Prevalence of vitreoschisis-induced vitreous cortex remnants over the peripheral retinal surface in eyes undergoing vitrectomy for primary rhegmatogenous retinal detachment

PURPOSE

Unremoved vitreoschisis-induced vitreous cortex remnants over the peripheral retinal surface posterior to the vitreous base (pVCR) may increase the risk of surgical failure after primary rhegmatogenous retinal detachment (RRD) repair. The purpose of this study was to validate our previous findings on pVCR prevalence during vitrectomy for RRD and to examine their association with proliferative vitreoretinopathy (PVR) and surgical failure.

METHODS

Prospective observational multisurgeon study of 100 eyes of 100 consecutive patients who underwent vitrectomy for RRD by one of four vitreoretinal surgeons. Collected data included detected pVCR and known PVR risk factors. Pooled analysis with our previous retrospective study (251 eyes of 251 patients) was also performed.

RESULTS

Initial PVR (≥C) was present and removed in 6/100 (6%) patients, pVCR were detected in 36/100 (36%) patients, pVCR were removed in 30/36 (83%) patients with pVCR, and 4/36 (11%) patients with pVCR were high myopes (≤-6D). Six per cent (6/100) developed a retinal redetachment, of which 3/6 (50%) had initial PVR (≥C). Surgical failure rates in eyes with and without pVCR were 17% (6/36) and 0% (0/64), respectively. In eyes with pVCR and surgical failure, pVCR were not or not completely removed during the first surgery. Overall analysis showed that pVCR were statistically significantly associated with PVR.

CONCLUSIONS

This study confirms our previous findings: a pVCR prevalence of around 35% and an association between pVCR, PVR formation and surgical failure in patients undergoing vitrectomy for RRD. More research is needed to determine which patients would benefit most from pVCR removal.

[Acute onset of floaters, even without flashes, is an urgent ophthalmic warning sign]

Acute onset of floaters is most likely caused by a posterior vitreous detachment (PVD). A PVD can lead to a retinal tear and subsequently to a retinal detachment with permanent vision loss if left untreated. A patient who presents to a primary care physician with acute onset of floaters, in the absence flashes or visual field loss, is often referred to an ophthalmologist without urgency. In the current Dutch general practitioners standard, acute onset or increase of floaters, without flashes or visual loss, is not included as a reason for urgent referral to an ophthalmologist. Patients who present with acute onset of floaters without flashes have a 14-23% risk of having a retinal tear. Risk factors for developing a retinal tear are high myopia, trauma, cataract surgery, or a retinal tear or retinal detachment in the past medical or family history. Patients with acute onset of floaters should be triaged for urgent ophthalmologic assessment.

Multimodal imaging comparison of perifoveal exudative vascular anomalous complex and resembling lesions

Purpose

Perifoveal exudative vascular anomalous complex (PEVAC) was initially described as an isolated aneurysmal lesion in healthy eyes. Similar aneurysmal abnormalities may occur in association with retinal vascular diseases such as diabetic retinopathy or retinal vein occlusions (PEVAC‐resembling). The aim of this study was to compare several imaging characteristics of PEVAC and PEVAC‐resembling lesions.

Methods

Ten eyes with a PEVAC and 27 eyes with a PEVAC‐resembling lesion were included in this cross‐sectional study. They were all imaged with optical coherence tomography (OCT), OCT angiography (OCT‐A) and colour fundus photography (CFP). Several clinical, morphological and vascular characteristics were assessed and compared between both PEVAC types.

Results

All PEVAC lesions were unilateral, while PEVAC‐resembling lesions appeared bilateral in 23% of patients (p > 0.05). Unilateral multifocal PEVAC‐resembling lesions were more frequently observed (56%) than unilateral multifocal PEVAC lesions (10%, p < 0.01). Furthermore, 90% of the PEVAC lesions were located within 500 µm from the centre of the fovea, while this was only true for 56% of the PEVAC‐resembling lesions (p > 0.05). No notable differences were observed in other studied characteristics.

Conclusions

The clinical, morphological and vascular features of PEVAC and PEVAC‐resembling lesions are similar based on multimodal imaging. Given the bilaterality and multifocality seen in PEVAC‐resembling lesions, an underlying retinal vascular disease may stimulate the quantity of aneurysmal abnormalities. Due to the similarities with PEVAC‐resembling lesions, PEVAC may also be considered a microangiopathy but with an unknown origin.

ANATOMICAL CHANGES ON SEQUENTIAL MULTIMODAL IMAGING IN PERIFOVEAL EXUDATIVE VASCULAR ANOMALOUS COMPLEX

PURPOSE

To report a series of 21 patients with perifoveal exudative vascular anomalous complex (PEVAC) and to investigate the anatomical changes over time.

METHODS

We conducted a retrospective study. Clinical data of consecutive patients, presenting at the Rotterdam Eye Hospital between 2014 and 2019, were analyzed. The data collected included best-corrected visual acuity, fundus photography, optical coherence tomography (OCT), OCT-angiography, fluorescence angiography, and indocyanine green angiography.

