Vortex vein decompression for nanophthalmic uveal effusion

Scleral Thickness in Simple Versus Complex Central Serous Chorioretinopathy

PURPOSE

To evaluate the association between scleral thickness and a newly developed multimodal imaging-based classification of central serous chorioretinopathy (CSC).

DESIGN

Retrospective, cross-sectional study.

METHODS

This study included 217 eyes of 217 patients classified as simple or complex CSC based on the established protocols. Clinical and anatomical factors were compared between the 2 types. The scleral thickness was measured at 4 locations using anterior-segment optical coherence tomography.

RESULTS

Of the 217 eyes, 167 were classified as simple CSC and 50 as complex CSC. The complex CSC group showed older age (P = .011), higher male ratio (P = .001), more bilateral involvement (P < .001), poorer visual acuity (P < .001), greater subfoveal choroidal thickness (P = .025), and higher frequency of loculation of fluid (P < .001) and ciliochoroidal effusion (P < .001) than the simple CSC group. The complex CSC group had significantly greater scleral thicknesses in the superior, temporal, inferior, and nasal directions (all P < .001) than the simple CSC group. Multivariable analysis revealed that older age (odds ratio [OR] 1.054, 95% confidence interval [CI] 1.013-1.097, P < .001), male sex (OR 10.445, 95% CI 1.151-94.778, P < .001), bilateral involvement (OR 7.641, 95% CI 3.316-17.607, P < .001), and the mean value of scleral thicknesses in 4 directions (OR 1.022, 95% CI 1.012-1.032, P < .001) were significantly associated with the complex CSC.

CONCLUSIONS

Older age, male sex, bilateral involvement, and thick sclera were associated with the complex CSC. Scleral thickness seemed to determine the clinical manifestations of CSC.

CLINICAL CHARACTERISTICS, TREATMENT MODALITIES, AND THEIR ASSOCIATION WITH LONG-TERM VISUAL OUTCOMES IN UVEAL EFFUSION SYNDROME

PURPOSE

Uveal effusion syndrome (UES) is a rare eye condition characterized by fluid accumulation in the uveal layer. We investigated its clinical characteristics and treatment modalities and their association with long-term visual outcomes.

METHODS

This retrospective cohort study included patients with UES treated at two tertiary hospitals between November 2005 and June 2023. Clinical characteristics and treatment outcomes by modality were compared between nanophthalmic Type 1 UES (UES-1) and non-nanophthalmic Type 2 UES (UES-2), and between initial and final visits. Logistic regression analysis was used to identify factors associated with vision loss.

RESULTS

Twenty-three eyes were included (UES-1, n = 10; UES-2, n = 13). Retinal pigment epithelium mottling was significantly more common in UES-1 than in UES-2 ( P = 0.043); no other between-group differences were observed. Post-treatment, in UES-1, best-corrected visual acuity ( P = 0.028) and central macular thickness ( P = 0.046) significantly decreased; in UES-2, best-corrected visual acuity significantly improved ( P = 0.021), and subfoveal choroidal thickness ( P = 0.048), central subretinal fluid height ( P = 0.011), and central macular thickness ( P = 0.010) significantly decreased. UES-2 was associated with a lower risk of vision loss (odds ratio, 0.024; P = 0.044). No other associated factors were identified.

CONCLUSION

The UES type was the sole independent prognostic factor for vision loss, whereas treatment modalities had no significant impact on visual outcomes.

Surgical Approaches to Serous Retinal Detachment With Retina-Lens Touch in Eyes With Nanophthalmos

Purpose:To describe the visual outcomes and problems that resulted from surgical treatment of nanophthalmic complete retinal detachment (RD) with retina-lens contact. Methods: A multicenter retrospective case series with deep sclerectomy as a treatment was performed. Results: Five cases had extensive deep sclerectomies, 3 with intended drainage of subretinal fluid (SRF). The RD resolved 1 week postoperatively in 4 cases and within 1 month in 1 case. The visual acuity improved from light perception to a median of 20/100. Three cases had longstanding lens touch beyond 1 year and improved VA to 20/100, 20/150, and hand motions, respectively. Complications included focal lens dialysis in 2 cases (passive drainage of SRF) and lens or intraocular lens dislocation in 1 case each (active drainage of SRF). Ultrasound biomicroscopy and anterior optical coherence tomography showed a very narrow angle and short zonules. Conclusions: Deep sclerectomy results in good anatomic and functional improvements in advanced cases of nanophthalmos exudative detachment, which is often considered to be incurable.

Scleral Thickness as a Risk Factor for Central Serous Chorioretinopathy and Pachychoroid Neovasculopathy

In the pathophysiology of central serous chorioretinopathy (CSC), scleral changes inducing increased venous outflow resistance are hypothesized to be involved. This work aims to investigate anterior scleral thickness (AST) as a risk factor for pachychoroid disorders. A randomized prospective case-control study was performed at the Ludwig Maximilians University, Department of Ophthalmology. In patients with CSC or pachychoroid neovasculopathy (PNV) and in an age- and refraction-matched control group, swept source optical coherence tomography (SS-OCT) was used to measure anterior scleral thickness (AST). Subfoveal choroidal thickness (SFCT) was assessed using enhanced depth imaging OCT (EDI-OCT). In total, 46 eyes of 46 patients were included in this study, with 23 eyes in the CSC/PNV and 23 eyes in the control group. A significantly higher AST was found in the CSC/PNV compared with the control group (403.5 ± 68.6 (278 to 619) vs. 362.5 ± 62.6 (218 to 498) µm; p = 0.028). Moreover, the CSC/PNV group showed a higher SFCT (392.8 ± 92.8 (191-523) vs. 330.95 ± 116.5 (167-609) µm, p = 0.004). Compared with the age- and refraction-matched controls, patients with CSC and PNV showed a significantly thicker anterior sclera. Scleral thickness might contribute to the venous overload hypothesized to induce pachychoroid phenotypes.

Medical Therapy and Scleral Windows for Uveal Effusion Syndrome: A Case Series and Literature Review

INTRODUCTION

Uveal effusion syndrome (UES) is a rare ocular disease causing idiopathic uveal effusion, often with associated ciliochoroidal and retinal detachment. UES diagnosis is challenging because of overlapping features with other ocular inflammatory, neoplastic, iatrogenic, and drug-induced causes of uveal effusion. While several successful surgical treatments have been described, such as full-thickness or partial-thickness sclerectomy, medical therapies may also have a therapeutic role.

