refractions were compared with preoperative target refractions. Patients were excluded if they did not have a preoperative target refraction documented or if they did not have a recorded postoperative manifest refraction within 90 days. MAIN OUTCOME MEASURES The main outcome measure was percentage of cases achieving a postoperative spherical equivalent ± 1.0 diopter (D) of target spherical equivalent. RESULTS We performed 1368 cataract surgeries from January through December of 2010. Of these, 1275 (93%) had sufficient information for analysis. Of the included cases, 94% (1196 of 1275) achieved ± 1.0 D of target refraction by 90 days after cataract surgery. CONCLUSIONS This paper establishes a new benchmark for a teaching hospital, where 94% of patients achieved within 1.0 D of target refraction after cataract surgery. The refractive outcomes after cataract surgery at this academic teaching institution were higher than average international benchmarks.

Retinal Detachment After Open-globe Injury

Open-globe injuries are a major cause of vision loss worldwide, with over 200,000 such injuries occurring each year. Defined as any fullthickness wound of the eye wall, open-globe injuries can result in significant damage to the anterior and posterior segments of the eye and necessitate multiple surgical interventions over the course of years. Although visual outcomes with surgical repair of open globes have improved over the past several decades, many severely damaged eyes continue to have poor visual potential. Multiple predictors of visual outcome after open-globe injury have been identified, including the presence of relative afferent pupillary defect, preoperative visual acuity (VA), mechanism of injury, location of rupture site, and retinal detachment. Many studies have demonstrated that retinal detachment both at the time of initial presentation and in the postoperative course after open-globe repair is associated with poor vision, phthisis, and enucleation. This review will examine the pathogenesis, incidence, predictors, repair, possible prophylaxis, and prognosis of retinal detachments after open-globe injuries.

Choroidal rupture: a review.

Choroidal ruptures have been reported in up to 5% to 10% of cases of blunt ocular trauma but can also occur in the setting of penetrating or perforating injuries. In one study of 111 cases of choroidal rupture presenting at a single institution, 28% were due to open globe injuries, whereas 72% were due to closed globe injuries. Patients with angioid streaks are at particularly high risk of choroidal rupture after trauma, owing to the brittle nature of their Bruch membrane. Virtually any form of traumatic injury to the eye can result in choroidal ruptures. Sports injuries predominate in the literature, including injuries occurring during karate, or caused by various sports equipment including a hockey puck, soccer ball, cricket ball, basketball, tennis ball, golf ball, baseball, or paint ball. Other reported injuries include assault, or trauma from a stone, brick, ice ball, champagne cork, elastic cord, or other miscellaneous objects. Choroidal rupture has been reported after a kick by a horse, as well as after deployment of a car airbag. They have been reported in neonates from forceps used during delivery.

Prevention of Proliferative Vitreoretinopathy by Suppression of Phosphatidylinositol 5-Phosphate 4-Kinases.

Purpose Previous studies have shown that vitreous stimulates degradation of the tumor suppressor protein p53 and that knockdown of phosphatidylinositol 5-phosphate 4-kinases (PI5P4Kα and -β) abrogates proliferation of p53-deficient cells. The purpose of this study was to determine whether vitreous stimulated expression of PI5P4Kα and -β and whether suppression of PI5P4Kα and -β would inhibit vitreous-induced cellular responses and experimental proliferative vitreoretinopathy (PVR). Methods PI5P4Kα and -β encoded by PIP4K2A and 2B, respectively, in human ARPE-19 cells were knocked down by stably expressing short hairpin (sh)RNA directed at human PIP4K2A and -2B. In addition, we rescued expression of PI5P4Kα and -β by re-expressing mouse PIP4K2A and -2B in the PI5P4Kα and -β knocked-down ARPE-19 cells. Expression of PI5P4Kα and -β was determined by Western blot and immunofluorescence. The following cellular responses were monitored: cell proliferation, survival, migration, and contraction. Moreover, the cell potential of inducing PVR was examined in a rabbit model of PVR effected by intravitreal cell injection. Results We found that vitreous enhanced expression of PI5P4Kα and -β in RPE cells and that knocking down PI5P4Kα and -β abrogated vitreous-stimulated cell proliferation, survival, migration, and contraction. Re-expression of mouse PIP4Kα and -β in the human PI5P4Kα and -β knocked-down cells recovered the loss of vitreous-induced cell contraction. Importantly, suppression of PI5P4Kα and -β abrogated the pathogenesis of PVR induced by intravitreal cell injection in rabbits. Moreover, we revealed that expression of PI5P4Kα and -β was abundant in epiretinal membranes from PVR grade C patients. Conclusions The findings from this study indicate that PI5P4Kα and -β could be novel therapeutic targets for the treatment of PVR.

The Role of Vitrectomy in the Management of Fungal Endophthalmitis

ABSTRACT Fungal endophthalmitis is an important cause of vision loss worldwide with a large body of literature describing the treatment of the disease. The evidence supporting the use of pars plana vitrectomy in the management of fungal endophthalmitis is largely comprised of case reports and case series and demonstrates the important role of vitrectomy surgery. Vitrectomy can improve the likelihood of establishing the diagnosis, enhance the treatment of infection by removing fungal elements in the vitreous, aid in the removal of other inoculated intraocular structures, and is an important tool in the management of vision-threatening post-infectious sequelae like retinal detachment and epiretinal membrane.

