Uveal melanoma: Recent advances in immunotherapy

Uveal melanoma (UM) is the most common primary intraocular cancer in adults. The incidence in Europe and the United States is 6-7 per million population per year. Although most primary UMs can be successfully treated and locally controlled by irradiation therapy or local tumor resection, up to 50% of UM patients develop metastases that usually involve the liver and are fatal within 1 year. To date, chemotherapy and targeted treatments only obtain minimal responses in patients with metastatic UM, which is still characterized by poor prognosis. No standard therapeutic approaches for its prevention or treatment have been established. The application of immunotherapy agents, such as immune checkpoint inhibitors that are effective in cutaneous melanoma, has shown limited effects in the treatment of ocular disease. This is due to UM's distinct genetics, natural history, and complex interaction with the immune system. Unlike cutaneous melanomas characterized mainly by BRAF or NRAS mutations, UMs are usually triggered by a mutation in GNAQ or GNA11. As a result, more effective immunotherapeutic approaches, such as cancer vaccines, adoptive cell transfer, and other new molecules are currently being studied. In this review, we examine novel immunotherapeutic strategies in clinical and preclinical studies and highlight the latest insight in immunotherapy and the development of tailored treatment of UM.

Recent Developments in Gene Therapy for Neovascular Age-Related Macular Degeneration: A Review

Age-related macular degeneration (AMD) is a complex and multifactorial disease and a leading cause of irreversible blindness in the elderly population. The anti-vascular endothelial growth factor (anti-VEGF) therapy has revolutionized the management and prognosis of neovascular AMD (nAMD) and is currently the standard of care for this disease. However, patients are required to receive repeated injections, imposing substantial social and economic burdens. The implementation of gene therapy methods to achieve sustained delivery of various therapeutic proteins holds the promise of a single treatment that could ameliorate the treatment challenges associated with chronic intravitreal therapy, and potentially improve visual outcomes. Several early-phase trials are currently underway, evaluating the safety and efficacy of gene therapy for nAMD; however, areas of controversy persist, including the therapeutic target, route of administration, and potential safety issues. In this review, we assess the evolution of gene therapy for nAMD and summarize several preclinical and early-stage clinical trials, exploring challenges and future directions.

Recent Advances of Adipose-Tissue-Derived Mesenchymal Stem Cell-Based Therapy for Retinal Diseases

With the rapid development of stem cell research in modern times, stem cell-based therapy has opened a new era of tissue regeneration, becoming one of the most promising strategies for currently untreatable retinal diseases. Among the various sources of stem cells, adipose tissue-derived mesenchymal stem cells (ADSCs) have emerged as a promising therapeutic modality due to their characteristics and multiple functions, which include immunoregulation, anti-apoptosis of neurons, cytokine and growth factor secretion, and antioxidative activities. Studies have shown that ADSCs can facilitate the replacement of dying cells, promote tissue remodeling and regeneration, and support the survival and growth of retinal cells. Recent studies in this field have provided numerous experiments using different preclinical models. The aim of our review is to provide an overview of the therapeutic strategies, modern-day clinical trials, experimental models, and potential clinical use of this fascinating class of cells in addressing retinal disorders and diseases.

Innovative Strategies for Drug Delivery to the Ocular Posterior Segment

Innovative and new drug delivery systems (DDSs) have recently been developed to vehicle treatments and drugs to the ocular posterior segment and the retina. New formulations and technological developments, such as nanotechnology, novel matrices, and non-traditional treatment strategies, open new perspectives in this field. The aim of this mini-review is to highlight promising strategies reported in the current literature based on innovative routes to overcome the anatomical and physiological barriers of the vitreoretinal structures. The paper also describes the challenges in finding appropriate and pertinent treatments that provide safety and efficacy and the problems related to patient compliance, acceptability, effectiveness, and sustained drug delivery. The clinical application of these experimental approaches can help pave the way for standardizing the use of DDSs in developing enhanced treatment strategies and personalized therapeutic options for ocular pathologies.