OBJECTIVE

To provide an updated review of the published literature on the course of the disease, medical and surgical management strategies, as well as newer treatment modalities.

Effect of Combined Surgery in Patients with Complex Nanophthalmos

(1) Background: To evaluate the efficacy and safety of combined surgery (limited pars plana vitrectomy, anterior-chamber stabilized phacoemulsification, IOL implantation and posterior capsulotomy, LPPV + ACSP + IOL + PC) in complex nanophthalmos. (2) Methods: Patients with complex nanophthalmos were recruited to undergo LPPV + ACSP + IOL + PC from January 2017 to February 2021. Preoperative and post-operative intraocular pressure (IOP), best corrected visual acuity (BCVA), anterior chamber depth (ACD), and number of glaucoma medications were compared using the paired t-test or Wilcoxon signed rank sum tests. Surgical success rate was evaluated. Surgery-associated complications were documented. (3) Results: Forty-five eyes of 37 patients with complex nanophthalmos were enrolled. The mean follow-up period was 21.7 ± 10.6 months after surgery. Mean IOP decreased from 32.7 ± 8.7 mmHg before surgery to 16.9 ± 4.5 mmHg (p < 0.001) at the final follow-up visit, mean logMAR BCVA improved from 1.28 ± 0.64 to 0.96 ± 0.44 (p < 0.001), mean ACD significantly increased from 1.14 ± 0.51 mm to 3.07 ± 0.66 mm (p < 0.001), and the median number of glaucoma medications dropped from 3 (1, 4) to 2 (0, 4) (p < 0.001). The success rate was 88.9% (40 eyes) at the final follow-up visit. Two eyes had localized choroidal detachments which resolved with medical treatment. (4) Conclusions: LPPV + ACSP + IOL + PC is a safe and effective surgical procedure, which can decrease IOP, improve BCVA, deepen the anterior chamber, and reduce the number of glaucoma medications in patients with complex nanophthalmos. It can be considered as one of the first treatment in nanophthalmic eyes with complex conditions.

A report on a series of nanophthalmos with histopathology and immunohistochemistry analyses using light microscopy

We aimed to study the histopathological and immunohistochemistry features in clinically diagnosed cases of nanophthalmos using light microscopy. This was an observational comparative study. We enrolled four eyes of four consecutive patients with nanophthalmos and visually significant cataract, who underwent cataract surgery with prophylactic posterior sclerostomy. Histological analysis of the excised scleral tissue was done and compared with age-matched cadaver controls between January 2021 and October 2021. Hematoxylin and Eosin (H&E) stains were used for histological analysis, and was further supplemented with immunohistochemistry (IHC) and immunofluorescence (IF) analyses using a simple light microscope. The immunostained sections were analyzed using confocal microscope for the fibronectin expression level. The main outcome measure was demonstration of histological changes of sclera in nanophthalmic eyes undergoing cataract surgery. Light microscopic features of nanophthalmos revealed thick fibers with fraying and lightly stained cores, irregular serrated edges, and randomly interspersed fibroblasts compared to regular arrangement of collagen fibers seen in cadaver controls. Immunohistochemistry analysis with anti-fibronectin antibody showed strong positivity in clustered fibers in nanophthalmos, and less intense diffuse staining in cadaver tissue. Histoclinical correlation was observed in one nanophthalmic scleral tissue with axial length less than 17 mm showing severe disorganization with diffuse collagenization, loss of fibrillary architecture compared to another specimen with axial length more than 17 mm. Simple, cost-effective light microscopy using basic stains was effective in identifying the characteristic histopathological features in nanophthalmic eyes, and this was further highlighted by immunohistochemistry and immunofluorescence analyses.

Uveal Effusion Syndrome: Clinical Characteristics, Outcome of Surgical Treatment, and Histopathological Examination of the Sclera

Purpose

In this study, we aimed to investigate clinical characteristics and histopathology and evaluate surgical outcomes of quadrantic lamellar-sclerectomy with sclerostomy for uveal effusion syndrome (UES).

Design

Retrospective, cohort study.

Participants

Overall, 106 eyes of 66 patients diagnosed with UES were treated at the Beijing Tongren Hospital between January 1, 2001 and June 26, 2021.

Methods

Patients were examined by routine ophthalmologic examinations, fluorescein and indocyanine green angiography (FFA/ICGA); axial length determination; color Doppler ultrasound (CDU); ultrasound biomicroscopy (UBM), optical coherence tomography (OCT), and optical coherence tomographic angiography (SD/SS-OCTA). Quadrantic lamellar-sclerectomy with sclerostomy was performed at the equator in all patients and histopathological examination of the excised sclera was analyzed in all samples.

Main Outcome Measures

The reattachment of the choroid and retina with resolution of the serous fluid, best corrected visual acuity (BCVA), choroidal thickness, and recurrence of ciliochoroidal detachment were the main outcome measures.

Results

Two subgroups were identified: (1) type 1 (nanophthalmic eye), wherein the eyeball was small (average axial length 15.83 ± 1.45 mm) with high hypermetropia (average 12.6 diopters) and (2) type 2 (non-nanophthalmic eye), wherein the eyeball size was normal (average axial length 23.45 ± 1.68 mm) with or without refractive error, combined with or without systemic symptoms. Histopathologically, types 1 and 2 demonstrated similarly abnormal sclera with the disorganization of collagen fiber bundles and deposits of proteoglycans in the matrix. Quadrantic lamellar-sclerectomy with sclerostomy was effective in both types 1 and 2, inducing post-operative resolution of the subretinal fluid accumulation and increasing the useful BCVA. The choroidal thickness was significantly different before and after surgery (P < 0.05). Approximately 98.1% of cases attained permanent reattachment within 6 months after one operation through this procedure. The single operation success rate was 96.2%, and success with one or two operations was 100%.

Conclusions

UES is caused by abnormalities of the sclera and increased resistance to transscleral fluid outflow, combined with increased choroidal thickness. Quadrantic lamellar-sclerectomy with sclerostomy is an effective treatment for UES that can rescue correct the useful visual acuity.

