The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis

TOPIC

Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial.

CLINICAL RELEVANCE

This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat.

METHODS

Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR).

RESULTS

Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data.

DISCUSSION

Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Visual outcomes and prognostic factors of early pars plana vitrectomy for open globe injury

OBJECTIVES

To identify the clinical features and outcomes of early vitrectomy in patients with open globe injury (OGI) and the prognostic factors for visual outcome.

METHODS

This retrospective observational case series included 390 eyes in 389 patients diagnosed with OGI receiving vitrectomy within four days after injury. Preoperative parameters included the injury types, wound locations, consequent tissue damages, initial visual acuity (VA), and ocular trauma score. Postoperative outcome measures included surgical procedures, retinal (re)attachment, complications, and final VA. The logistic analysis evaluated the prognostic factors for visual outcome.

RESULTS

Intraocular foreign bodies (59.2%) and penetrating injuries (28.7%) were the most common injury types. Among the 165 eyes with retinal detachment (RD), 121 (73.3%) had retinal reattachment during early primary vitrectomy, and 32 (19.4%) were repaired during a second or subsequent surgery. Thirteen eyes (3.3%) were enucleated. The final VA improved from the initial level in 207 eyes (55.2%), remained unchanged in 123 (32.8%), and decreased in 45 (12.0%). Multivariable regression revealed that the injury zone, initial VA, RD, and endophthalmitis were associated with poor visual outcomes (P < 0.05).

CONCLUSIONS

Higher zone injury, low initial VA, RD, and endophthalmitis are predictors of poor visual outcome in eyes undergoing early vitrectomy for OGI.

Direct Laser Photocoagulation of the Retinal Pigment Epithelium: A Novel Method to Seal Retinal Breaks during Pars Plana Vitrectomy for Retinal Detachment

BACKGROUND

This study evaluates the clinical effectiveness of employing direct retinal pigment epithelium (RPE) laser photocoagulation as a technique for achieving chorioretinal adhesion to effectively seal retinal breaks.

METHODS

A total of 20 eyes from 20 patients were enrolled in the study; all selected eyes exhibited either rhegmatogenous or combined rhegmatogenous-tractional retinal detachment. During vitrectomy, direct RPE laser photocoagulation was executed, employing a power range of 100-150 mW and a duration of 120-200 ms, targeting the peripheries where the edges of each retinal break were anticipated to settle post-reattachment. This treated area's neuroretina thickness was compared to measurements obtained after conventional transretinal laser photocoagulation.

RESULTS

Patients were followed for an average duration of 24 months, with a range of 11-46 months. A visible pigmentary reaction in the ophthalmoscopic examination was evident in the treated regions for all but one eye, where the retinal break was situated amidst myelinated nerve fibers. The study encountered no severe complications, and successful retinal reattachment was achieved in all 20 eyes. The mean best-corrected visual acuity (BCVA) at the final follow-up showed a statistically significant improvement compared to preoperative levels (p < 0.0001). A noteworthy difference in neuroretinal thickness was observed one-month post-surgery between areas treated with direct RPE and those treated with transretinal photocoagulation, measuring 217 μm and 104 μm, respectively.

CONCLUSIONS

Our findings suggest that direct RPE laser photocoagulation is an effective therapeutic intervention for sealing retinal breaks.

The Use of Preoperative Prophylactic Systemic Antibiotics for the Prevention of Endopthalmitis in Open Globe Injuries: A Meta-Analysis

TOPIC

This study reports the effect of systemic prophylactic antibiotics (and their route) on the risk of endophthalmitis after open globe injury (OGI).

CLINICAL RELEVANCE

Endophthalmitis is a major complication of OGI; it can lead to rapid sight loss in the affected eye. The administration of systemic antibiotic prophylaxis is common practice in some health care systems, although there is no consensus on their use.

METHODS

PubMed, CENTRAL, Web of Science, CINAHL, and Embase were searched. This was completed July 6, 2021 and updated December 10, 2022. We included randomized and nonrandomized prospective studies which reported the rate of post-OGI endophthalmitis when systemic preoperative antibiotic prophylaxis (via the oral or IV route) was given. The Cochrane Risk of Bias tool and ROBINS-I tool were used for assessing the risk of bias. Where meta-analysis was performed, results were reported as an odds ratio. PROSPERO registration: CRD42021271271.

RESULTS

Three studies were included. One prospective observational study compared outcomes of patients who had received systemic or no systemic preoperative antibiotics. The endophthalmitis rates reported were 3.75% and 4.91% in the systemic and no systemic preoperative antibiotics groups, a nonsignificant difference (P = 0.68). Two randomized controlled trials were included (1555 patients). The rates of endophthalmitis were 17 events in 751 patients (2.26%) and 17 events in 804 patients (2.11%) in the oral antibiotics and IV (± oral) antibiotics groups, respectively. Meta-analysis demonstrated no significant differences between groups (odds ratio, 1.07; 95% confidence interval, 0.54-2.12).

