The Efficacy of Fluid-Gas Exchange for the Treatment of Postvitrectomy Retinal Detachment

Purpose

This study was designed to evaluate the efficacy of fluid-gas exchange for the treatment of postvitrectomy retinal detachment.

Methods

We retrospectively reviewed the records of 33 consecutive patients (35 eyes) who underwent fluid-gas exchange treatment for postvitrectomy retinal detachment using the two-needle pars plana approach technique.

Results

The retinal reattachment rate was 80.0% after complete intravitreal gas disappearance following the fluid-gas exchange; the overall success rate was 65.7%. Visual acuity was improved or stable in 80.0% of cases; a two-line or greater vision improvement or a best-corrected visual acuity of 0.4 or better occurred in 62.9% of cases. The success rates for superior retinal detachments and posterior pole retinal detachments were 76.5% and 85.7%, respectively.

Conclusions

Fluid-gas exchange represents a simple and cost-effective alternative outpatient procedure for retinal reattachment without reoperation for the treatment of superior and posterior pole retinal detachments.     

B-scan ultrasonography following open globe repair

Purpose

To examine the accuracy and predictive ability of B-scan ultrasonography in the post-repair assessment of an open globe injury.

Methods

In all, 965 open globe injuries treated at the Massachusetts Eye and Ear Infirmary between 1 January 2000 and 1 June 2010 were retrospectively reviewed. A total of 427 ultrasound reports on 210 patients were analyzed. Ultrasound reports were examined for the following characteristics: vitreous hemorrhage, vitreous tag, retinal tear, RD (including subcategories total RD, partial RD, closed funnel RD, open funnel RD, and chronic RD), vitreous traction, vitreous debris, serous choroidal detachment, hemorrhagic choroidal detachment, kissing choroidal detachment, dislocated crystalline lens, dislocated intraocular lens (IOL), disrupted crystalline lens, intraocular foreign body (IOFB), intraocular air, irregular posterior globe contour, disorganized posterior intraocular contents, posterior vitreous detachment, choroidal vs retinal detachment, vitreal membranes, and choroidal thickening. The main outcome measure was visual outcome at final follow-up.

Results

Among 427 B-scan reports, there were a total of 57 retinal detachments, 19 retinal tears, 18 vitreous traction, 59 serous choroidal detachments, 47 hemorrhagic choroidal detachments, and 10 kissing choroidal detachments. Of patients with multiple studies, 26% developed retinal detachments or retinal tears on subsequent scans. Ultrasound had 100% positive predictive value for diagnosing retinal detachment and IOFB. The diagnoses of retinal detachment, disorganized posterior contents, hemorrhagic choroidal detachment, kissing choroidal detachment, and irregular posterior contour were associated with worse visual acuity at final follow-up. Disorganized posterior contents correlated with particularly poor outcomes.

Conclusions

B-scan ultrasonography is a proven, cost-effective imaging modality in the management of an open globe injury. This tool can offer both diagnostic and prognostic information, useful for both surgical planning and further medical management.     

Relationship between perifoveal capillaries and pathomorphology in macular oedema associated with branch retinal vein occlusion

Purpose

To study the relationship between macular ischaemia on fluorescein angiography (FA) and pathomorphology at the foveal centre delineated by spectral-domain optical coherence tomography (OCT) in macular oedema (MO) associated with branch retinal vein occlusion (BRVO).

Methods

One hundred and five consecutive eyes of 105 patients with MO (centre point thickness (CPT) ≥300 μm) associated with BRVO in which FA using Heidelberg Retinal Angiography 2 and Spectralis OCT were performed on the same day were retrospectively reviewed. We evaluated the foveal pathomorphology using OCT images and the association with macular ischaemia.