CILIOCHOROIDAL EFFUSION IN CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To investigate the prevalence of ciliochoroidal effusion (CE) in central serous chorioretinopathy (CSC) using anterior-segment optical coherence tomography and its association with the clinical features of CSC.

METHODS

Overall, 164 eyes of 164 patients with CSC and 51 eyes of 51 age- and sex-matched normal control participants were retrospectively examined. Anterior-segment optical coherence tomography was used to assess patients with CSC and control subjects for CE and scleral thickness. Central serous chorioretinopathy eyes were divided into two groups: eyes with CE (CE group) and eyes without CE (non-CE group). Scleral thickness was measured at the point that was 6 mm posterior to the scleral spur in four directions.

RESULTS

Among the 164 eyes with CSC, 32 eyes (19.5%) displayed CE, and this proportion was significantly higher than that in control subjects (2.0%) (P = 0.001). Scleral thickness was significantly greater in the CE group compared with the non-CE group at all four directions (P < 0.05 for all). Multivariable analysis revealed that the mean scleral thickness (odds ratio: 1.01; 95% confidence interval: 1.00-1.02; P = 0.007) was significantly associated with the incidence of CE.

CONCLUSION

Central serous chorioretinopathy may accompany fluid accumulation in the anterior segment more frequently than previously expected in association with thick sclera.

Treatment of Nanophthalmos-Related Uveal Effusion with Two- vs. Four-Quadrant Partial-Thickness Sclerectomy and Sclerotomy Surgery

Objectives

To report visual and anatomical outcomes following two- or four-quadrant partial-thickness sclerectomy and sclerotomy surgery to treat nanophthalmos (NO)-related uveal effusion (UE).

Materials and Methods

Consecutive patients with NO-related UE were treated with four-quadrant or two-quadrant (for those with associated glaucoma) partial-thickness sclerectomy and sclerotomy surgery. Axial length, extent of UE, preoperative, postoperative, and final best corrected visual acuity (BCVA), time to retinal reattachment, and rates of retinal reattachment and recurrence were noted.

Results

Fourteen eyes of 10 patients with NO-related UE were operated. Retinal detachment (RD) involved mainly the peripheral retina in 7 (50%) eyes, macula in 2 eyes (14.2%), both macula and peripheral retina in 4 eyes (28.6%), and the whole retina in 1 eye. Eleven eyes had four-quadrant surgery, and 3 eyes with associated glaucoma had two-quadrant surgery. External subretinal drainage was performed in one patient who had total RD. The mean preoperative logMAR BCVA of 1.50±0.53 increased significantly to 0.92±0.49 after surgery (p=0.002). Resolution of RD could be achieved with two-quadrant surgery in only 1 of 3 eyes. In the other 2 eyes, retinal reattachment was achieved after a secondary surgery for the remaining two quadrants to complete four-quadrant sclerectomy. Final outcome was total reattachment of the retina in 11 eyes (78.6%), partial reattachment in 1 eye (7.1%), and recurrence of macular detachment in 2 (14.3%) eyes.

Conclusion

Quadrantic partial-thickness sclerectomy and sclerotomy surgery seems effective for treating UE in eyes with NO. Twoquadrant surgery may be tried for mild UE associated with glaucoma to preserve the superior quadrants for future possible glaucoma surgeries, but secondary surgery for the superior quadrants may be needed. External drainage of subretinal fluid may be an option in severe cases to achieve quicker resolution.

Suprachoroidal haemhorrage and vortex vein varix: A potential association

Purpose:

To report on the association between a vortex vein varix and suprachoroidal hemorrhage.

Case description:

A healthy 60 years-old man with high myopia (–10 diopters) was seen because of sudden paracentral metamorphopsias after emesis. Multimodal imaging included Spectral-Domain Optical Coherence Tomography (SD-OCT), ultrasonography and retinal angiography with fluorescein and indocyanine green. His vision was 20/20 but clinical assessment and imaging procedures evaluations showed a suprachoroidal hemorrhage in the temporal part of the para-macular area. The lesion corresponded to a mild hypo-fluorescence area on fluorescein angiography and to a massive detachment of the inner part of the choroid from the suprachoroidal space on SD-OCT. Indocyanine green angiography disclosed engorgement of a big choroidal vessel in the area of the lesion. An adjacent vortex vein varix was found on SD-OCT. A few weeks later the suprachoroidal hemorrhage resolved spontaneously, whereas the vortex vein varix persisted.

Conclusion:

We speculate that vortex vein varixes might represent a risk factor for the occurrence of suprachoroidal hemorrhage in high myopia and that this association may be worth investigating.

Summary statement:

In a high myopia suprachoroidal hemorrhage might be secondary to vortex vein varixes.

Surgical Management of Choroidal Diseases

Accumulation of serous fluid in the suprachoroidal space, known as uveal effusion, and choroidal or suprachoroidal haemorrhage (SCH) following rupture of ciliary blood vessels are considered rare, but serious, events with extremely poor functional prognosis. As a result, uveal effusion, and expulsive suprachoroidal haemorrhage in particular, continue to be considered as more or less fatal complications. However, clinical experience demonstrates that both clinical entities can be managed by conservative as well as surgical strategies, depending on their severity and localisation, with sometimes surprisingly favourable visual outcome. In addition to prognostic factors, timely recognition and prompt, if possible preventive, acute care, as well as carefully considered timing of adequate surgical measures taking advantage of the specific characteristics of the choroidal tissue, are crucial to treatment success. Along with technical advances in the field of vitreoretinal surgery, numerous variants of therapeutic approaches to the treatment of choroidal effusion and suprachoroidal haemorrhage have been proposed to date. This review presents some of the most important surgical techniques and strategies in the field.

Vortex Vein Imaging: What Can It Tell Us?

This review article summarizes the patho-anatomy of the vortex veins, the major drainage channels for the choroid, and describes the various pathways of diseases associated with vortex vein abnormalities. This report also details the technical advancements to image the vortex veins, such as ultra-widefield indocyanine green angiography, which are critical to elucidate the importance of the vortices in various retino-choroidal disorders. Future applications of these advanced imaging systems to better understand the role of the vortex veins in health and disease are also discussed.