CONCLUSIONS

The incidences of endophthalmitis after OGI were low with and without systemic antibiotic prophylaxis, although high-risk cases were excluded in the included studies. When antibiotic prophylaxis is considered, there is moderate evidence that oral antibiotic administration is noninferior to IV.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Preventing Retinal Detachment: The Encircling Laser Retinopexy Technique

Encircling (360 degree) retinal detachment prophylaxis using indirect ophthalmoscope laser delivery recently achieved strong proof of safety and effectiveness by preventing the development of peripheral retinal tears and detachments in the eyes of patients with Stickler syndrome (syndromic eyes). Untreated, Stickler syndrome patients have a 65% lifetime risk of retinal detachment (half by age 20, 80% bilateral). This report describes an optimal technique of encircling laser retinopexy to also prevent the more common retinal detachments seen in aging (non-syndromic) eyes that share with Stickler syndrome the common pathogenesis of peripheral retinal tears caused by vitreous traction.

Clinical presentations, management and factors affecting outcomes in posterior segment open globe injuries - An analysis of 2360 eyes

Aim To report the clinical presentations, management, and factors affecting the outcomes in posterior segment open globe injuries in 2,360 consecutive eyes. Methods This was a retrospective, consecutive, non-comparative interventional case series. All cases with scleral and corneoscleral wounds presenting to these centers from January 2014 to January 2021 were included. The cases were defined according to the Birmingham Eye Traumatology Terminology system (BETTs) classification. The Ocular Trauma Score (OTS) was applied to the dataset. Results Mean age of presentation was 36.63±19.92 years (median 35 years). Penetrating trauma accounted for 70.92%, rupture for 18.6%, perforation for 4.6% and IOFB in 5.88% eyes. In 76.6% the location of injury involved zone I extending till Zone II while in 23.4% it involved Zone II and/or Zone III. Vision at presentation was logMAR 3.03±0.99 and at the last visit was logMAR 2.47±1.42 (p<0.0001). Time interval between presentation to the treatment center and globe repair was 13.93±19.56 hours (median 7.6 hours). Favorable functional outcome was seen in 29.2% eyes and favorable anatomic outcome in 66.9%. Decreasing age at presentation, penetrating injury instead of rupture or perforating injury, a higher OTS, absence of corneal involvement, absence of retinal detachment at presentation and absence of concurrent orbital fracture were associated with a favorable functional outcome (>20/200). Final visual acuity in logMAR correlated with the OTS value calculated at presentation. Conclusions In the absence of retinal detachment and orbital fracture, posterior open globe injuries typically have a favorable functional outcome. OTS correlated with the final visual acuity.

Preventing Retinal Detachment: Where are We? Implications from Stickler Syndrome

Stickler syndrome, a rare inherited disease, carries a lifetime risk of rhegmatogenous retinal detachment (RRD) of up to 65%, higher than any other predisposing condition known. Both syndromic and non-syndromic eyes suffer RRD predominately from the same pathogenesis, vitreous tractional tears in the peripheral retina. Consequently, extraordinary publications in 2021-2022, each reporting successful prevention of RRD in Stickler syndrome, using 360-degree (encircling) laser retinopexy, provide the first strong evidence upon which similar prophylaxis in non-syndromic eyes at high risk of RRD from peripheral retinal tears can confidently go forward.

Successive trabecular meshwork photocoagulation in the treatment and prevention of refractory hypotony

PURPOSE

To evaluate the effect of successive trabecular meshwork photocoagulation (sTMP) on the elevation of intraocular pressure (IOP) to treat or prevent refractory hypotony.

METHODS

The IOP changes of 15 refractory hypotonic eyes (or estimated to be hypotonic after silicon oil removal) in 15 consecutive patients were retrospectively analysed after sTMP. Fourteen eyes had intraocular silicone oil that was to be removed. Different lasers were used to destroy the trabecular meshwork 1-5 times (2.00±1.20 times on average) via the gonioscope or endoscope. Twelve eyes had a large area of exposed retinal pigment epithelium due to a large area of retinecotomy, one eye had a severe cyclitic scar, and two eyes had both a scar and a retinal defect.

RESULTS

After sTMP (1 to 125 months of follow-up, 22.87 ± 38.88 months), the average IOP in the 15 eyes was 11.70 ± 3.19mmHg (n = 15), significantly higher than the value before sTMP (8.26 ± 1.93 mmHg, P < 0.05). The IOP of the 15 eyes increased by 3.44 ± 2.61 mmHg, Eight eyes with an IOP of less than 10 mmHg before sTMP showed an IOP ≥10 mmHg after sTMP. Following sTMP, the silicone oil was removed from six eyes, and one of these eyes suffered a retinal detachment.

CONCLUSION

sTMP can significantly increase the IOP with a long-lasting effect and provide an opportunity for the removal of silicone oil despite large-area retinal defects or cyclitic scars in selected eyes.