Results

Within 1 year from symptom onset, 94 eyes were classified with perfused macula (34 eyes) or non-perfused macula (60 eyes). Eyes with perfused macula had better visual acuity and less CPT than those with non-perfused macula (P=0.024 and P<0.001, respectively). Fourteen eyes with perfused macula had serous retinal detachment (SRD) alone at the presumed foveal centre (SRD type); seven, a sponge-like swelling at that area (retinal swelling type); 11, foveal cystoid spaces alone (cystoid MO (CMO) type), and 2, with both SRD and foveal cystoid spaces (SRD+CMO type). However, 58 eyes with non-perfused macula had foveal cystoid spaces (42 of CMO type and 16 of SRD+CMO type), with a significant association between them (P<0.001). Among 11 eyes with symptoms exceeding 1 year, 6 eyes had perfused macula, and none had the SRD type.

Conclusion

Most eyes without foveal cystoid spaces have perfused macula in MO associated with BRVO.     

Refractory Coats’ Disease of Adult Onset

Purpose

We present the case of an 18-year-old Caucasian male with a unilateral macular star and retinal vascular anomalies compatible with adult onset Coats’ disease.

Methods

Diagnosis was based on fundoscopic, fluorescein angiography and optical coherence tomography findings.

Results

The patient presented to our emergency department with complaints of low vision in his left eye (LE) detected 10 days before. The best-corrected visual acuity in the LE was 20/50. Fundoscopy of the LE evidenced a complete macular star. Optical coherence tomography showed increased retinal thickness, infiltration of the retinal wall, and detachment of the neuroepithelium. Angiography revealed no appreciable diffusion in the macula. Above the superior temporal (ST) arcade, anomalies in the retinal vasculature were found, with interruption of the peripheral vessels and vessels which were ‘sausage’-like. After 1 month, the LE vision evolved to hand movements. Laser photocoagulation was performed in the ST quadrant. Intravitreal injection of bevacizumab 1.25 mg/0.05 ml and photodynamic therapy were performed without any significant changes, progression of ST serous detachment of the neuroepithelium, and finally progression to macular fibrosis.

Discussion

Coats’ disease is usually diagnosed in childhood, but rare cases may occur in adults. Those cases usually have a more indolent course which was not observed in our patient. When there is macular involvement, prognosis is more guarded, despite treatment.Key words: Coats’ disease, Adult onset, Macular star, Laser photocoagulation, Photodynamic therapy, Intravitreal bevacizumab     

Spontaneous Large Serous Retinal Pigment Epithelial Tear

Purpose

To report cases of spontaneous retinal pigment epithelial (RPE) tear complicating serous pigment epithelial detachment (PED).

Methods

The records of 3 Asian patients with spontaneous giant RPE tear were reviewed retrospectively by including clinical presentation, angiography, optical coherence tomography, fundus autofluorescence imaging, and visual outcome.

Results

Three patients (4 eyes) were included in this study, with a mean age of 48.3 (42–56) years, and a mean follow-up period of 7.75 (4–18) months. Fundus examination in all patients showed giant RPE tear associated with bullous PED. Two cases had a history of prior corticosteroid use, and 1 had no history of medication use. All 3 patients developed spontaneous resolution of subretinal fluid with no treatment. However, in patients who used corticosteroids, initial progression of the tear and subretinal fluid were observed despite ceasing medication. On subsequent follow-up, an incomplete RPE regeneration was demonstrated by fundus autofluorescence imaging, and choroidal neovascularization developed in 1 patient.

Conclusion

Large PED with RPE tear is a rare manifestation. When the fovea is spared, visual prognosis is favorable. No specific treatment is required, but careful choroidal neovascularization monitoring should be performed.Key Words: Retinal pigment epithelial tear, Pigment epithelial detachment, Retinal pigment epithelial rip     

Indirect optic nerve injury in two-wheeler riders in northeast India

Purpose:

To investigate the association of posterior indirect traumatic optic neuropathy and superior temporal orbital rim injury in two-wheeler riders and documentation of the clinical profile of such cases.

Design:

Retrospective observational study.

Materials and Methods:

Records of all patients reporting with cranio-orbital injury and vision loss following road traffic accidents between October 1994 and April 2006 were reviewed and from them cases with vision loss solely from indirect optic nerve injury were taken up for study. The prognostic significance of different presenting features, role of intravenous methyl prednisolone (IVMP) and relative risk of superior orbital rim injury to posterior indirect traumatic optic neuropathy (at 95% confidence interval) was calculated.