X-Linked Retinoschisis: Deep Phenotyping and Genetic Characterization

PURPOSE

To examine the genetic and clinical features in children and adults with X-linked retinoschisis (XLRS).

DESIGN

Single-center consecutive, retrospective, observational study.

PARTICIPANTS

Adults and children with molecularly confirmed XLRS followed up between 1999 and 2020.

METHODS

Analysis of genetic, clinical, and retinal imaging findings, including OCT and fundus autofluorescence (FAF), cross-sectionally and longitudinally, was performed.

MAIN OUTCOMES MEASURES

RS1, variants, type of variants and phenotype correlations, age of onset, complications rates and types, fundoscopy findings, OCT metrics, FAF patterns, correlations including between best corrected visual acuity (BCVA) and age, and OCT characteristics.

RESULTS

One hundred thirty-two male patients were identified harboring 66 retinoschisin 1 variants, with 7 being novel. The mean age at onset was 16.5 years (range, 0-58 years). Seventy-one patients (71/75 [94.7%]) were symptomatic at presentation; all had decreased best-corrected visual acuity (BCVA). Funduscopy findings were symmetric in 104 patients (104/108 [96.3%]), with the most common finding being macular schisis (82.4%), whereas peripheral retinoschisis was present in 38.9% and macular atrophy was present in 11.1%. Twenty patients (18.5%) demonstrated complications (vitreous hemorrhage, retinal detachment, or both). Mean BCVA was 0.65 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/89) in the right eye and 0.64 logMAR (Snellen equivalent, 20/87) in the left eye. Mean BCVA change over a mean interval of 6.7 years was 0.04 and 0.01 logMAR for right and left eyes, respectively. A normal FAF pattern was identified in 16 of 106 eyes (15.1%); 45 eyes (42.5%) showed a spoke-wheel pattern, 13 eyes (12.3%) showed foveal hyperautofluorescence, and 18 eyes (17.0%) showed a central reduction in signal. In total, 14 patients demonstrated evidence of progression on FAF over time. On OCT, foveoschisis was observed in 172 eyes (172/215 [80%]), parafoveal schisis was observed in 171 eyes (171/215 [79.5%]), and foveal atrophy was observed in 44 eyes (44/215 [20.5%]). Cystoid changes were localized to the inner nuclear layer (172/181 eyes [95%]), the outer nuclear layer (97/181 [53.6%]), and the ganglion cell layer (92/181 [50.8%]). Null variants were associated with worse final BCVA and aforementioned complications.

CONCLUSIONS

X-linked retinoschisis is highly phenotypically variable, but with relative foveal and BCVA preservation until late adulthood, allowing more accurate prognostication. The slowly (often minimally) progressive disease course may pose a challenge in identification of early end points for therapeutic trials aimed at altering the kinetics of degeneration.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FINDINGS BEFORE AND AFTER VITRECTOMY FOR MACULAR HOLES: Useful or Useless?

PURPOSE

To investigate the vascular remodeling of optical coherence tomography angiography in full-thickness macular hole surgery.

METHODS

This retrospective, observational case series included 33 eyes of 33 patients with a full-thickness macular hole who underwent epiretinal membrane removal. Data were collected on best-corrected visual acuity, structural B-scan optical coherence tomography, and optical coherence tomography angiography preoperatively and at 1, 3, and 6 months postoperatively. Optical coherence tomography angiography was used to assess the retinal vascular density (VD) of the superficial vascular plexus and deep vascular plexus (DVP). Vascular density was assessed using the Early Treatment Diabetic Retinopathy Study grid for the whole, inner, and outer grids.