Guideline for the treatment of no light perception eyes induced by mechanical ocular trauma

Severe mechanical ocular trauma with no light perception (NLP) predicts a poor prognosis of visual acuity and enucleation of the eyeball. Since the innovative treatment concept of exploratory vitreoretinal surgery has developed and treatment technology has advanced, the outcomes of severe ocular trauma treatment in NLP patients have greatly improved. However, there remains a lack of unified standards for the determination, surgical indication, and timing of vitrectomy in NLP eye treatment. To address these problems, we aimed to create evidence-based medical guidelines for the diagnosis, treatment, and prognosis of mechanical ocular trauma with NLP. Sixteen relevant recommendations for mechanical ocular trauma with NLP were obtained, and a consensus was reached. Each recommendation was explained in detail to guide the treatment of mechanical ocular trauma associated with NLP.

Globe and Adnexal Trauma Terminology Survey

Importance

Ocular trauma terminology should be periodically updated to enable comprehensive capturing and monitoring of ocular trauma in clinical and research settings.

Objective

To update terminology for globe and adnexal trauma.

Design, Setting, and Participants

A 2-round modified Delphi survey was conducted from January 1 to July 31, 2021, using an expert panel, including 69 ophthalmologists identified through their membership in ophthalmology (globe and adnexal trauma) societies. Consensus was defined as at least 67% expert agreement. A steering committee developed questions after identifying gaps in the current terminology via a targeted literature review. Round 1 sought consensus on existing and newly proposed terminology, and round 2 focused on unresolved questions from round 1. Experts included ophthalmologists who had managed, on average, 52 globe or adnexal trauma cases throughout their careers and/or published a total of 5 or more globe or adnexal trauma-related peer-reviewed articles.

Main Outcomes and Measures

Expert consensus on ocular and adnexal terms.

Results

A total of 69 experts participated in and completed round 1 of the survey. All 69 participants who completed round 1 were asked to complete round 2, and 58 responses were received. Consensus was reached for 18 of 25 questions (72%) in round 1 and 4 of 7 questions (57%) in round 2. Existing Birmingham Eye Trauma Terminology system terminology achieved consensus of 84% (58 of 69 experts) in round 1 and 97% (56 of 58 experts) in round 2. Experts agreed on the need for further refinement of the definition of zones of injury (55 of 69 [80%]), as the zone affected can have a substantial effect on visual and functional outcomes. There was consensus that the mechanism of injury (52 of 69 [75%]) and status of the lacrimal canaliculi (54 of 69 [78%]), nasolacrimal ducts (48 of 69 [69%]), lens (46 of 58 [80%]), retina (42 of 58 [73%]), and central and paracentral cornea (47 of 58 [81%]) be included in the revised terminology.

Conclusions and Relevance

There was consensus (defined as at least 67% expert agreement) on continued use of the existing Birmingham Eye Trauma Terminology system definitions and that additional terms are required to update the current ocular trauma terminology.

Globe ruptures: outcomes and prognostic analysis of severe ocular trauma

PURPOSE

Eye trauma is an important causes of monocular visual loss worldwide. This study aimed to describe the structural and functional characteristics and outcomes of 281 globe ruptures.

METHODS

Medical records of all patients undergoing surgery for a ruptured globe at Centro Hospitalar Universitário do Porto in the last 17 years were retrospectively reviewed.

RESULTS

Two hundred and eighty-one eyes of 277 patients were included. The majority of them were males (71%) with a mean age of 59.7±20.5. In 38.8% of the cases the cause was a fall. At the time of admission, 29.5% of the eyes had a visual acuity greater than 20/200 and 12.5% had no light perception. The median time between trauma and primary repair was less than 8h (interquartile range 5-12 h). A primary reconstruction was always attempted. Primary evisceration was performed in 14 cases (5%). In multivariable analysis, independent predictors of vision survival were male gender, shorter wound size and absence of vitreous hemorrhage.

CONCLUSION

In this large, retrospective study on globe ruptures we identified male gender, short wound length, and the absence of vitreous hemorrhage or retinal detachment as predictors of improved functional outcome. We found a correlation between the presenting and final visual acuities and the Ocular Trauma Score. Our determination to reconstruct the traumatized eyes as early and as completely as possible was justified by the functional results: despite the severity of the injuries, one out of four eyes reached a final visual acuity greater than 20/200.

Analysis of ocular injury 1-year outcome in survivors of Beirut Port ammonium nitrate blast

Purpose

Ascertain the 1-year outcome of patients who sustained open eye injuries from the Beirut Port ammonium nitrate (AN) explosion, one of the most powerful non-nuclear explosions in history.

Methods

Retrospective chart review of the operated eyes in 2 major eye hospitals.