Genotype-phenotype spectrum in isolated and syndromic nanophthalmos

PURPOSE

To (i) describe a series of patients with isolated or syndromic nanophthalmos with the underlying genetic causes, including novel pathogenic variants and their functional characterization and (ii) to study the association of retinal dystrophy in patients with MFRP variants, based on a detailed literature review of genotype-phenotype correlations.

METHODS

Patients with nanophthalmos and available family members received a comprehensive ophthalmological examination. Genetic analysis was based on whole-exome sequencing and variant calling in core genes including MFRP, BEST1, TMEM98, PRSS56, CRB1, GJA1, C1QTNF5, MYRF and FAM111A. A minigene assay was performed for functional characterization of a splice site variant.

RESULTS

Seven patients, aged between three and 65 years, from five unrelated families were included. Novel pathogenic variants in MFRP (c.497C>T, c.899-3C>A, c.1180G>A), and PRSS56 (c.1202C>A), and a recurrent de novo variant in FAM111A (c.1706G>A) in a patient with Kenny-Caffey syndrome type 2, were identified. In addition, we report co-inheritance of MFRP-related nanophthalmos and ADAR-related Aicardi-Goutières syndrome.

CONCLUSION

Nanophthalmos is a genetically heterogeneous condition, and the severity of ocular manifestations appears not to correlate with variants in a specific gene. However, retinal dystrophy is only observed in patients harbouring pathogenic MFRP variants. Furthermore, heterozygous carriers of MFRP and PRSS56 should be screened for the presence of high hyperopia. Identifying nanophthalmos as an isolated condition or as part of a syndrome has implications for counselling and can accelerate the interdisciplinary care of patients.

Venous overload choroidopathy: A hypothetical framework for central serous chorioretinopathy and allied disorders

In central serous chorioretinopathy (CSC), the macula is detached because of fluid leakage at the level of the retinal pigment epithelium. The fluid appears to originate from choroidal vascular hyperpermeability, but the etiology for the fluid is controversial. The choroidal vascular findings as elucidated by recent optical coherence tomography (OCT) and wide-field indocyanine green (ICG) angiographic evaluation show eyes with CSC have many of the same venous patterns that are found in eyes following occlusion of the vortex veins or carotid cavernous sinus fistulas (CCSF). The eyes show delayed choroidal filling, dilated veins, intervortex venous anastomoses, and choroidal vascular hyperpermeability. While patients with occlusion of the vortex veins or CCSF have extraocular abnormalities accounting for the venous outflow problems, eyes with CSC appear to have venous outflow abnormalities as an intrinsic phenomenon. Control of venous outflow from the eye involves a Starling resistor effect, which appears to be abnormal in CSC. Similar choroidal vascular abnormalities have been found in peripapillary pachychoroid syndrome. However, peripapillary pachychoroid syndrome has intervortex venous anastomoses located in the peripapillary region while in CSC these are seen to be located in the macular region. Spaceflight associated neuro-ocular syndrome appears to share many of the pathophysiologic problems of abnormal venous outflow from the choroid along with a host of associated abnormalities. These diseases vary according to their underlying etiologies but are linked by the venous decompensation in the choroid that leads to significant vision loss. Choroidal venous overload provides a unifying concept and theory for an improved understanding of the pathophysiology and classification of a group of diseases to a greater extent than previous proposals.

A pilot study of scleral thickness in central serous chorioretinopathy using anterior segment optical coherence tomography

The aim of this study is to compare the scleral thickness of central serous chorioretinopathy (CSC) eyes with controls using anterior segment optical coherence tomography (AS OCT). This prospective case control study included 15 patients (15 eyes) with CSC and 15 age and gender matched healthy subjects. All subjects underwent spectral domain OCT with enhanced depth imaging and swept source AS OCT of temporal sclera. We investigated difference in scleral thickness between the two groups and relationship between choroidal and scleral thickness. Among the 15 eyes in the study group, 1 eye had acute CSC, 4 had recurrent CSC, 7 had inactive CSC, and 3 had chronic CSC. There was no significant difference in terms of age, gender, axial length and spherical equivalent between the two groups. The choroidal and scleral thickness of the study group were significantly greater than those of the control group (P < 0.001, P = 0.034). Choroidal thickness was positively correlated with scleral thickness (P = 0.031). A thick sclera along with a thick choroid were demonstrated in CSC eyes using AS OCT. Scleral characteristics might be involved in the pathogenesis of CSC by affecting outflow resistance of venous drainage in choroidal circulation.

A Retrospective Case Series of Uveal Effusion Syndrome

PURPOSE

This study aimed to describe the clinical findings and management of eyes affected by uveal effusion syndrome.

METHODS

We retrospectively evaluated the charts of 13 eyes of 8 consecutive patients diagnosed with uveal effusion syndrome attending the Ophthalmology Unit of the University Hospitals Leuven, Belgium, between 2007 and 2018. The presenting features, investigations, management, and outcomes were analyzed for each case.

RESULTS

Cataract surgery was the predisposing factor for uveal effusion in 6 eyes, 2 bilateral uveal effusions (4 eyes) were considered to be medication-induced, and in 3 eyes, the uveal effusion was described as idiopathic. Fundus examination of 5 of 13 eyes showed bullous choroidal detachment, treated with pars plana vitrectomy with superotemporal sclerectomy or transscleral punction. Fundoscopy showed uveal effusion without serous retinal detachment in 3 eyes. Serous retinal detachment accompanied by uveal swelling was observed in 3 eyes and the 2 remaining eyes presented with uveal swelling only. The 8 nonbullous choroidal detachments were treated in a conservative way. A rapid resolution of subretinal fluid and uveal effusion was observed in all cases.

CONCLUSIONS

A conservative approach with acetazolamide treatment or just observation was used in our case series in choroidal detachment without substantial visual loss if, over time, slow improvement was documented. However, further studies are needed to verify the effectiveness of the reported therapy.

