IMPORTANCE: Autologous retinal transplant is a recently described treatment modality for myopic and other refractory macular holes (MH). Establishment of blood supply may influence survival of a ...transplanted tissue. However, there are currently no reports on the vascular status of a transplanted retinal graft. OBJECTIVE: To report on vascularization and reperfusion of autologous retinal graft after transplant for giant MHs demonstrated by multimodal imaging. DESIGN, SETTING, PARTICIPANTS: Two patients with giant MH (basal diameter ≥2000 μm) who underwent autologous retinal transplant at Retina-Vitreous Associates Medical Group in Los Angeles, California, in June 2018 and February 2019, respectively, were included. MAIN OUTCOMES AND MEASURES: Status of MH, Snellen visual acuity, optical coherence tomography, optical coherence tomography angiography, and fluorescein angiography findings. RESULTS: Two eyes of 2 female patients were included. The mean age was 68.5 years. Baseline visual acuity was counting fingers and 20/200, and MHs measured 3441 μm and 2387 μm, respectively. Six weeks postoperatively, MHs were closed and the superficial inner retina blood vessels within the graft appeared perfused. Optical coherence tomography and optical coherence tomography angiography demonstrated early integration of the graft into the surrounding retina and perfused graft vasculature in both patients. Fluorescein angiography confirmed perfusion of retinal graft. At the last follow-up, visual acuity was 20/200 and 20/150, respectively, the MH was closed, and the retinal grafts were perfused. CONCLUSIONS AND RELEVANCE: Autologous neurosensory retinal transplant may be used for the treatment of giant MHs. Vascularization and reperfusion of the retinal graft is observed within 6 weeks of transplant. It is hypothesized that visual improvement occurs as a result of flattening of the MH rim, partial centripetal migration of MH edges during the early healing phase, and further centripetal migration in the later phase associated with the shrinkage of the retinal graft.
To report on the imaging of internal limiting membrane (ILM) flap following macular hole (MH) surgery.
Three eyes of 3 patients with baseline Snellen visual acuities (VAs) of 20/250, 20/30, and ...20/100 underwent superior wide-base internal limiting membrane flap transposition (SWIFT) for MH. Indocyanine green (ICG) was used for intraoperative staining of the ILM. Following MH surgery, MH closed in all cases and VAs were 20/30, 20/30, and 20/60 respectively. An “en face” ICG fluorescence image of the ILM flap was obtained using infrared confocal scanning laser imaging at 795 nm. ICG fluorescence demonstrated the ILM flap to be intact and in good position with complete coverage of the MH in all cases. An area of hypofluorescence was present superiorly, corresponding to the flap harvest site with absent ILM. ICG hyperfluorescence of varying intensity was present at the MH site in all 3 cases. Folding of the ILM flap was present in one case.
Following MH surgery, the status of an ILM flap may be evaluated by an “en face” image of the flap obtained by ICG fluorescence imaging. This imaging modality may be valuable in the study of various ILM flap techniques.
Purpose To describe the spectrum of retinal capillary ischemia, including superficial and deep capillary ischemia, as identified with spectral-domain optical coherence tomography (SD OCT), that ...occurs in retinal arterial occlusive disease. Design Retrospective observational case series. Methods Clinical charts, color fundus photography, red-free fundus photography, fluorescein angiography, near-infrared reflectance, and SD OCT imaging in 40 eyes of 35 patients with retinal arterial occlusive disease were studied in both the acute and chronic phases in multicenter clinical practices. SD OCT imaging analysis was employed to characterize the presence of superficial and deep capillary ischemia in each eye. Results Of the 40 eyes, 15 eyes had central retinal artery occlusion (CRAO), 22 eyes had branch retinal artery occlusion (BRAO), and 3 eyes had cilioretinal artery occlusion. During the acute phase, SD OCT showed the following 3 distinct patterns, related to retinal ischemia occurring at varying levels within the retina: (1) thickening and hyperreflectivity of the inner retinal layers, including the nerve fiber and ganglion cell layers owing to ischemia of the superficial capillary plexus; (2) a hyperreflective band at the level of the inner nuclear layer, termed “paracentral acute middle maculopathy,” representing ischemia of the intermediate and deep retinal capillary plexuses (deep capillary ischemia); and (3) diffuse thickening and hyperreflectivity of both the inner and middle retinal layers, which represented both superficial and deep capillary ischemia. Of all eyes, 31 (78%) had both superficial and deep lesions. The remaining 9 eyes (22%) had isolated deep capillary ischemia producing paracentral acute middle maculopathy with sparing of the superficial capillary plexus and a normal fluorescein angiographic appearance. As the lesions evolved into the chronic phase over the ensuing 3 months, the resultant thinning and atrophy reflected the retinal layers affected during the acute phase. Conclusion SD OCT imaging reveals the spectrum of capillary ischemia in retinal artery occlusive disease showing variable involvement of the superficial and intermediate/deep capillary plexuses. Isolated deep capillary ischemia manifested as paracentral acute middle maculopathy on SD OCT and may be seen in some eyes with retinal arterial circulation compromise despite complete absence of perfusion abnormalities on fluorescein angiography.