RESULTS

A statistically significant correlation was found between the VD (whole, inner, and outer grids) of the superficial vascular plexus alone from baseline to 1-month postoperatively (P < 0.001). Similarly, VD was correlated from baseline to 1, 3, and 6 months postoperatively to the whole (P < 0.0005, F = 23.22), inner (P < 0.0005, F = 28.23), and outer Early Treatment Diabetic Retinopathy Study grids of DVP (P = 0.033, F = 3.49). The best-corrected visual acuity and VD were significantly correlated with the superficial vascular plexus and DVP at baseline and 6 months (P < 0.05, all correlations). The most significant correlation was observed at 6 months between best-corrected visual acuity and DVP in the whole, inner, and outer Early Treatment Diabetic Retinopathy Study grids (P < 0.001).

CONCLUSION

Superficial vascular plexus and DVP are affected by full-thickness macular holes, with the most significant effects being on the DVP. Full-thickness macular hole surgery leads to an improvement in the best-corrected visual acuity in many eyes and the restoration of the VD, especially of the DVP.

Adaptive Optics Imaging in Patients Affected by Pseudoxanthoma Elasticum

PURPOSE

To describe the retinal findings of patients affected by pseudoxanthoma elasticum (PXE) using a multimodal imaging approach including flood-illumination adaptive optics ophthalmoscopy (AO).

DESIGN

Retrospective case series.

MATERIALS AND METHODS

Patients affected by PXE were retrospectively studied. Clinical data, color, infrared and autofluorescence fundus imaging, optical coherence tomographic scans, and AO examinations were collected. Furthermore, the photoreceptor count was assessed. PXE diagnosis was confirmed by a positive skin biopsy and/or genetic testing.

RESULTS

Twenty-one eyes of 18 patients (11 females and 7 males) were included in the study. In 3 patients, both eyes were studied. The mean age at examination was 37.7 ± 16.4 years (range 14-66) and the mean best-corrected visual acuity (BCVA) was 0.1 ± 0.2 logMAR (range 0-1). We identified 3 types of angioid streaks (AS) using AO: "crack," "band," and "hypopigmented." The first 2 were very similar and they differed in size; the third type showed specific clinical features. Comet lesions appeared as hyper-reflective round lesions on AO imaging. In all eyes, the cone mosaic appeared reduced inside the streaks compared to the neighboring areas (13,532.8 ± 1,366.5 cones/mm² vs 16,817.1 ± 1,263.0 cones/mm² respectively).

CONCLUSION

Using AO imaging in PXE-related retinopathy, we were able to observe the presence of the photoreceptors within the angioid streaks, differentiate 3 types of angioid streaks, based on size and reflective features, and identify the very small crystalline bodies not identifiable using other retinal imaging techniques.

Optical Coherence Tomography Angiography for the Evaluation of Retinal Vasculature in Fabry Disease: Our Experience and Review of Current Knowledge

Purpose: Optical coherence tomography angiography (OCTA) is a non-invasive and objective tool for the evaluation of the retinal microvascular changes in Fabry disease (FD). We investigated changes in retinal vasculature in FD patients, and the possible correlation with systemic parameters, by using OCTA, and reviewed the current status of literature.

Methods: Thirteen FD patients (eight females, five males, mean age 49.85 ± 14.7 years) were compared with 13 age- and sex-matched healthy controls. OCTA 3 × 3 mm macular scans were performed in all subjects. We evaluated the vessel density and vessel perfusion in distinct macular areas (whole, inner, and outer) of both the superficial capillary plexus (SCP VD and SCP VP) and of the deep capillary plexus (DCP VD and DCP VP). We also evaluated the foveal avascular zone (FAZ) metrics (area, perimeter, and circularity), and correlation between systemic and OCTA parameters. A literature review on the current understanding of OCTA in FD is then presented.