Results

Out of 42 patients with open globe injury that was originally sutured, 29 patients (34 eyes) were followed at the 1-year mark. The initial vision in logMAR (mean ± SD) was 2.93 ± 0.87 (hand motion equivalent) and the final vision was 1.80 ± 1.47 (counting finger 2 m equivalent). No light perception (NLP) vision was noted in 12 eyes on presentation and 10 eyes remained so, while 2 eyes reached light perception (LP) vision. Eight eyes had an intraoperative expulsive choroidal hemorrhage (7 NLP and 1 LP both pre- and postoperatively), and 6 of the 8 developed phthisis. All eyes that developed phthisis had NLP preoperatively and postoperatively. Ocular Trauma Score (OTS) correlated inversely with both initial and final vision (p < 0.001). Zone of injury inversely correlated with initial vision (p = 0.02) and positively with final vision (p < 0.001). Final vision was significantly worse in zone 3 vs. zones 1 and 2 (3.2 ± 0.5) vs. 0.9 ± 1.1) (p < 0.001) injuries, as was the initial vision (3.3 ± 0.5 vs. 2.7 ± 0.8; p = 0.002).

Conclusion

The OTS, which provides prognostic information for serious ocular trauma, also yields valuable prognostic information for AN-associated ocular injuries. Expulsive choroidal hemorrhage and NLP vision at presentation remain very poor prognostic signs.

The application of clinical registries in ophthalmic trauma-the International Globe and Adnexal Trauma Epidemiology Study (IGATES)

Ophthalmic trauma is a leading cause of preventable monocular blindness worldwide. The prevalence of ophthalmic trauma varies considerably based on geographic location, socio-economic status, age groups, occupation, and cultural practices such as firework celebrations. Clinical registries are known to be valuable in guiding the diagnosis, management, and prognostication of complex diseases. However, there is currently a lack of a centralized international data repository for ophthalmic trauma. We draw lessons from past and existing clinical registries related to ophthalmology and propose a new suitable international multicenter clinical registry for ophthalmic trauma: the International Globe and Adnexal Trauma Epidemiology Study (IGATES). IGATES is hosted on a secure web-based platform which exhibits user-friendly smart features, an integrated Ocular Trauma Score (OTS) prognosis calculator, efficient data collection points, and schematic graphical software. IGATES currently has 37 participating centers globally. The data collected through IGATES will be primarily used to develop a more robust and improved ophthalmic trauma prognostic classification system, the Ocular Trauma Score-2 (OTS-2), which builds on previous systems such as the Birmingham Eye Trauma Terminology System (BETTS) and Ocular Trauma Score (OTS). Furthermore, IGATES will act as a springboard for further research into the epidemiology, diagnosis, and management of ophthalmic trauma. Ultimately, IGATES serves to advance the field of ophthalmic trauma and improve the care that patients with ophthalmic trauma receive.

Ophthalmic Trauma Correlation Matrix (OTCM): a potential novel tool for evaluation of concomitant ocular tissue damage in open globe injuries

PURPOSE

To introduce a novel tool to investigate the correlation between concomitant injuries and primary open globe injury (OGI) in the setting of ophthalmic trauma, the "Ophthalmic Trauma Correlation Matrix" (OTCM).

METHODS

Retrospective cohort review, performed at a tertiary referral eye care center in Eastern Nepal, involving all eyes with OGI meeting the inclusion criteria from 2015-2018. Clinical data including details of primary injury, concurrent injuries, and clinical course were noted from hospital medical records. A correlation matrix chart was devised using matrix correlation and Pearson's correlation coefficient. This chart was then used to evaluate the association of the various injuries in the setting of OGI.

RESULTS

A total of 109 eyes with OGI were included. Majority of the eyes (78, 71.6%) had zone I injuries, while most of the eyes (66, 60.6%) had penetrating injury. The most frequent concomitant injuries in all zones of OGI were traumatic lens injury (77, 70.64%), followed by hyphema (48, 44.03%), and vitreous hemorrhage (35, 32.11%). The most common concomitant injury associated with zone I was hyphema (0.873), while traumatic subluxation/cataract (0.894) and vitreous hemorrhage (0.972) were commonly associated with zone II and III, respectively.

CONCLUSIONS

OTCM could be a useful tool to manage injuries related to the primary ocular injury. This additional information will aid in the prognostication, planning, and management of OGI and potentially prevent repeat surgeries and inadequate treatments.

Complete and early vitrectomy for endophthalmitis

We recently co-authored a report on the ten-year (2007-2017) results achieved at our center (Retina Specialists of Alabama) in the treatment of Acute Post-Cataract Endophthalmitis (APCE). Of all eyes, 77.4% were initially treated with Complete and Early Vitrectomy for Endophthalmitis (CEVE). Visual acuity of ≥ 20/40 was restored in 79% of all eyes versus 53% of eyes reported in the Endophthalmitis Vitrectomy Study. We believe that CEVE is the initial treatment of choice whenever the fundus is obscured by endophthalmitis vitreous opacity.