Comparing the Results of Vitrectomy and Sclerectomy in a Patient with Nanophthalmic Uveal Effusion Syndrome

Nanophthalmic uveal effusion syndrome (UES) is an extremely rare idiopathic disease characterized by a short axial length of the eye, extremely thick sclera and choroid. These structural changes can lead to spontaneous serous detachment of the retina and peripheral choroid. There are many other causes of UES such as trauma, inflammation, cataract surgery, glaucoma, or retinal detachment. UES is classified into three types. All are characterized by a relapsing-remitting clinical course. The loss of visual acuity ranges from mild to very severe, depending on macular involvement. Changes of the retinal pigment epithelium develop secondary after long-standing choroidal effusion and retinal detachment. Subretinal exudates could be seen and mistakenly diagnosed as chorioretinitis. UES can be very difficult to treat. The most commonly used treatment is surgery involving the creation of surgical sclerostomies (scleral window surgery) or partial thickness sclerectomies to support transscleral drainage. In our case, we present a bilateral nanophthalmic UES, which was misdiagnosed as bilateral ocular Vogt-Koyanagi-Harada disease. We documented the course of the disease and the results of the different surgical approaches in both eyes. A pars plana vitrectomy was performed in the right eye and a sclerectomy with sclerostomies in the left eye. In the left eye, even long lasting loss of visual acuity due to a serous retinal detachment was partially reversed.

A prospective, population-based, surveillance (BOSU) study of uveal effusion syndrome in the UK

PURPOSE

To determine the incidence and demographic profile of uveal effusion syndrome (UES), and to describe the visual and anatomic outcome following deep sclerectomy or vortex vein decompression.

METHODS

The British Ophthalmological Surveillance Unit (BOSU) mails reporting cards monthly to 1149 senior UK ophthalmologists, who are requested to report incident cases of specified rare diseases. UES was included in the reporting system from October 2009 to October 2011. If UES was identified, ophthalmologists were mailed a questionnaire to collect anonymized clinical data at baseline, and 12 months after.

RESULTS

Over 2 years, 29 cases were reported. Two cases were duplicates and 12 failed to meet the eligibility criteria. Of the 15 eligible cases, age ranged from 11 to 91 years (mean 62) and nine were males (60%). Ten patients were hypermetropic; three had an axial length of 19.0 mm or less. Estimated annual incidence was 1.2 per 10 million population. Seven cases were managed nonsurgically, including observation (one case), topical steroids (two cases), systemic steroids (three cases), and cyclodiode laser (one case). Eight cases (11 eyes) underwent full-thickness sclerectomy; the elevated flap was retained in four. The sclera was noted to be thick and rigid during surgery in five cases. Median preoperative visual acuity was 6/18, changing slightly to 6/21.5 at final review, with three eyes showing complete anatomic response, five showing some improvement, and three failing to respond.

CONCLUSIONS

UES is extremely rare. It occurs in a range of ages, but is most common in middle-aged, hypermetropic men. Visual acuity can be materially reduced. The most commonly used surgical treatment in the UK is deep sclerectomy.

Quantitative Assessment of Asymmetric Choroidal Outflow in Pachychoroid Eyes on Ultra-Widefield Indocyanine Green Angiography

Purpose

To quantitatively demonstrate asymmetric choroidal outflow in pachychoroid (central serous chorioretinopathy [CSC]/pachychoroid pigment epitheliopathy [PPE]) eyes using mid-phase, ultra-widefield indocyanine green angiography (UWF ICGA) images.

Methods

Eyes with a clinical diagnosis of CSC/PPE were imaged with multimodal imaging including UWF ICGA (Optos California). Quadrant brightness was measured by manually segmenting based on vortex vein location, calculating the brightness “max-min” value to assess nonuniformity between quadrants, and comparing between CSC/PPE and control eyes. A multivariate linear regression was performed to determine, across individual eyes, which specific quadrants have the greatest brightness in pachychoroid eyes, after taking into account patient-eye-specific variability.

Results

Thirty-three eyes (18 patients) with CSC/PPE along with 16 eyes of 9 controls had a mean age of 51.94 ± 9.72 vs. 53.78 ± 17.92 years (P = 0.731), respectively. Max-min analysis showed significantly increased likelihood of nonuniform drainage between vortex veins in both CSC/PPE and control eyes. Multivariate linear regression in control eyes showed that on average, the inferotemporal quadrant was significantly brighter than the superonasal quadrant (9.72 units, P < 0.001). Among CSC/PPE eyes, adjusting for the preferential, nonuniform drainage in control eyes, the inferonasal and inferotemporal quadrants in CSC/PPE eyes remained significantly brighter than the reference quadrant by 5.36 units (P = 0.034) and 7.51 units (P = 0.008), respectively.

Conclusions

Asymmetric choroidal venous outflow occurs in both control and CSC/PPE eyes based on UWF ICGA quantitative brightness levels in each quadrant. Increased brightness levels along inferior quadrants in mid-phase ICGA images suggest venous outflow congestion among eyes with CSC or PPE.

The Pathogenesis and Treatment of Complications in Nanophthalmos

Microphthalmos is a type of developmental disorder ophthalmopathy, which can occur isolated or combined with other ocular malformations and can occur secondary to a systemic syndrome. Nanophthalmos is one of the clinical phenotypes of microphthalmos. Due to the special and complex structure of nanophthalmic eyes, the disorder is often associated with many complications, including high hyperopia, angle-closure glaucoma, and uveal effusion syndrome. The management of these complications is challenging, and conventional therapeutic methods are often ineffective in treating them. The purpose of this paper was to review the concept of nanophthalmos and present the latest progress in the study of the pathogenesis and treatment of its complications. As it is considerably challenging for ophthalmologists to prevent or treat these nanophthalmos complications, timely diagnosis and a suitable clinical treatment plan are vital to ensure that nanophthalmos patients are treated and managed effectively.

The Value and Caveats of Interpreting Small Case Series: Implications for Patient Care

PURPOSE

To discuss the value and limitations of interpreting small case series for the purpose of understanding the pathophysiology of conditions affecting the visual system and how they may influence patient care decision making.

DESIGN

Selective review of English-language ophthalmic articles published in peer-reviewed journals since 1950.

METHODS

Author-initiated PubMed Central query of small case series in glaucoma, pediatric neuro-ophthalmology, and diabetic retinopathy.

RESULTS

A review of well-known ophthalmic case studies by Gass, Irvine, Brockhurst, and others shows that small samples can provide suggestions to the skilled clinician for adding steps to the examination process when uncovering rare or previously unknown associated complications, as is the case for this perspective's initiating studies by Groth and Brodsky. However, as shown by the now-retracted small case series in Lancet connecting measles-mumps-rubella vaccinations with autism, small case series do not replace the value of clinical trials, with rare exception, when considering impacts to widespread, common clinical practice.