Results:

Out of 129 consecutive cases of cranio-orbital injury, 35 had posterior indirect traumatic optic neuropathy with minor ipsilateral superior temporal orbital rim trauma and none used any protective headwear. Presenting clinical features like relative afferent pupillary defect (P= 0.365), optic disc status (P= 0.518) and visual evoked potential (VEP) (P= 0.366) were disproportionate to visual loss. Only VEP had prognostic significance. The IVMP did not provide any added therapeutic benefit. The remaining 94 cases sustained direct blinding ocular trauma and 28 of them had associated intracranial pathology. The relative risk of superior temporal orbital rim injury to posterior indirect optic nerve trauma was 2.25.

Conclusion:

Superior temporal orbital rim injury, even when minor, carries a potential risk for development of blindness from indirect posterior indirect traumatic optic neuropathy in two-wheeler drivers. Presenting signs do not correlate with visual status. Only VEP has prognostic significance and the condition is untreatable.     

Ulnar neuropathy as a complication of retinal detachment surgery and face-down positioning

Purpose

To report a case of bilateral ulnar neuropathy as an extraocular complication following retinal detachment surgery and face-down positioning.

Methods

Case report.

Results

Bilateral hypoesthesia and numbness of the 4th and 5th finger started 2 weeks after vitrectomy for retinal detachment and face-down positioning. Due to progressive symptoms 6 months later, unilateral ulnar nerve decompression at the elbow was performed.

Conclusions

This case report demonstrates that strict face-down positioning bears the risk of ulnar neuropathy.Key Words: Face-down positioning, Ulnar neuropathy, Vitrectomy complications     

Correlation of structure and function of the macula in patients with retinitis pigmentosa

Purpose

To correlate the structure of the macula, as measured by spectral-domain optical coherence tomography (SD-OCT) and function, as measured by microperimetry (MAIA) in patients with retinitis pigmentosa (RP) and relatively good visual acuity.

Design

Prospective, cross-sectional, non-intervention study.

Subjects

Patients with RP.

Methods

Thirty patients with RP and good central visual acuity were identified. Each patient underwent SD-OCT of the macula and microperimetry. The images were overlaid using the custom-designed software. The retinal sensitivity by microperimetry was correlated with corresponding retinal thickness, as measured by the SD-OCT. ELM, COST, and IS/OS junction were scored as intact, disrupted, or absent.

Main outcome measures

Comparing the retinal sensitivity on the MAIA with various measurements on the SD-OCT.

Results

The retinal sensitivity on the MAIA showed a significant correlation with total retinal thickness and outer retinal thickness on the SD-OCT. There was no association with either the inner retinal thickness or the choroidal thickness. ORT showed a statistically significant correlation with the anatomical classification of ELM (r=−0.76, P<0.001), IS/OS (r=−0.800, P<0.001), and COST (r=−0.733, P<0.001).

Conclusion

This study determined that there was a high correlation of the structure and function of the central macula in patients with RP. These studies are important to establish surrogate markers that can be used as end points for various tests in future therapeutic clinical trials.     

Massive Bilateral Serous Retinal Detachment in a Case of Hypertensive Chorioretinopathy

Introduction

Systemic high blood pressure is related to a variety of retinal manifestations. We present an atypical case of hypertensive chorioretinopathy with massive bilateral serous retinal detachment.

Case Report

A 26-year-old male with a genitourinary malformation and secondary grade IV chronic kidney failure as well as high blood pressure complained of acute vision loss. Dilated fundus examination evidenced a bilateral serous retinal detachment with macular involvement. The patient was unresponsive to oral antihypertensive therapy and dialysis treatment. The serous retinal detachment progressively decreased after the restoration of dialysis and antihypertensive therapy. The final visual acuity was 0.50 in both eyes.