Epiretinal membrane vitrectomy: outcomes with or without cataract surgery and a novel prognostic factor for cystoid macular edema

PURPOSE

To assess the outcomes of vitrectomy with or without cataract surgery for the treatment of idiopathic ERM in phakic eyes and evaluate predictors of functional and anatomical outcomes.

METHODS

Retrospective cohort of consecutive phakic ERM eyes distributed in three groups: a) combined (phacovitrectomy) group, b) PPV-only group, and c) consecutive group (PPV followed by cataract surgery). Main outcomes were final visual acuity (VA) and cystoid macular edema (CME) occurrence. Potential predictors of VA or CME included clinical variables and SD-OCT parameters.

RESULTS

A total of 108 eyes were included in this study. There were no differences in the final VA between consecutive and combined groups (0.22 vs 0.10 logMAR, p = 0.851). Twelve eyes from the combined group (23%) and one eye from the PPV-only group presented CME (p = 0.001). There were no differences between postoperative CME occurrence in combined versus consecutive group (12 vs 7, p = 0.38). The presence of cotton-ball sign predicted the development of CME [OR 2.86 (95%CI 1.01-8.18), p = 0.049] while separated ERM-ILM complex was found to be protective [OR 0.25 (95%CI 0.08-0.77), p = 0.015].

CONCLUSIONS

Functional and anatomical results of PPV with ERM and ILM peeling combined with cataract surgery was equivalent to the consecutive procedure, with both strategies being effective. Separated ERM-ILM complex has prognostic value in these patients, as its presence at baseline was found to be protective for postoperative CME.

Stickler Syndrome (SS): Laser Prophylaxis for Retinal Detachment (Modified Ora Secunda Cerclage, OSC/SS)

Purpose

To introduce a novel technique of encircling laser prophylaxis (ora secunda cerclage Stickler syndrome, OSC/SS) to prevent rhegmatogenous retinal detachment (RRD) in Stickler syndrome eyes.

Patients and Methods

After first eye RRD at age 50 and at age 18, respectively, a 53-year-old father and his 22-year-old son with type 2 SS (STL2) gave informed consent and underwent OSC/SS prophylaxis, performed in each fellow eye. A 26-year-old STL2 daughter then suffered first eye retinal detachment and similarly chose fellow eye OSC/SS prophylaxis. A second son, 28 years of age with STL2, chose OSC/SS prophylaxis in both eyes.

Results

The three OSC/SS treated fellow eyes have gone 12 years, 11 years, and 8 years without RRD. STL1 and less common STL2 eyes are known to have a similar rate of RRD, and 80% of STL1 fellow eyes develop RRD at a median of 4 years in the absence of prophylaxis. Moreover, five of six (83%) known STL2 family members suffered RRD, only the STL2 son with bilateral OSC/SS remaining bilaterally attached. All five OSC/SS treated eyes (average 8.7 years post-prophylaxis) retained preoperative visual acuity of 20/20 to 20/30, with an average, asymptomatic reduction of meridional field in each eye to 50 degrees. In contrast, in the three eyes having suffered RRD prior to presentation, visual acuity ranged from 20/125 to 8/200 and average meridional field was 29 degrees.

Conclusion

Encircling grid laser (OSC) modified in Stickler eyes to encompass the ora serrata and extend posteriorly to and between the vortex vein ampullae (OSC/SS) is a reasonable RRD prophylaxis option to offer STL1 and STL2 patients as an alternative to no treatment or less effective prophylaxis. Because of rarity and severity, the ultimate proof of safety and efficacy will likely come not from randomized trials, but from a non-randomized, prospective, cohort comparison study of such individual efforts.

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Complete and Early Vitrectomy for Endophthalmitis After Cataract Surgery: An Alternative Treatment Paradigm

Purpose

In this study, we report the treatment outcomes of complete and early vitrectomy for endophthalmitis (CEVE) after cataract surgery as the predominate initial treatment, accompanied by systemic antibiotics and retreatment of persistent or recurrent purulence (CEVE+).

Patients and Methods

Clinical features and microbiological factors were retrospectively reviewed in 62 eyes of 62 patients who were treated for acute postcataract endophthalmitis (APCE) occurring within three weeks of cataract surgery at Retina Specialists of Alabama, between 2007 and 2017.

Results

Visual acuity on presentation included light perception (LP) in 18 eyes (29%) and hand motion (HM) in 23 eyes (37%). Initial treatment was maximum possible vitrectomy in 48 eyes (77%) and tap-and-inject in 14 eyes (23%), with 38 eyes (61%) receiving two or more treatments. Cultures for the first intervention were positive in 49 eyes (79%) and virulent in 18 eyes (29%). At a median follow-up time of five months, final visual acuity was ≥20/40 in 49 eyes (79%), between 20/50 and 5/200 in seven eyes (11%), and <5/200 in six eyes (10%). Virulence was the strongest predictor of poor visual outcome. Retinal detachment occurred in four eyes (6%), likely from necrotic retinal defects in each case.