CONCLUSION

Small case series may contribute to an improved understanding of pathophysiology of rare ophthalmic conditions, but alone are insufficient to provide evidence for changing clinical practice of common eye diseases.

CASE OF IDIOPATHIC UVEAL EFFUSION THAT DEVELOPED PROLIFERATIVE DIABETIC RETINOPATHY AFTER SCLERAL RESECTION SURGERY

BACKGROUND/PURPOSE

To report a diabetic patient with uveal effusion that developed proliferative diabetic retinopathy after unsuccessful scleral resection for the uveal effusion.

CASE REPORT

A 50-year-old Japanese man with nonproliferative diabetic retinopathy and uveal effusion in his right eye underwent partial thickness sclerectomies at the four quadrants to treat the uveal effusion. These procedures reduced the amount of subretinal fluid and thus the choroidal and retinal detachment. However, the retinal detachment recurred and proliferative diabetic retinopathy developed with pre- and subretinal proliferation at 5 months after the surgery. The patient then underwent pars plana vitrectomy combined with phacoemulsification and implantation of an intraocular lens. During the surgery, the vasoproliferative membrane was removed, panretinal photocoagulation was performed, and intraocular tamponade with silicone oil was performed. After the removal of the silicone oil, the retina remained attached but the visual acuity was 2/20 because of macular atrophy.

CONCLUSION

Clinicians should be aware that treatment of a uveal effusion by scleral resection can lead to a progression of nonproliferative diabetic retinopathy to proliferative diabetic retinopathy.

Quadrantic vortex vein decompression with subretinal fluid drainage for manangement of Nanophthalmic choroidal effusions- a review of literature and case series

Background

Uveal effusion syndrome is a rare entity of idiopathic exudative detachments of uveal tissues and retina. Medical treatments with systemic steroids and antimetabolites have been tried but with variable results. Scleral windows or vortex decompressions are usually performed and surgeons usually perform partial sclerectomy in all the quadrants.

Case presentation

For the first time, we report 2 cases of nanophthalmic uveal effusion syndrome managed with our technique.

Conclusion

Quadrantic vortex vein decompression with external drainage for nanophthalmic uveal effusion can provide immediate and stable gain in vision.

Geographic filling delay of the choriocapillaris in the region of dilated asymmetric vortex veins in central serous chorioretinopathy

PURPOSE

To investigate the correlation between geographic filling delays in the choriocapillaris using indocyanine green angiography (ICGA) images and dilated vortex veins in central serous chorioretinopathy (CSC).

DESIGN

Observational case series.

PARTICIPANTS

Thirty-two eyes of 32 patients, 21 with acute and 11 with chronic CSC.

METHODS

Digital ICGA and fluorescein angiography (FA), with videoangiography, and swept-source optical coherence tomography (SS-OCT) for B-scan and en-face choroidal imaging were performed. Overlapping of the filling delay areas in the choriocapillaris in the early-phase ICGA images and the region of dilated vortex veins in the en-face images were analyzed. The consistency of both areas was graded as follows. Grade 3: filling delay area is entirely involved in the dilated vortex vein region. Grade 2: 50% or more of filling delay area overlaps with the dilated vortex vein region. Grade 1: less than 50% of filling delay area overlaps with the dilated vortex vein region. Grade 0: no tendency for overlapping of two areas. We evaluated the asymmetry of upper and lower vortex veins in en-face images of the Haller layer. Using the binarization method, we quantified the luminal and stromal areas of the choroid. The ratios of the Haller layer area and luminal areas in the Haller layer to total choroidal area were examined.

RESULTS

The consistency of overlapping of the two areas was grade 2.62 ± 0.49 in acute CSC and grade 1.55 ± 0.78 in chronic CSC (p = 0.0005). Asymmetry of upper and lower vortex veins was seen in 17 of 22 eyes (81%) with acute CSC and 6 of 11 eyes (54.5%) with chronic CSC (p = 0.114). Central choroidal thickness was 411 ± 79 μm in acute CSC and 326 ± 64 μm in chronic CSC (p = 0.004). In the posterior fundus with a 4500 μm diameter, the ratio of the Haller layer area to total choroidal area was 63.7 ± 8.6% in acute CSC and 57.1 ± 7.9% in chronic CSC (p = 0.047). The ratio of the luminal area in the Haller layer area to total choroidal area was 46.9 ± 7.6% in acute CSC and 40.0 ± 6.9% in chronic CSC (p = 0.014).

CONCLUSION

Filling delay areas in the choriocapillaris and dilated vortex vein regions showed marked overlapping in acute CSC. Increased choroidal thickness was attributed to dilated vortex veins. These findings suggest that the blood flow into the choriocapillaris is delayed as a result of congestion of the dominant vortex veins that supply this geographic area. CSC may be a disease characterized by vortex vein congestion that develops in eyes with asymmetric vortex veins.

Choroidal detachments: what do optometrists need to know?

Choroidal detachments occur when there is an accumulation of fluid or blood in the suprachoroidal space, a potential space situated between the choroid and the sclera. They are an uncommon ocular pathology. The most common cause of choroidal detachment is secondary to trabeculectomy; however, there are other causes such as trauma and inflammation. Clinically, choroidal detachments may vary in presentation from asymptomatic, to very poor vision, severe ocular pain, vomiting and nausea. Ocular findings associated with choroidal detachments include serous retinal detachment, secondary angle closure, and a very shallow anterior chamber. Optometrists, as primary eye care providers, need to be aware of the clinical signs and symptoms associated with choroidal detachments and ensure that appropriate and timely management, with a referral to an ophthalmologist, is instigated for optimal visual outcomes. In this review, the pathophysiology, detection, and associated risk factors for choroidal detachments are discussed, and evidence-based management recommendations in an optometric context are provided. The characteristics and management of uveal effusion syndrome are also reviewed, as this can cause idiopathic exudative choroidal detachments distinct from classical choroidal detachment.

Uveal effusion syndrome in 104 eyes: Response to corticosteroids - The 2017 Axel C. Hansen lecture

PURPOSE

The purpose of the study was to investigate the corticosteroids for uveal effusion syndrome (UES).