Results: FD patients showed significantly lower SCP VD values in the whole area (17.37 ± 2.08 mm⁻¹ vs. 18.54 ± 1.21 mm⁻¹; p-value 0.022), as well as in the outer area (17.46 ± 2.10 mm⁻¹ vs. 19.08 ± 1.14 mm⁻¹; p-value 0.002), but not in the inner. Even the DCP VD was significantly lower in all the imaged areas: whole (17.75 ± 3.93 mm⁻¹ vs. 19.71 ± 1.20 mm⁻¹; p-value 0.024), outer (18.25 ± 4.17 mm⁻¹ vs. 20.33 ± 1.20 mm⁻¹; p-value 0.023), and inner (19.54 ± 4.17 mm⁻¹ vs. 21.96 ± 1.55 mm⁻¹; p-value 0.011). There were no significant differences in vessel perfusion parameters (both SCP VP and DCP VP ones) and FAZ. No significant correlations were found between the OCTA parameters and systemic parameters (maximal left ventricular wall thickness and glomerular filtration rate) in FD patients.

Conclusions: OCTA can be considered as a promising non-invasive tool, which enables a quantitative evaluation of retinal vascular involvement in FD, despite the varying data reported in literature. Our results support the use of OCTA as an objective tool to evaluate retinal vascular abnormalities in FD. The utility of OCTA in FD needs to be validated by longitudinal studies taking into account the overall progression of the disease.

OCT Angiography Findings in Macula-ON and Macula-OFF Rhegmatogenous Retinal Detachment: A Prospective Study

Background: The aim of the study was to evaluate pre-operative and post-operative retinal vasculature using optical coherence tomography angiography (OCTA) in patients who underwent rhegmatogenous retinal detachment (RRD) surgery repair. Materials and Methods: A total of 33 eyes were included in this prospective consecutive observational study: 15 affected by macula-ON and 18 by macula-OFF RRD. Superficial (SCP), deep capillary plexus (DCP), and foveal avascular zone (FAZ) area variations were evaluated by OCTA and correlated with visual acuity (VA) during a six-month follow-up. Results: In the macula-ON group, the preoperative vascular density (VD) of the whole SCP (wSCP) on affected eyes was lower than that of the fellow eyes (p < 0.05); this difference disappeared at 6 months after surgery (p = 0.88). The wSCP VD and the parafoveal SCP (pfSCP) VD increased during follow-up (p < 0.05); moreover, the higher the preoperative wSCP and pfSCP VD, the better the baseline VA (p < 0.05). In the macula-OFF group, at the first and sixth months after surgery, the larger the FAZ, the lower the VA (p < 0.05). Conclusions: Macula-ON SCP VD affected preoperative VA, and it was lower than the fellow eye, but recovered over time. In the macula-OFF group, a larger FAZ area was related to a worse VA, as is the case in diabetes and in retinal vein occlusion (RVO).

Intravitreal Dexamethasone Implant as a Sustained Release Drug Delivery Device for the Treatment of Ocular Diseases: A Comprehensive Review of the Literature

Drug delivery into the vitreous chamber remains a great challenge in the pharmaceutical industry due to the complex anatomy and physiology of the eye. Intravitreal injection is the mainstream route of drug administration to the posterior segment of the eye. The purpose of this review is to assess the current literature about the widening use of the intravitreal 0.7 mg dexamethasone (Dex) implant, and to provide a comprehensive collection of all the ocular disorders that benefit from Dex administration. Although anti-vascular endothelial growth-factors (VEGFs) have been largely indicated as a first-choice level, the Dex implant represents an important treatment option, especially in selected cases, such as vitrectomized eyes or patients in whom anti-VEGF failed or are contraindicated. In this article, the safety profile as well as the list of the possible complications related to intravitreal Dex injection are also discussed.

Human Amniotic Membrane Plug to Restore Age-Related Macular Degeneration Photoreceptor Damage

PURPOSE

Age-related macular degeneration (AMD) is the leading cause of legal blindness in adults 65 years of age and older. Choroidal neovascularization (CNV) can complicate AMD and lead to severe visual acuity reduction. Despite the several treatments available, if the retinal pigment epithelium is damaged, we have to cope with the impossibility of restoring acceptable visual acuity using only medical treatments.