Conclusion

Complete and early vitrectomy is a safe and effective initial treatment for APCE. When accompanied by systemic antibiotics and retreatment (CEVE+) of recurrent media opacification, it improves recovery of 20/40 or better visual acuity by approximately 50% compared to a predominantly tap-and-inject treatment paradigm. We recommend CEVE for fundus-obscuring APCE (~75% of all cases) whenever the view is inadequate to rule out macular distress.

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Optic disc pit maculopathy: tamponade of maculoschisis

Purpose

To present rapid and safe closure of the pit-macula communication (PMC) by core vitrectomy and adequate duration gas tamponade as our preferred method of resolving optic disc pit (ODP) maculopathy and to define the term "maculoschisis" in ODP maculopathy as an alternative to the term "schisis-like."

Patient and methods

A twenty-four-year-old female presented with an optical coherence tomography (OCT) confirmed ODP and a "giant" communicating maculoschisis cavity. Central macular thickness (CMT) measured 906 microns, and macular volume was twice normal, at 20.8 mm³. Snellen corrected visual acuity was 20/70. Two months after initial vitrectomy performed elsewhere with short-term gas tamponade (SF₆ 20%), CMT and visual acuity were not significantly improved. Combined lens extraction/intraocular lens placement and repeat vitrectomy with C₃F₈ 15% gas tamponade were performed, with one supplemental (office) gas injection.

Results

OCT imaging six weeks postoperatively showed definitive closure of the PMC with CMT reduced by 405 microns. Sequestered from its ODP source, foveal schisis fluid then resolved by 12 weeks postoperatively. At final follow-up 3.4 years postoperatively, the macula remained dry with a CMT of 322 microns and a concave foveal contour. Macular volume was reduced to (a normal) 10.2 mm³ and visual acuity had improved to 20/25.

Conclusion

No report heretofore has documented rapid, sustained closure of the PMC by gas tamponade as the preferred method of expeditiously resolving ODP maculopathy. However, tamponade PMC closure sequesters ODP fluid and uniquely provides early assurance of ultimate maculopathy resolution. In all other techniques, PMC closure is a trailing phenomenon and success remains uncertain during months to a year or more of (unsequestered) fluid resolution. We suggest that more invasive techniques (laser barrier application to the peripapillary choroid, vitreoretinal interface maneuvers, and pit-plugging) be withheld unless a recurrence is detected during subsequent examinations.

Ocular Venous Air Embolism (OVAE): A Review

Purpose:

The purpose of this article is to review and analyze reported cases of ocular venous air embolism (OVAE) to develop a reliable clinical definition of OVAE and effective prevention strategies.

Methods:

We reviewed all reports of suspected air embolism during vitrectomy published in PubMed since the introduction of pars plana vitrectomy, and 5 cases found elsewhere and separately reported concurrent with this review.

Results:

OVAE is a precipitous drop in end-tidal CO2, a choroidal detachment, or a choroidal wound, followed by signs of impending or actual cardiovascular collapse, during vitrectomy air infusion. In each case meeting the above clinical definition, entrained air was found whenever it was sought (8/8, 100%), either by antemortem imaging or postmortem forensic investigations. Most OVAE cases were fatal (9/13, 69%), with 8 of 9 deaths (89%) occurring the day of surgery.

Conclusions:

OVEA is a rare but usually fatal complication of air infusion into the eye during vitrectomy. Although received with skepticism when first reported (2005), OVAE may be the most lethal type of surgical air embolization because of its high entrainment pressure and proximity to the heart. Because the effective response time to avoid a fatal OVAE outcome can be less than 1 minute, use of preventive measures is critical—most notably a “time out” before air infusion to confirm infusion cannula positioning, and immediate cessation of air infusion if choroidal detachment is detected.

Ocular Venous Air Embolism: A Report of 5 Cases

Purpose:

The purpose of this case series is to report 5 new cases of ocular venous air embolism (OVAE). We define OVAE as a precipitous drop in end-tidal carbon dioxide, a choroidal detachment, or a choroidal wound, followed by signs of impending or actual cardiovascular collapse, during vitrectomy air infusion.

Methods:

A case report series was retrospectively reviewed.

Results:

Four of the 5 OVAE cases (80%) were fatal, occurring in conjunction with repair of rhegmatogenous retinal detachment (2 cases); a large surgical wound of the choroid (1 case); and vitrectomy repair of an injured eye (1 case). One patient survived OVAE during choroidal melanoma endoresection after prompt discontinuance of air infusion by anesthesia personnel previously alerted to the OVAE risk.

Conclusions:

OVAE is a rare but usually fatal complication of air infusion into the eye during vitrectomy. Because the effective response time to avoid a fatal OVAE outcome can be less than 1 minute, use of preventive measures is critical.