Introduction of the MDM2 T309G Mutation in Primary Human Retinal Epithelial Cells Enhances Experimental Proliferative Vitreoretinopathy

Purpose The murine double minute (MDM)2 is a critical negative regulator of the p53 tumor suppressor, and MDM2 SNP309G is associated with a higher risk of proliferative vitreoretinopathy (PVR); in addition, the MDM2 T309G created using clustered regularly interspaced short palindromic repeats (CRISPR)/associated endonuclease (Cas)9 enhances normal rabbit vitreous-induced expression of MDM2 and survival of primary human retinal pigment epithelial (hRPE) cells in vitro. The goal of this study was to determine whether this MDM2 T309G contributes to the development of experimental PVR. Methods hRPE cells expressing MDM2 T309G or T309T only were treated with vitreous from human PVR donors (HV). The expression of MDM2 and p53 in the treated cells was examined by Western blot. The in vitro vitreous-induced cellular responses, such as contraction were assessed, and PVR was induced by intravitreal injection of the hRPE cells with MDM2 T309G or T309T only into rabbit eyes. Results Western blot analyses indicated that treatment of hRPE cells with HV led to a significant increase (1.7 ± 0.2-fold) in the expression of MDM2 and a significant decrease in p53 in the cells expressing MDM2 T309G compared with those with MDM2 T309T. In addition, HV promoted contraction of the hRPE cells expressing MDM2 T309G significantly more than those with MDM2 T309T only. Furthermore, MDM2 T309G in the hRPE cells enhanced the development of PVR in a rabbit model. Conclusions The MDM2 SNP309 in RPE cells enhances their potential of PVR pathogenesis.

Remarkable visual recovery after severe open globe injury

Purpose To describe a case of remarkable visual recovery after severe open globe injury. Observations We present a case of a 70-year-old man with an open globe injury with no light perception vision before and after primary repair of his ruptured globe and before secondary vitreoretinal surgery to repair a total retinal detachment with a 360° giant retinal tear and retinal incarceration in a posterior scleral wound who proceeded to recover vision to the 20/60 pinhole to 20/50 level. Conclusions and importance Poor presenting acuity is a known risk factor for poor visual outcome after open globe injury. We hypothesize this remarkable visual recovery could be attributable to the presence of a massive choroidal hemorrhage and limited intraocular hemorrhage elsewhere. In rare cases, vision can improve from the no light perception level after secondary vitreoretinal surgery.

Improving the Teaching Skills of Residents in a Surgical Training Program: Results of the Pilot Year of a Curricular Initiative in an Ophthalmology Residency Program

OBJECTIVE To design and implement a teaching skills curriculum that addressed the needs of an ophthalmology residency training program, to assess the effect of the curriculum, and to present important lessons learned. DESIGN A teaching skills curriculum was designed for the Harvard Medical School (HMS) Residency Training Program in Ophthalmology. Results of a needs assessment survey were used to guide curriculum objectives. Overall, 3 teaching workshops were conducted between October 2012 and March 2013 that addressed areas of need, including procedural teaching. A postcurriculum survey was used to assess the effect of the curriculum. SETTING Massachusetts Eye and Ear Infirmary, a tertiary care institution in Boston, MA. PARTICIPANTS Overall, 24 residents in the HMS Residency Training Program in Ophthalmology were included. RESULTS The needs assessment survey demonstrated that although most residents anticipated that teaching would be important in their future career, only one-third had prior formal training in teaching. All residents reported they found the teaching workshops to be either very or extremely useful. All residents reported they would like further training in teaching, with most residents requesting additional training in best procedural teaching practices for future sessions. CONCLUSIONS The pilot year of the resident-as-teacher curriculum for the HMS Residency Training Program in Ophthalmology demonstrated a need for this curriculum and was perceived as beneficial by the residents, who reported increased comfort in their teaching skills after attending the workshops.

Retinal Detachment Associated With Traumatic Chorioretinal Rupture

Traumatic chorioretinal rupture, also known as sclopetaria, is a full-thickness break of the choroid and retina caused by a high-velocity projectile striking or passing adjacent to, but not penetrating, the globe. Previous reports have emphasized that retinal detachment seldom occurs, and observation alone has been the recommended management strategy. However, the authors present herein a series of consecutive patients with retinal detachment associated with sclopetaria and provide a literature review of the topic. They recommend that patients with traumatic chorioretinal rupture be monitored closely for the development of retinal detachment during the first few weeks after the injury.

Posterior Nodular Scleritis

A, A 33-year-old woman presented with decreased vision in the right eye, pain, and a white subretinal elevated lesion. Fluorescein angiography showed diffuse late leakage (B) and optical coherence tomography revealed elevated choroid and subretinal fluid (C). D, An orbital magnetic resonance image displayed a hyperintense signal (arrowhead). JAMA Ophthalmol. 2015;133(1):e141801. doi:10.1001/jamaophthalmol.2014.1801