DESIGN

Prospective, consecutive, interventional study.

PARTICIPANTS

Eleven patients affected by AMD, 6 patients affected by CNV, and 5 patients affected by geographic atrophy.

METHODS

All patients underwent a pars plana vitrectomy with subretinal implantation of human amniotic membrane (hAM) to induce photoreceptor regeneration and partial visual acuity restoration.

MAIN OUTCOME MEASURES

Primary study outcome was visual acuity improvement. Secondary outcomes were multimodal imaging results.

RESULTS

Mean preoperative best-corrected visual acuity (BCVA) was 20/2000 (2 logarithm of the minimum angle of resolution [logMAR]), and all the patients showed a BCVA of counting fingers or less. Mean final BCVA was 20/400 (1.31 logMAR), ranging from 20/2000 to 20/100 (2-0.7 logMAR). OCT angiography was used to measure retinal vascularization in the treated eye compared with the fellow eye. A high correlation between BCVA and deep vascular density was evidenced. Adaptive optics findings, obtained over the retinal area where the highest functionality was observed, were evaluated using microperimetry. The images showed possible photoreceptor presence over the hAM membrane.

CONCLUSIONS

This work supports the feasibility and safety of the hAM to promote partial retinal function restoration 6 months after surgery with visual acuity improvement. The advanced diagnostics help to understand the interaction between the hAM and photoreceptors and suggest that photoreceptor regeneration may occur.

A human Amniotic Membrane plug to manage high myopic macular hole associated with retinal detachment

OBJECTIVE

To assess the efficacy of the human amniotic membrane (hAM) to treat (HMMH) associated with retinal detachment (RD).

MATERIAL AND METHODS

Ten eyes of 10 patients with recurrent HMMH and RD, who had already undergone one or more pars plana vitrectomy (PPV), underwent a PPV with an hAM plug implanted in the macular hole. The initial five patients enrolled were tamponaded with (SO) while the subsequent five patients with 10% octafluoropropane (C₃ F₈ ). Silicon oil was removed in all five patients 2 months later. No statistical differences were reported between the two groups.

RESULTS

Final retinal reattachment was achieved in all the patients. BCVA improved from 1.73 logMAR to 0.94 logMAR after 6 months. No adverse events were registered during follow-up.

CONCLUSION

An hAM plug is an efficient substrate to manage HMMH associated with RD resulting in encouraging visual acuity recovery.

Choroidal Vascularity Index: An In-Depth Analysis of This Novel Optical Coherence Tomography Parameter

Remarkable improvements in optical coherence tomography (OCT) technology have resulted in highly sophisticated, noninvasive machines allowing detailed and advanced morphological evaluation of all retinal and choroidal layers. Postproduction semiautomated imaging analysis with dedicated public-domain software allows precise quantitative analysis of binarized OCT images. In this regard, the choroidal vascularity index (CVI) is emerging as a new imaging tool for the measurement and analysis of the choroidal vascular system by quantifying both luminal and stromal choroidal components. Numerous reports have been published so far regarding CVI and its potential applications in healthy eyes as well as in the evaluation and management of several chorioretinal diseases. Current literature suggests that CVI has a lesser variability and is influenced by fewer physiologic factors as compared to choroidal thickness. It can be considered a relatively stable parameter for evaluating the changes in the choroidal vasculature. In this review, the principles and the applications of this advanced imaging modality for studying and understanding the contributing role of choroid in retinal and optic nerve diseases are discussed. Potential advances that may allow the widespread adoption of this tool in the routine clinical practice are also presented.

Combining cataract surgery with 25-gauge high-speed pars plana vitrectomy: A prospective study

PURPOSE

To compare visual outcome and postoperative complications of combined 25-gauge pars plana vitrectomy and phacoemulsification with vitrectomy alone surgery in patients with epiretinal membrane and macular hole.