RESULTS

We included 21 patients with a PEVAC lesion with a mean follow-up of 24.3 ± 13.8 months (range, 9-46 months). Patients with PEVAC were on average 75.3 ± 11.1 years (range, 53-90 years). The large perifoveal vascular aneurysmal abnormality was associated with small retinal hemorrhages in six patients and hard exudates in three patients. The PEVAC lesion was associated with intraretinal cystic spaces on OCT in 15 patients. Twelve of 21 patients showed no changes in cystic spaces on OCT during follow-up: 9 patients had stable cystic spaces and 3 patients had no cystic spaces. In contrast, in 9 of 21 patients, we observed changes in cystic spaces on OCT during follow-up. In two patients, cystic spaces appeared during follow-up, and in seven patients, there was a spontaneous resolution of cystic spaces. In three of these seven patients, the PEVAC lesion completely disappeared. Two patients, with stable intraretinal cystic spaces on OCT, were treated with intravitreal injections of anti-vascular endothelial growth factor without improvement.

CONCLUSION

Perifoveal exudative vascular anomalous complex is an idiopathic perifoveal retinal vascular abnormality that is associated with intraretinal cystic spaces. These intraretinal cystic spaces associated with a PEVAC lesion, and even the PEVAC lesion itself, can have a spontaneous resolution over time.

A single- versus double-layered closure technique for full-thickness lower eyelid defects: a comparative study

PURPOSE

To compare a simplified, single-layered closure technique with a double-layered closure technique in lower eyelid reconstruction following full-thickness pentagonal block excision.

METHODS

We conducted a retrospective, non-randomized, interventional case-control study. Clinical data of consecutive patients treated with primary closure of a full-thickness lower eyelid defect between 2011 and 2014 were analysed. In group A, the defect was closed in one layer, using non-absorbable polypropylene sutures. In group B, the defect was closed in two layers, using absorbable polyglactin acid sutures. In both techniques, we rarely used a grey line suture to adjust the eyelid margin. We assessed notching, wound dehiscence and other complications, as reported at 2 months after surgery.

RESULTS

We included 188 eyelids from 186 patients. In group A, we included 82 eyelids and in group B 106 eyelids. We noted no difference in notching (p = 0.96) whilst wound dehiscence had not occurred in either group. Subcutaneous granuloma formation had been noted in 0 cases in group A, versus 4 in group B (p = 0.08). Mild redness of the scar was seen in 2 cases in group A, versus 5 in group B (p = 0.41). A grey line suture was placed in 6 cases in group A (7.3%), versus 4 cases in group B (3.8%; p = 0.28).

CONCLUSION

Both single- and double-layered closure techniques are safe and effective methods for primary closure of full-thickness lower eyelid defects. In both techniques, a grey line suture was rarely required to adjust the eyelid margin.

Unraveling the signaling pathways promoting fibrosis in Dupuytren's disease reveals TNF as a therapeutic target

Dupuytren's disease is a very common progressive fibrosis of the palm leading to flexion deformities of the digits that impair hand function. The cell responsible for development of the disease is the myofibroblast. There is currently no treatment for early disease or for preventing recurrence following surgical excision of affected tissue in advanced disease. Therefore, we sought to unravel the signaling pathways leading to the development of myofibroblasts in Dupuytren's disease. We characterized the cells present in Dupuytren's tissue and found significant numbers of immune cells, including classically activated macrophages. High levels of proinflammatory cytokines were also detected in tissue from Dupuytren's patients. We compared the effects of these cytokines on contraction and profibrotic signaling pathways in fibroblasts from the palmar and nonpalmar dermis of Dupuytren's patients and palmar fibroblasts from non-Dupuytren's patients. Exogenous addition of TNF, but not other cytokines, including IL-6 and IL-1β, promoted differentiation into specifically of palmar dermal fibroblasts from Dupuytren's patients in to myofibroblasts. We also demonstrated that TNF acts via the Wnt signaling pathway to drive contraction and profibrotic signaling in these cells. Finally, we examined the effects of targeted cytokine inhibition. Neutralizing antibodies to TNF inhibited the contractile activity of myofibroblasts derived from Dupuytren's patients, reduced their expression of α-smooth muscle actin, and mediated disassembly of the contractile apparatus. Therefore, we showed that localized inflammation in Dupuytren's disease contributes to the development and progression of this fibroproliferative disorder and identified TNF as a therapeutic target to down-regulate myofibroblast differentiation and activity.

The mechanical environment in Dupuytren's contracture determines cell contractility and associated MMP-mediated matrix remodeling

Matrix metalloproteinases (MMPs) are expressed in Dupuytren's contracture and play a role in matrix remodeling. We tested the role of tension on contractility and MMP expression in Dupuytren's nodule and cord cells. Cells were subjected to pre-determined loading patterns of known repeatable magnitudes (static load, unloading, and overloading) and tested for MMP gene expression (MMP-1, -2, -9, -13, and TIMP-1, -2) and force generation using a tension-culture force monitor. Matrix remodeling was assessed by addition of cytochalasin D and residual matrix tension was quantified. Nodule compared to cord and control cells demonstrate greater force generation and remodeling (p < 0.05). Nodule cells subjected to a reduced load and overloading led to threefold increase of MMP-1, -2, and -9 compared to static load, whilst cord and control cells only showed a twofold increase of MMP-9. Nodule cells subjected to overloading showed a twofold increase in TIMP-2 expression, whilst cord and control cells showed a twofold increase in TIMP-1 expression. Nodule cells differ from cord cells by increased force generation in response to changes in the mechanical environment and related MMP/TIMP-mediated matrix remodeling. In turn this may lead to permanent matrix shortening and digital contracture. Interventional therapies should be aimed at nodule cells to prevent contraction and subsequent permanent matrix remodeling.