METHODS

Retrospective series of 104 eyes with UES treated with oral corticosteroids (OCS), periocular corticosteroids (PCS), topical corticosteroids (TCS), or observation (OBS). Main outcome measure was UES resolution.

RESULTS

Of 104 eyes, treatment included OCS (n = 27), PCS (n = 12), TCS (n = 11), and OBS (n = 54). A comparison of the four groups (OCS vs. PCS vs. TCS vs. OBS) revealed differences in those managed with OCS versus OBS as younger (66 vs. 72 years, P = 0.049), PCS versus OBS as male (100% vs. 54%, P = 0.002), PCS versus OBS with decreased visual acuity (VA)/visual field (91% vs. 51%, P = 0.018), and OBS versus OCS as asymptomatic (28% vs. 0%, P = 0.001). Of the 59 with follow-up information, management included OCS (n = 21), PCS (n = 12), TCS (n = 6), and OBS (n = 20). There were differences in initial VA <20/400 in PCS versus OBS (42% vs. 5%, P = 0.018), effusion thickness in TCS versus OCS (7 vs. 3 mm, P = 0.004), and serous retinal detachment in PCS versus OBS (100% vs. 30%, P < 0.001) and PCS versus OCS (100% vs. 57%, P = 0.012). Regarding outcomes, VA showed less worsening in OCS versus OBS (0% vs. 30%, P = 0.008) and OCS versus PCS (0% vs. 33%, P = 0.012). There was no difference in rate of effusion resolution or effusion recurrence. Overall, using combination of corticosteroid therapies, effusion resolution was achieved in 56/59 (95%) cases and the need for surgical management with scleral windows was necessary in only 3/59 (5%) cases. Complications included cataract (n = 9) and no instance of steroid-induced glaucoma.

CONCLUSION

Management of UES is complex and depends on disease severity. Using various corticosteroid delivery routes, UES control was achieved in 95%, and scleral window surgery was required in only 5%. A trial of corticosteroids can benefit patients with UES.

Dilatation of Asymmetric Vortex Vein in Central Serous Chorioretinopathy

PURPOSE

To characterize the outer choroidal vessels in normal control eyes and those with central serous chorioretinopathy (CSC).

DESIGN

Prospective case-control study.

PARTICIPANTS

Thirty-eight eyes of 35 patients with acute CSC and 39 age-matched normal subjects.

METHODS

Swept-source optical coherence tomography was performed to obtain B-scan and en face images in the posterior pole in both groups. All patients with CSC underwent fluorescein angiography (FA) and indocyanine green angiography (ICGA).

MAIN OUTCOME MEASURES

Ascertainment of the patterns of the outer choroidal vessels in the en face and B-scan images in normal controls and patients, and the relationship between the en face images and dye leakage in the FA images and hyperpermeability in the ICGA images.

RESULTS

En face and ICGA images showed 2 choroidal drainage routes that served the upper and lower halves of the posterior pole. Twenty-four of the 39 eyes (62%) of the normal subjects had symmetrically distributed outer choroidal vessels; 15 eyes (38%) had asymmetrically distributed outer choroidal vessels. Asymmetry was seen in all 38 eyes (100%) of the 35 patients with CSC. The outer choroidal vessels all had vortex veins on en face and ICGA images. In eyes with CSC, a dominant vortex vein served the macular region (9 eyes) or the posterior pole (24 eyes) or extended beyond the vascular arcades (5 eyes). Dominant vortex veins were relatively dilated in normal controls but dilated markedly in CSC, with the distal ends in the macular region abruptly dilated. The sites of dye leakage on the FA images and hyperpermeability on the ICGA images corresponded to the dilated dominant vortex veins.

CONCLUSION

The presence of an asymmetric vortex vein was a common variation (38%) in normal subjects; this asymmetry was seen in all eyes (100%) with CSC. Dominant vortex veins were dilated markedly in CSC. Congestion of the dominant vortex veins might enhance the permeability of fenestrated choriocapillaris in the macular region. Asymmetric dominant vortex veins appear to be a predisposing factor for CSC.

Spectrum of Angle Closure, Uveal Effusion Syndrome, and Nanophthalmos

Nanophthalmos, uveal effusion syndrome, and acute angle closure glaucoma (ACG) can present as a continuum in a patient, as is described here. This patient's angle closure was thought to be caused by idiopathic uveal effusion syndrome, and while there are no generally accepted diagnosis criteria for nanophthalmos, our patient fulfilled the criteria as defined by Wu.¹⁰ To prevent development of further angle closure, the decision was made to do cataract extraction as opposed to medical management.

Scleral resection in chronic central serous chorioretinopathy complicated by exudative retinal detachment

BACKGROUND

Effective therapeutic options are limited for the management of chronic central serous chorioretinopathy (CSCR) complicated by exudative retinal detachments (RD). The authors describe the resolution of one such case following partial thickness scleral resection with mitomycin C.

CASE PRESENTATION

This 39-year-old male presented with a unilateral inferior exudative RD in the right eye. There was no history of steroid use either locally or systemically. The fundus fluorescein angiogram showed window defects and leaks typical of chronic CSCR. The axial length was 21.06 mm in the right eye and 21 mm in the left eye. Thickening of the ocular coats was evident on ocular ultrasound. Considering an axial length in the borderline-low range inferotemporal and inferonasal partial thickness scleral resection with mitomycin C was performed. The exudative RD resolved at 4 months.

CONCLUSION

Partial thickness scleral resection may be considered as an option for treating chronic CSCR patients with borderline-low axial length complicated by exudative RD.

Uveal effusion syndrome mimicking severe chronic posterior uveitis: a case series of seven eyes of four patients

PURPOSE

To describe the clinical findings and management of eyes affected by uveal effusion syndrome (UES) presenting with clinical features mimicking inflammatory ocular diseases, treated using individualized surgical approaches.

METHODS

We report a consecutive interventional case series of seven eyes of four patients affected by UES. On presentation in our clinic, all patients showed signs of steroid effects as a consequence of a presumptive diagnosis; one eye had undergone vitrectomy for retinal detachment (RD), without benefit. Diagnosis of UES was based on ophthalmic examination, ultrasonography, fluorescein angiography, biometry and magnetic resonance imaging. Five eyes with active disease were treated using scleral thinning surgical procedures based on the extent and characteristics of the disease: sclerectomy sites were ultrasound-guided to the area of maximal choroidal swelling, associated with evacuative puncture in the case of bilateral funnel-shaped RD.