To evaluate the safety and efficacy of Ozurdex (dexamethasone intravitreal implant) 0.7 mg in the treatment of diabetic macular edema in vitrectomized eyes.
This was a prospective, multicenter, ...open-label, 26-week study. Fifty-five patients with treatment-resistant diabetic macular edema and a history of previous pars plana vitrectomy in the study eye received a single intravitreal injection of 0.7-mg dexamethasone intravitreal implant. The primary efficacy outcome measure was the change in central retinal thickness from baseline to Week 26 measured by optical coherence tomography.
The mean age of patients was 62 years. The mean duration of diabetic macular edema was 43 months. The mean (95% confidence interval) change from baseline central retinal thickness (403 μm) was -156 μm (-190, -122 μm) at Week 8 (P < 0.001) and -39 μm (-65, -13 μm) at Week 26 (P = 0.004). The mean (95% CI) increase in best-corrected visual acuity from baseline (54.5 letters) was 6.0 letters (3.9, 8.1 letters) at Week 8 (P < 0.001) and 3.0 letters (0.1, 6.0 letters) at Week 26 (P = 0.046). At Week 8, 30.4% of patients had gained ≥10 letters in best-corrected visual acuity. Conjunctival hemorrhage, conjunctival hyperemia, eye pain, and increased intraocular pressure were the most common adverse events.
Treatment with dexamethasone intravitreal implant led to statistically and clinically significant improvements in both vision and vascular leakage from diabetic macular edema in difficult-to-treat vitrectomized eyes and had an acceptable safety profile.
Purpose:
To analyze a case series of retinal vasculitis reported to the American Society of Retina Specialists (ASRS) following Food and Drug Administration approval of brolucizumab for treatment of ...neovascular age-related macular degeneration.
Methods:
The ASRS Research and Safety in Therapeutics Committee analyzed clinical and imaging characteristics from submitted reports of retinal vasculitis after brolucizumab.
Results:
Retinal vasculitis was reported in 26 eyes of 25 patients (22 88% female) after treatment with brolucizumab. Imaging studies were available for 24 of 26 eyes. Most cases (92%) were associated with intraocular inflammation, which presented at a mean of 25 days (range, 3-63 days) after the most recent brolucizumab injection. Mean visual acuity (VA) was 20/52 (range, 20/25-4/200) before the adverse event, 20/151 (range, 20/25-hand motion) at presentation of the adverse event, and 20/243 (range, 20/30-light perception) at last follow-up. Twelve eyes (46%) had a greater than 3-line decrease in VA at final follow-up, and 12 eyes (46%) had a final VA of 20/200 or worse. Analysis of retinal imaging identified vasculopathy that involved retinal arteries (91%), retinal veins (79%), and choroidal vessels (48%). Occlusive disease was apparent on imaging in 83% of eyes. Treatment approaches were varied.
Conclusions:
Retinal vasculitis has been identified in a series of eyes following brolucizumab. Although a few eyes in this series were asymptomatic or minimally symptomatic, some eyes had significant vision loss. A careful examination for signs of active inflammation prior to brolucizumab injection is recommended. Once vasculopathy is suspected, angiographic imaging may help define the spectrum of involvement. Optimal treatment strategies remain unknown.
To report on the technique of scleral fixation of fluocinolone acetonide (FAc) implant in 2 eyes with recalcitrant diabetic macular edema (DME).