Discussion

In cases of serous macular detachment, it is mandatory to rule out different systemic and ocular diseases. The presence of uncontrolled high blood pressure may produce aggressive bilateral retinal changes, thus hypertension must be under early and strict control in order to improve the visual outcomes.Key words: Hypertensive chorioretinopathy, Serous retinal detachment, Optical coherence tomography     

Evaluation of the central macula in commotio retinae not associated with other types of traumatic retinopathy

Purpose

To report on the anatomical and functional changes to the macula in nine patients suffering from commotio retinae not accompanied by any other types of traumatic retinopathy.

Methods

Nine injured eyes with commotio retinae were evaluated soon after ocular trauma with ophthalmic examination, including Spectral-domain optical coherence tomography (SD-OCT). In 12 eyes of 6 patients, Humphrey visual field (HVF) and multifocal electroretinogram (mfERG) were performed. Re-examinations were periodically performed for a mean of 26 days. Data from 9 injured eyes were collected and compared to data collected from the 9 non-affected eyes of the same patients.

Results

SD-OCT revealed no significant differences in the foveal thickness and total macular volume between traumatized and intact eyes in all 9 patients. Only 3 out of the 9 injured eyes showed abnormal findings in SD-OCT images such as discontinuity of the inner/outer segment (IS/OS) junction or abnormal hyper-reflectivity from the IS/OS and retinal pigment epithelium (RPE) lines in the macula. HVF and mfERG results did not show any functional deterioration in the injured eyes compared with intact eyes. During follow-up, the commotio retinae resolved in all 9 eyes. The changes to the outer retinal region detected in 3 patients by SD-OCT were also resolved.

Conclusions

Acute retinal changes in commotio retinae, not associated with other retinal pathologies, were resolved without histological and functional sequelae. In a few cases of commotio retinae, SD-OCT revealed transient abnormalities mainly observed at the IS/OS and RPE complexes.     

Tear of Retinal Pigment Epithelium following YAG Laser Posterior Capsulotomy in a Patient on Anti-VEGF Treatment for AMD: Six Months’ Follow-Up

Purpose

To present a rare case of retinal pigment epithelium (RPE) rupture following YAG laser posterior capsulotomy (YAG PC) in a patient with exudative age-related macular degeneration (AMD).

Materials and Methods

An 85-year-old pseudophakic male patient on ranibizumab 0.5 mg/0.05 ml treatment due to exudative AMD received YAG PC for dense posterior capsule opacification (PCO) in his right eye. The patient had received his last intravitreal ranibizumab injection 3 months before YAG PC; his macula appeared stable on fundoscopy and optical coherence tomography scans at repeated visits, but his vision deteriorated to counting fingers due to PCO.

Results

Following left eye posterior YAG PC, his best-corrected visual acuity (BCVA) improved to 6/12 (Snellen chart). Despite satisfactory visual results, the patient developed a parafoveal inferotemporal RPE rupture. A decision for further treatment with ranibizumab (0.5 mg/0.05 ml) intravitreal injections was made. After a total of 7 injections, the patient was clinically stable and his BCVA was 6/18 (Snellen chart).

Conclusions

RPE rupture is a well-known, serious complication in patients with exudative AMD, which often has devastating results on patients’ vision. Offering YAG PC to those patients could lead to a rupture of the RPE even in cases which appear to be stable and well controlled. Clinicians should be aware of this complication and inform the patients accordingly.Key Words: Retinal pigment epithelium tear, YAG Laser, Age-related macular degeneration, Pigment epithelial detachment rupture, Ranibizumab     

Rhegmatogenous Retinal Detachment with a High Risk of Proliferative Vitreoretinopathy Treated with Episcleral Surgery and an Intravitreal Dexamethasone 0.7-mg Implant

Purpose

To report a case of rhegmatogenous retinal detachment with a high risk of proliferative vitreoretinopathy (PVR) effectively treated with episcleral surgery and an intravitreal dexamethasone 0.7-mg implant.