The treatment of postoperative endophthalmitis: should we still follow the endophthalmitis vitrectomy study more than two decades after its publication?

Conducted in the early 1990s Endophthalmitis Vitrectomy Study (EVS) have helped in establishing reasonable guidelines for the management of infectious postoperative endophthalmitis. However at present, more than 20 years after its publication, tremendous progress has been introduced in vitrectomy technology, which now permits the vitreoretinal surgeon to perform surgery more safely, and with better outcomes. Moerover, performing a complete vitreous removal, along with the moving up of the surgical intervention to as early as possible allows the prevention of complications that would limit the functional improvement postoperatively. Thus, it is now highly needed to re-evaluate the conclusions of the EVS study.

Improvement of Siderotic ERG

For fear of endophthalmitis and siderosis, ferrous intraocular foreign bodies are usually removed as soon as they are discovered; markedly reduced, siderotic ERG changes are considered permanent. We report a patient who presented with a chronically retained intravitreal foreign body and significant clinical as well as electrophysiologic signs of siderosis. Only 3 months after surgery, the ERG showed almost complete recovery. If siderosis is not present, adequate and regular follow-up examinations may in certain cases substitute for immediate removal of chronically retained intraocular foreign bodies.

Intraocular Foreign Bodies: Myths and Truths

Over the centuries, the management of eyes with intraocular foreign bodies (IOFB) has posed a special challenge to the physician, and the anxiety created by such injuries has never abated. During the past few decades, several new diagnostic tests, IOFB removal techniques, and methods to treat the complications of the injury have been introduced. Nevertheless, old habits die hard: many of the management options that used to be standard are not appropriate any more but have proved difficult to change. This article reviews over forty of these die-hard myths and confronts them with factual statements published in the peer-review international literature.

Microencapsulation of essential thyme oil by spray drying and its antimicrobial evaluation against Vibrio alginolyticus and Vibrio parahaemolyticus

The aims of this research were first, to evaluate the antibacterial potential of commercial thyme essential oil against V. alginolyticus and V. parahaemolyticys and second, using the spray drying technique to produce microcapsules. chemical compounds of thyme oil and microcapsules were identified and quantified being thymol the chemical component present at the highest concentration. Oil-in-water (O/W) emulsions were prepared and the microcapsules were obtained with a spray dryer using maltodextrin as wall material (ratio 1:4). Thyme oil and the microcapsules exhibited antimicrobial activity against V. parahaemolyticus and V. alginolyticus. The spray drying process did not affect the antimicrobial activity of thyme essentialoil.

Outcome of vitrectomy and chorioretinectomy in perforating eye injuries

PURPOSE

To evaluate the anatomical and functional results of patients who underwent pars plana vitrectomy for perforating eye injuries as well as to analyze the benefit of the chorioretinectomy procedure.

METHODS

Retrospective and descriptive study of 24 eyes of 22 patients with perforating eye injuries operated on at the Centro Hospitalar do Porto between January 2006 and December 2012.

RESULTS

An early vitrectomy was accomplished in 67% of the eyes and a delayed vitrectomy in 33% of the eyes. A concomitant chorioretinectomy was carried out in 78%. Final proliferative vitreoretinopathy (PVR) was found in 11%. The anatomical success was 83%. At the final follow-up, 78% had best-corrected visual acuity equal to or superior to 5/200. Of the eyes that underwent early vitrectomy, 58% regained a visual acuity of 40/200 or better, versus 17% of the cases that underwent delayed vitrectomy.

CONCLUSION

Early vitrectomy with prophylactic chorioretinectomy seems to be an effective approach to prevent PVR and improve the visual outcome and globe survival in perforating injuries.

An endoscopic overview of the anterior vitreous base in retinal detachment and anterior proliferative vitreoretinopathy

PURPOSE

Anterior proliferative vitreoretinopathy (PVR) is an important cause of persistent or recurrent retinal detachment (RD). Endoscopy provides 360° panoramic viewing of the vitreous cavity and high-magnification viewing of the anterior vitreous base (AVB). This study describes the 'in vivo' anatomy and pathoanatomy of the AVB using an ocular endoscope in RD and anterior PVR.

METHODS

An intraoperative analysis of over 2000 consecutive eyes undergoing vitrectomy for RD operated with endoscopy-assisted vitrectomy was performed. It was recorded in notes dictated during surgery and in standardized operative reports. Around 1500 surgical videotapes, with the exclusion of diabetic retinopathy and trauma, selected by reviewing the OR reports and notes were retrospectively reviewed.

RESULTS

Seven endoscopic criteria associated with anterior PVR complicating RD are described: 'en bloc' stiff anterior vitreous retraction, ciliary detachment, seeding of the AVB by abundant pigmented and/or white granulations, anterior tissue displacement, stiff 'wrinkling' at the vitreoretinal juncture, persistent shallow ciliary/RD under perfluorocarbon liquids and traction-related retinal surface haemorrhages. Causes responsible for failure of conventional vitrectomy for RD are highlighted. Findings in case of hypotony and cyclitic membranes are described.