RESULTS

One patient was diagnosed with type 1 UES, two with type 2, and one with type 3. Mean postoperative follow-up was 26 months. In all eyes, surgery resolved the ciliochoroidal and retinal detachment and improved visual acuity. In two eyes, visual restoration was limited by a prolonged disease course.

CONCLUSION

UES may be mistaken for other sources of ciliochoroidal effusion. Early diagnosis and treatment is critical to avoid unnecessary procedures and to prevent severe visual loss as a result of neuroretinal damage. Surgical treatment based on the extent and characteristics of the disease may be effective for the resolution of ciliochoroidal effusion, even in type 3 UES, where conventional surgery has proved unsuccessful.

Cataract surgery in small adult eyes

AIM

To evaluate the clinical outcomes of phacoemulsification cataract surgery in microphthalmos.

METHODS

Retrospective consecutive case series of eyes with axial length <20.9 mm, and requiring a high intraocular lens (IOL) power (≥30 or ≥35 dioptres for anterior or posterior chamber fixation, respectively), with no history of previous ocular surgery, and undergoing planned phacoemulsification cataract surgery with IOL implantation at Moorfields Eye Hospital was investigated to observe the incidence of intraoperative and postoperative complications.

RESULTS

During a 5-year study period, 47 of 22,093 eyes were treated in two locations (0.21%). Thirty-nine eyes met the study inclusion criteria. No serious intraoperative adverse events were recorded. Severe postoperative complications (retinal detachment and chronic postoperative uveitis) occurred in two cases. The postoperative corrected distance visual acuity (CDVA) was logMAR 0.30 or better in 24 eyes (62%), and only three eyes obtained worse vision. The overall ocular comorbitidy rate was 53%; 10 microphthalmic eyes (26%) presented with associated congenital or hereditary pathology, and had worse visual outcomes (p<0.0001).

CONCLUSIONS

Microphthalmic eyes requiring high IOL power are rare, and their presence is often associated with other ocular congenital or acquired disorders. Overall, the clinical outcomes were satisfactory and the surgical procedure affected by a low complication rate.

Full-thickness sclerotomy for uveal effusion syndrome

To report the surgical outcome of full-thickness sclerotomy in five cases of uveal effusion syndrome (UES). Full-thickness sclerotomy without sclerectomy was performed on five eyes of four patients with UES with or without nanophthalmos. In four of the eyes, exudative retinal detachment associated with UES resolved after the sclerotomy. The subretinal fluid in one eye, which had a normal axial length, was relieved after undergoing three sclerotomy procedures. Full-thickness sclerotomy without vortex vein decompression or sclerectomy is an effective surgical option for the management of significant UES.

A novel technique for choroidal fluid drainage in uveal effusion syndrome

BACKGROUND AND OBJECTIVE

Uveal effusion syndrome (UES) is a rare disorder associated with thickening of the choroid and secondary retinal detachment as a possible serious complication. UES occurs in hypermetropic or nanophthalmic eyes or can be idiopathic and is a diagnosis of exclusion. Vortex vein decompression, sclerectomy or sclerotomy, and drainage of choroidal fluid are surgical treatment options.

PATIENTS AND METHODS

The authors describe a novel surgical technique for drainage of serous choroidal detachment using a penetrating diathermy probe in two patients with UES. The procedure involves drainage of choroidal fluid by using a penetrating diathermy probe (2 mm tip length) after placing a 20-gauge infusion line in the anterior chamber.

RESULTS

Choroidal fluid drainage was successful in both patients, with satisfactory outcome on follow-up.

CONCLUSION

The proposed simple and feasible surgical drainage technique may improve the management of patients with UES.

Resolution of serous retinal detachment following partial sclerectomy with mitomycin C in nanophthalmos

The authors report the results of partial-thickness sclerectomy combined with mitomycin C in a nanophthalmic eye with serous retinal detachment. Partial sclerectomy in two quadrants with adjuvant use of mitomycin C without drainage of subretinal fluid was performed. The patient was monitored with serial fundus photographs and spectral-domain optical coherence tomography (SD-OCT) for up to 16 weeks postoperatively. Best corrected visual acuity improved from counting fingers at 1 meter preoperatively to 6/60 at final follow-up. There was gradual but complete resolution of serous retinal detachment both clinically and on SD-OCT. Partial-thickness sclerectomy with mitomycin C is an effective and safe procedure in the management of nanophthalmic eyes with uveal effusion.

A modified ultrasound-guided surgical technique for the management of the uveal effusion syndrome in patients with normal axial length and scleral thickness

PURPOSE

The purpose of this study was to describe a modified surgical technique for the management of the uveal effusion syndrome (UES).

METHODS

A consecutive interventional case series of six eyes with UES is reported. The diagnosis of the UES was based on detailed ophthalmic examination, fluorescein angiography, B-scan ultrasonography, biometry, and magnetic resonance imaging. All eyes underwent an ultrasound-guided placement of the sclerostomies subjacent to the area of maximal choroidal swelling using a scleral punch without scleral flaps or vortex vein decompression.

RESULTS

All patients were men with a mean age of 53 years. The mean postoperative follow-up was 16.25 months. Five eyes had normal axial lengths (22.54-23.05 mm) by ultrasound and normal sclera thickness on magnetic resonance imaging. One eye had a shorter axial length (21.65 mm) and mild scleral thickening on magnetic resonance imaging. All six eyes had anterior peripheral choroidal swelling. Three eyes had associated serous retinal detachment, and three eyes had acute appositional angles. After surgery, five eyes had total resolution of the peripheral choroidal swelling and retinal detachment or normalization of the angle. One eye had partial resolution of the retinal detachment. Of the three eyes with retinal detachment, two eyes experienced improvement in visual acuity after surgery. No complications were noted.

CONCLUSION

This modified ultrasound-guided surgical technique for sclerostomy placement seems to be effective in the management of the UES, including eyes with normal axial length and scleral thickness, a subset of the UES that has been previously reported not to respond to surgery.