Methods

A 35-year-old Caucasian man with a macula-off rhegmatogenous subtotal retinal detachment that had persisted for 1 month in his myopic left eye presented several risk factors that could have led to the development of PVR after retinal detachment surgery. His best corrected visual acuity was hand motion. He received an intravitreal dexamethasone 0.7-mg implant (Ozurdex^®) after episcleral surgery to prevent this complication.

Results

At least 9 months after surgery, no sign of PVR or pucker has developed in the treated eye. Visual acuity improved to 0.2, the retina was attached and no complications were observed.

Conclusion

Intravitreal dexamethasone 0.7-mg implant (Ozurdex) could be considered as off-label treatment following episcleral surgery to prevent PVR.Key words: Retinal detachment, Dexamethasone 0.7 mg, Ozurdex^®, Proliferative vitreoretinopathy, Episcleral surgery     

Diabetic Retinopathy and Peripapillary Retinal Thickness

Purpose

To assess the diagnostic efficacy of macular and peripapillary retinal thickness measurements for the staging of diabetic retinopathy (DR) and the prediction of disease progression.

Methods

In this prospective study, 149 diabetic patients (149 eyes) and 50 non-diabetic control subjects were included. Baseline optical coherence tomography was employed to measure retinal thickness in the macula (horizontal, vertical, and central) and the peripapillary zone (superior, inferior, nasal, and concentric to the optic disc). Seven baseline parameters were correlated with the DR stages identified by fluorescein angiography. Baseline retinal thickness was compared between groups of patients requiring panretinal photocoagulation (PRP) within 6 months (PRP group) and patients not requiring PRP (No-PRP group).

Results

Macular and peripapillary retinal thicknesses in diabetic subjects were significantly greater than that in normal controls (p<0.05). All retinal thickness parameters, and particularly peripapillary circular scans, tended to increase with increasing DR severity (p<0.05). The baseline thicknesses of the peripapillary circular scans were greater in the PRP group than in the no-PRP group (p<0.05).

Conclusions

Peripapillary retinal thickness may prove to be a useful criterion for DR severity and may also serve as an indicator of disease progression.     

Characteristic Findings of Optical Coherence Tomography in Retinal Angiomatous Proliferation

Purpose

To identify the unique pathologic findings of retinal angiomatous proliferation (RAP) in optical coherence tomography (OCT).

Methods

Retrospectively, 29 eyes of 25 patients with age-related macular degeneration and complicated RAP were analyzed. All 29 eyes had choroidal neovascularization (CNV) in the area of pigment epithelial detachment (PED) or adjacent to it, which was visible with fluorescein angiography or indocyanine green angiography. Cross-sectional images were obtained by OCT scanning through the CNV lesions.

Results

Six distinctive findings of OCT included drusen (100%), inner retinal cyst (80%), outer retinal cyst (68%), fibrovascular PED (84%), serous retinal detachment (40%), and PED (68%).

Conclusions

Through analysis of OCT findings, we revealed six different types of lesions distinctive of RAP which may provide helpful diagnostic information for subsequent treatment and predicting the prognosis of RAP.     

Intravitreal Ranibizumab in the Treatment of Butterfly-Shaped Pattern Dystrophy Associated with Choroidal Neovascularization: A Case Report

Purpose

To present and document the effectiveness of intravitreal ranibizumab in the treatment of patients with choroidal neovascularization due to butterfly-shaped pattern dystrophy (PD) of the macula.

Methods

Three intravitreal ranibizumab injections of 0.5 mg/0.05 ml in monthly intervals were given to a patient with a previously diagnosed butterfly-shaped PD who subsequently developed subfoveal choroidal neovascularization on the right eye. The patient had previously received a combination of verteporfin/photodynamic therapy for a juxtafoveal choroidal neovascular membrane on the left eye.

Results

At the end of the treatment course, there was significant improvement of the patient''s vision and the appearance of the macula on optic coherence tomography and fluorescein angiography. Best-corrected visual acuity improved from 6/12 to 6/6 and retinal thickness at the macula decreased from 323 to 247 μm. No subretinal fluid remained. The patient is clinically stable over a 12-month follow-up period.