METHODS

A total of 110 eyes (73 eyes with epiretinal membrane and 37 eyes with macular hole) were enrolled in this prospective study. The eyes were divided into two groups: Group A included 55 eyes which underwent phacovitrectomy at the same time and Group B included 55 eyes which underwent vitrectomy alone. Follow-up visits were at 1, 3, and 6 months.

RESULTS

The best-corrected visual acuity correlation by analysis of variance measurement showed statistically non-significant differences between the two groups (p = 0.32). The post hoc analysis from baseline, 1°, 2°, and 3° follow-ups was not statistically significant (p > 0.05). The most common postoperative complication was cystoid macular edema that has been detected in 11 patients (10%) (seven eyes in Group A and four eyes in Group B): 2 patients (1.8%) developed a chronic macular edema. Intraocular hypertension occurred in five eyes (4.5%) (three in Group A and two in Group B). Four eyes (3.6%) underwent another surgical procedure for a persistent macular hole (two in Group A and two in Group B). The intraocular lens repositioning was performed one day after surgery in three eyes (2.7%) (Group A). The mean preoperative visual acuity was not different between the two groups (p = 0.80).

CONCLUSION

No significative differences between combined surgery and vitrectomy alone have been detected, in terms of postoperative complications and visual outcome.

Morpho-Functional Evaluation of Full-Thickness Macular Holes by the Integration of Optical Coherence Tomography Angiography and Microperimetry

(1) Objective: To use optical coherence tomography angiography (OCTA) and microperimetry (MP) to evaluate the correlation between retinal structure and function in patients with idiopathic, full-thickness macular holes (FTMHs) (2) Methods: This prospective, observational study included 11 eyes of 10 patients with FTMHs evaluated before surgery using OCTA and MP. MP sensitivity maps were superimposed and registered on slabs corresponding to superficial capillary plexus (SCP) and deep capillary plexus (DCP) on OCTA, and on the outer plexiform layer (OPL) and the Henle fiber layer (HFL) complex in en face OCT. On these maps, mean retinal sensitivity was calculated at 2° and 4°, all centered on the FTMH. Cystic cavity extension was assessed on the slab corresponding to the OPL + HFL complex in en face OCT and DCP in OCTA using the Image J software (Version 1.49v; National Institutes of Health, Bethesda, MD, USA); (3) Results: Absolute scotomas were observed corresponding to the FTMH. Additionally, rings of relative scotoma in the perilesional area were detected and correlated to the cystic spaces on en face OCT and OCTA. There was a significant correlation between reduced retinal sensitivity at 2° and 4° diameters around the FTMH and the extension of cystic areas (p < 0.01). There was a significant correlation between the extension of cystic cavities and BCVA (p < 0.01). (4) Conclusions: Morpho-functional analysis of FTMH using OCTA and MP, and the correlation between vascular abnormalities and impaired retinal sensitivity, may provide new, useful information. This integrated evaluation of FTMH may be useful to determine the function–structure correlation before and after vitreoretinal surgery, in order to gain a better understanding of the functional consequences induced by the morphological alterations, assessing outcomes in a more objective way, and potentially adding new surgical prognostic factors.

IOL repositioning using iris sutures: a safe and effective technique

This retrospective non-comparative consecutive case series study was conducted at Azienda Ospedaliera Universitaria Careggi, Florence, Italy and describes a useful intraocular lens (IOL) repositioning technique using iris sutures. In our study, 41 consecutive cases of posteriorly dislocated IOLs were surgically treated between January 2015 and May 2017. Six of the cases were post-traumatic luxations, and 20 patients had pseudoexfoliation syndrome. All the patients underwent pars plana vitrectomy and same IOL repositioning using iris sutures. The mean follow-up was 12.2mo. The mean preoperative best corrected visual acuity (BCVA) was 0.10±0.15 logMAR, whereas the mean postoperative BCVA was 0.08±0.14 logMAR. The mean postoperative BCVA did not change significantly from the preoperative BCVA. The final mean spherical equivalent was -0.44±0.49 SD. Three lenses (7.31%) were found tilted during post-operative follow-up. Two eyes (4.87%) had postoperative cystoid macular edema. No eyes had endophthalmitis, hypotony, retinal or choroidal detachment. The iris fixation technique seems to be a safe and valid option for the management of dislocated IOLs.