Two eyes of 2 patients with persistent DME, partially ...responsive to anti-VEGF therapy, underwent intravitreal FAc implant injection. First case had a history of pars plana vitrectomy (PPV) and scleral fixated posterior chamber intraocular lens implant (PCIOL) for retained lens fragments and dislocated IOL. Subsequently, the patient presented with intermittent anterior chamber migration of the FAc implant associated with an increase in DME. The FAc implant was fixated to the sclera, preventing further migrations, and improving the DME. The second case had a history of persistent DME, PCIOL with open capsule, epiretinal membrane (ERM), and a free-floating FAc implant within the vitreous cavity. She underwent PPV, membrane peel, and simultaneous scleral fixation of the free-floating FAc implant. The surgical technique included 23 G PPV, externalization of FAc implant, re-implantation and scleral fixation through the same sclerotomy utilizing a 10/0 prolene suture.
A surgical technique for scleral fixation of FAc implant is described. The technique is valuable in the management of patients with persistent diabetic macular edema or uveitis who benefit from treatment with fluocinolone acetonide implant but are at risk for anterior chamber migration of the implant.
BACKGROUND AND OBJECTIVE:
To investigate the clinical course and outcomes of patients with vitreomacular traction (VMT) managed initially by observation.
PATIENTS AND METHODS:
This noncomparative ...case series included patients with a diagnosis of VMT based on clinical symptoms and findings on spectral-domain optical coherence tomography (SD-OCT) between 2005 and 2014. VMT was documented using a standardized grading system based on the degree of distortion of the foveal contour. Data were collected at five retina clinics using standardized collection forms. Visual acuity, changes in SD-OCT findings, and timing of the release of VMT as seen on SD-OCT were recorded.
RESULTS:
The study included 230 eyes of 185 patients. Mean age was 72.5 years, and mean follow-up was 32 months. At baseline, VMT grading was grade 1 in 92 eyes (40%), grade 2 in 118 eyes (51.3%), and grade 3 in 20 eyes (8.7%). By last follow-up, spontaneous release of VMT occurred in 73 eyes (31.7%). Spontaneous release of VMT occurred at a mean of 18 months (median: 10.9 months) after initial visit. Mean logMAR best corrected visual acuity (BCVA) was 0.28 (20/55) (range: 20/20 to 20/400) at baseline and 0.25 (20/51) (range: 20/20 to 20/400) at last follow-up. Pars plana vitrectomy was performed in 10 eyes (4.1%) for macular hole (six eyes) and increased VMT (four eyes); BCVA was at least 20/40 in eight of the 10 eyes at last follow-up.
CONCLUSION:
Patients with VMT generally had a favorable clinical course when managed initially by observation. Spontaneous release of VMT occurred in approximately one-third of patients. At last follow-up, pars plana vitrectomy was performed in fewer than 5% of patients.
Ophthalmic Surg Lasers Imaging Retina
. 2015;46:571–576.
To evaluate the visual outcomes, choroidal neovascular complex status, and adverse events in patients with visually significant cataract and neovascular age-related macular degeneration (AMD) who had ...cataract surgery.
Private practices, Beverly Hills, California, and New London, Connecticut, USA.
Case series.
Data were abstracted from the medical records of patients with neovascular AMD treated by anti-vascular endothelial growth factor (anti-VEGF) therapy who had cataract surgery. The main outcome measures were Snellen corrected distance visual acuity (CDVA), perioperative adverse events, and status of the choroidal neovascular complex.
The study enrolled 30 eyes of 28 patients. The CDVA was 20/40 or better in 10% of eyes preoperatively and 40% postoperatively; 20/50 to 20/100 in 53% and 33%, respectively; and 20/200 or worse in 37% and 27%, respectively. The change in CDVA from preoperatively to postoperatively was statistically significant, with a mean change of 0.22 logMAR ± 0.27 (SD) at 2 months (P<.0001), 0.22 ± 0.36 logMAR at 6 months (P=.001), and 0.17 ± 0.54 logMAR at the last follow-up (P=.01). Patients received a mean of 0.32 injections per month postoperatively compared with 0.49 injections per month preoperatively. Perioperative macular adverse events did not occur in any eye.
With regular evaluations and appropriate treatment with anti-VEGF agents, cataract surgery did not appear to be associated with an increased incidence of perioperative complications or macular adverse events.
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.
PDF