Conclusions

Intravitreal ranibizumab seems to be an effective and safe option for the treatment of subfoveal choroidal neovascularization in patients with butterfly-shaped PD.Key Words: Intravitreal ranibizumab, Pattern dystrophy of the macula, Choroidal neovascular membrane, Choroidal neovascularization     

Spontaneous Closure of a Full-Thickness Stage 2 Idiopathic Macular Hole without Posterior Vitreous Detachment

Objective

We report a 50-year-old female patient with a stage 2 idiopathic macular hole that closed spontaneously.

Method

The case is presented on the basis of an observational case report.

Results

The stage 2 idiopathic macular hole closed spontaneously in 6 weeks with a lamellar defect in the outer retina due to the formation of the bridging retinal tissue, but without any evidence of the common mechanisms of spontaneous closure such as posterior vitreous detachment or epiretinal membrane formation.Key words: Macular holes, Posterior vitreous detachment, Retina, Optical coherence tomography     

Structural Recovery of the Detached Macula after Retinal Detachment Repair as Assessed by Optical Coherence Tomography

Purpose

To investigate correlations between preoperative and postoperative foveal microstructures in patients with macula-off rhegmatogenous retinal detachment (RRD).

Methods

We reviewed the records of 31 eyes from 31 patients with macula-off RRD who had undergone successful re-attachment surgery. We analyzed data obtained from complete ophthalmologic examinations and optical coherence tomography (OCT) before and 9 to 12 months after surgery. All postoperative OCT measurements were taken with spectral-domain OCT, but a subset of preoperative OCT measurements were taken with time-domain OCT.

Results

The mean duration of macular detachment was 15.5 ± 15.2 days, and mean preoperative best-corrected visual acuity (BCVA, logarithm of the minimum angle of resolution) was 1.03 ± 0.68. Preoperative visual acuity was correlated with retinal detachment height (p < 0.001) and the existence of intraretinal separation (IRS) along with outer layer undulation (OLU) (p = 0.022), but not with macula-off duration. The final BCVA was significantly correlated with integrity of the junction between the photoreceptor inner and outer segments (IS/OS) combined with the continuity of external limiting membrane (ELM) (p = 0.025). The presence of IRS and OLU on a detached macula were highly correlated with the final postoperative integrity of the IS/OS junction and the ELM (p = 0.017).

Conclusions

Eyes preoperatively exhibiting IRS and OLU showed a higher incidence of disruption to the photoreceptor IS/OS junction and the ELM at final follow-up. Such a close correlation between preoperative and postoperative structural changes may explain why ultimate visual recovery in such eyes is poor.     

Modulation of retinal wound healing by systemically administered bone marrow-derived mesenchymal stem cells

Purpose

To evaluate whether systemically injected bone marrow-derived mesenchymal stem cells (MSCs) can be incorporated into neuroretinal tissues and play an important role in retinal wound healing in the laser-induced retinal trauma model.

Methods

Retinotomies were made by applying an Nd:YAG laser to rat retina. On the first day after the injuries, cell suspensions that were obtained from the same line of rat (containing 1 × 10⁶ green fluorescence protein [GFP]-marked bone marrow-derived MSCs) were injected through a tail vein in the experimental group and phosphate buffer solution (PBS) was injected in the same way in the control group. Fundus photographs were taken serially for fundus examination and eyeballs were enucleated for histological studies that were conducted at five and seven weeks after MSC and PBS injection. After the tissues were prepared, the retinotomy sites were observed with routine histological staining and confocal microscopy.

Results

Retinal detachment resolved in the experimental group, whereas it progressed in the control group. The retinotomy sites closed partially with identifiable GFP positive cells 5 weeks after MSC injection. At 7 weeks after MSC injection, complete healing without retinal detachment and plentiful GFP positive cells were observed at the transitional zone between damaged and normal retina.

Conclusions

Systemically administered GFP-marked MSCs may be incorporated into the neuroretinal tissues and play an important role in the wound modulation of physically damaged retinal tissues.