Perfluorodecalin Versus Densiron 68 Heavy Silicone Oil in the Management of Inferior Retinal Detachment Recurrence

BACKGROUND AND OBJECTIVE

To assess the efficacy of perfluorodecalin (PFD) or Densiron 68 heavy silicone oil (HSO) in the management of inferior complex retinal detachment recurrence.

PATIENTS AND METHODS

A retrospective, comparative consecutive case series study. Twenty-four eyes of 24 patients affected by inferior complex retinal detachment recurrence underwent pars plana vitrectomy with PFD or HSO as endotamponade. All patients recruited were affected by complicated inferior retinal detachments and had already undergone at least one vitreoretinal procedure. The primary endpoint was anatomical success with primary and secondary surgery. The secondary endpoints were functional outcome and inflammatory complications.

RESULTS

Out of 24 cases of inferior retinal detachment recurrence, 12 were tamponed with PFD (PFD group) and 12 with HSO (D68 group). Retinal reattachment rate at first surgery was 50% for the D68 group and 66.6% for the PFD group. Final reattachment rate after two or more surgical operations was 91.6% for the PFD group and 83.3% for the D68 group. Best-corrected visual acuity improved in both groups from a mean of 1.00 logMAR (20/200; standard deviation [SD]: 1) to 0.60 logMAR (20/80; SD: 0.3), and from a mean of 1.81 logMAR (20/2000; SD: 1.1) to a mean of 2.00 logMAR (20/2,000; SD:1) for the PFD and D68 groups, respectively.

CONCLUSION

Both the endotamponades used showed good results in solving inferior retinal detachment recurrence with a slightly better rate in the PFD group, but it was not statistically significant (P > .05). [Ophthalmic Surg Lasers Imaging Retina. 2019;50:274-280.].

Densiron 68 heavy silicone oil in the management of inferior retinal detachment recurrence: analysis on functional and anatomical outcomes and complications

AIM

To assess the efficacy and safety of a heavy silicone oil (Densiron 68) in the management of inferior retinal detachment recurrence.

METHODS

A retrospective non-comparative consecutive case series study. Forty-nine cases of complex inferior retinal detachment were treated using Densiron 68 heavy silicone oil (HSO) as the endotamponade. Our main purpose was anatomic reattachment following Densiron 68 removal. Functional outcomes, rate of recurrences, the presence of inflammatory complications and intraocular pressure alterations were evaluated.

RESULTS

Forty-nine patients affected by complex retinal re-detachment were recruited. The mean follow-up was 7.6 (±1.5) mo. The mean best corrected visual acuity after Densiron 68 removal was 0.95 logMAR, standard error (SE: 0.068). Retinal reattachment was 61.2% after first surgery and 81.6% after second surgery. Nineteen cases (38.8%) had recurrences when intraocular heavy silicon oil was in situ, 26.3% (5 cases) of which involved the inferior retina.

CONCLUSION

Densiron 68 efficiently fills the inferior retinal periphery and might lower the risk of inferior proliferative vitreoretinopathy development, in particular after a standard silicon oil tamponade that reduces the proliferative process in the upper quadrants of the retina.