CONCLUSIONS

Endoscopy is a significant adjunct to our understanding of the development of anterior loop traction by obviating the two constitutive parts of the AVB, anterior and posterior, their interconnections and their respective connections to the anterior segment and to the retina. It provides a unique evaluation and thorough eradication of the anterior vitreous cortex as a scaffold for anterior PVR. It might be an adjunct to the prevention of anterior PVR.

Presumed air by vitrectomy embolisation (PAVE) a potentially fatal syndrome

Background

Since first being reported in the ophthalmology literature in 2010, three cases (one fatal) of suspected venous air embolism (VAE) during vitrectomy have received little notice, and the vitrectomy/VAE connection has been described as unproven. We investigated the ability of air to exit the eye through vortex veins after accidental suprachoroidal air infusion.

Methods

Vitrectomy was performed on four donor eyes. Unsutured cannulas were partially withdrawn during air fluid exchange, producing choroidal detachments that emulated accidental suprachoroidal air infusion from a slipping cannula. Eyes with and without clamping of the vortex vein stumps were partially submerged in a water bath.

Results

Extensive choroidal detachment was created in all eyes during air infusion. All eyes with open vortex veins demonstrated rapid air extravasation/bubbling. An eye with clamped vortex vein stumps showed no air extravasation until the clamps were removed.

Conclusions

When combined with existing clinical reports of suspected VAE in the eyes of living patients during ocular air fluid exchange, this experiment justifies recognition of presumed air by vitrectomy embolisation (PAVE) as a rare but potentially fatal vitrectomy complication. Simple surgical precautions can change PAVE from a ‘rare event’ to a ‘never event’, beginning with acknowledgment of its existence.

Staining of the internal limiting membrane with the use of heavy brilliant blue G

BACKGROUND

Brilliant blue G (BBG) is frequently used in chromovitrectomy to facilitate internal limiting membrane (ILM) peeling. A study was initiated to evaluate if heavy BBG is safe and effective in staining the ILM.

METHODS

We studied 30 eyes, 23 with idiopathic macular holes and 7 of patients with diabetic macular edema. Removal of the ILMs was assisted by heavy BBG staining. In cases with histopathological correlation the ILMs were evaluated with hematoxylin and eosin, Masson's trichrome, periodic acid-Schiff and glial fibrillary acidic protein staining. In addition, immunohistochemistry was also performed using specific antibodies for vimentin, neuron-specific enolase, factor VIII and CD68. Using the Image-Pro Plus software of Media Cybernetics Co. we found an average thickness in ILMs.

RESULTS

Of the ILM specimens sent, 19/30 (63.33%) could not be processed properly because of the limited sample material, recognizing only fragments of dispersed fibrillar material. In macular hole ILMs we found an average thickness of 1.3 ± 0.65 µm, and in diabetic macular edema ILMs an average thickness of 6.2 ± 1.4 µm.

CONCLUSIONS

In heavy BBG-assisted ILM peeling we observed no intraoperative or postoperative complications after a mean follow-up of 12 months. Heavy BBG could be an effective and safe vehicle for staining the ILM.

Late versus prophylactic chorioretinectomy for the prevention of trauma-related proliferative vitreoretinopathy

INTRODUCTION

Certain injuries, especially those with a deep-impact (involving the choroid and even the sclera) intraocular foreign body (IOFB), have a high risk for developing either full-blown proliferative vitreoretinopathy (PVR) or full-thickness retinal folds. Although less severe than the former, this so-called 'stage 0 PVR' can severely impact vision, and effective treatment for these folds has not existed heretofore.

PATIENTS AND METHODS

Four eyes of 4 patients sustained an IOFB injury with deep impact. All eyes underwent vitrectomy and IOFB removal soon after the injury, and all eyes showed substantial visual improvement postoperatively. However, in a few months the visual acuity dropped again, due to the development of full-thickness retinal folds radiating from the scar. All four eyes then underwent a second vitrectomy with (late rather than prophylactic) chorioretinectomy by creating a 1-mm-wide ring of bare sclera around the scar. The highest setting of the diathermy machine was used as the endodiathermy probe evaporated both the retina and the choroid to create the ring. Laser retinopexy to surround the ring was used only if the lesion was not in the posterior pole.

RESULTS

Within a few days, the retinal folds completely disappeared in each eye, and the visual acuity reached the highest earlier value seen after the initial surgery. All patients have long-term follow-up (mean, 22 months) with no postoperative complications.

CONCLUSIONS

Chorioretinectomy, although it is ideally used as a prophylaxis against PVR formation and the development of retinal fold formation, also proved equally effective as a late treatment option in the presence of such folds. Such late chorioretinectomy, however, is applicable only for eyes with deep-impact IOFB injuries, not for eyes with a perforating injury or rupture.