Multimodal imaging of benign yellow dot maculopathy

PURPOSE

To describe the clinical features of 2 unrelated families affected with Benign Yellow Dot Maculopathy and to analyze anatomical and functional findings of this peculiar phenotype Methods: Case series Results: We retrospectively described 5 patients (3 males, 2 females) affected with Benign Yellow Dot Maculopathy. The mean age at referral was 50,8 years (range 34-69 yrs.). All patients were characterized by a good visual acuity (20/20 in both eyes) and by symmetric multiple yellow dots at the posterior pole in both eyes. In 3 patients (P1, P3, P4) the yellow dots were mainly located at the nasal side of the macula. The yellow dots appeared hyper-autofluorescent at the fundus autofluorescence (FAF) imaging. OCT examination revealed in 3 patients (P1, P3, P4) mild irregularities at the level of the retinal pigment epithelium (RPE) and at the interdigitation (IZ) and ellipsoid zone (EZ). OCT angiography (OCT-A), performed in 3 patients (P1, P4,P5), was normal. Adaptive Optics imaging (AO) showed a peculiar pattern of the cone mosaic: the yellow dots were detectable as hyper-reflective lesions at the macular region. In 2 patients (P1, P4) we reported a follow-up of 2 and 18 years respectively. Genetic examination performed on patient P1 did not reveal pathogenic variants for retinal dystrophies.

CONCLUSIONS

Our work confirmed the benign nature of this peculiar macular phenotype showing a normal macular function and a stable clinical picture during a long-term follow-up. Multimodal imaging allows a detailed detection and monitoring of Benign Yellow Dot Maculopathy.

Assessment of Postoperative Morphologic Retinal Changes by Optical Coherence Tomography in Recipients of an Electronic Retinal Prosthesis Implant

Importance

The postoperative retinal changes at the interface between an implant electrode array and the retina and whether these anatomic changes have an association with the patient visual performance are unknown.

Objective

To report morphologic changes in recipients of an Argus II Retinal Prosthesis.

Design, Setting, and Participants

This consecutive, noncomparative case series study included a retrospective review of the preoperative and postoperative optical coherence tomography of 33 eyes among 33 individuals who underwent Argus II Retinal Prosthesis System implantation between October 28, 2011, and June 8, 2017, at 2 different centers, by the same surgeon (S.R.). Thirteen patients received an implant at Azienda Ospedaliero Universitaria Pisana, Pisa, Italy, between October 28, 2011, and October 27, 2014, and 20 patients underwent surgery at Azienda Ospedaliera Universitaria Careggi, Florence, Italy, between December 20, 2014, and June 8, 2017. Patients were excluded if they did not reach the 6-month follow-up.

Main Outcomes and Measures

All patients were evaluated before surgery, during the first postoperative day, and at 1, 3, 6, 12, and 24 months (subsequently once a year, except for patient-related adverse events), with a comprehensive ophthalmic examination, retinal fundus photography, spectral-domain optical coherence tomography, and visual function tests to evaluate the stability or improvement of their visual performance.

Results

Of the 20 patients included in the analysis, all were of white race/ethnicity, 12 (60%) were male, and the mean (SD) age was 57.4 (11.6) years. Optical coherence tomography revealed the development of a fibrosislike hyperreflective tissue limited at the interface between the array and retina in 10 eyes (50%). In 9 of 10 patients (90%), fibrosis evolved and progressed to retinal schisis. Despite the development of the fibrosis and schisis, there was no deterioration in the patient's visual performance evaluated prospectively with visual function tests (square localization and direction of motion).

Conclusions and Relevance

Optical coherence tomography may be used to observe the retinal anatomic changes in patients with an Argus II Prothesis. This analysis revealed the development of a fibrosislike hyperreflective tissue limited at the interface between array and retina that progressed to retinal schisis but with no deterioration in the patients' visual performance.

Choroidal vascularity index changes after vitreomacular surgery

PURPOSE

To study the structural changes in the choroid using swept-source (SS) optical coherence tomography (OCT), a tool for the choroidal vascularity index (CVI) following epiretinal membrane removal.

METHODS

Fifty-two eyes of 26 patients were evaluated in this prospective, single-centre, observational study. Twenty-six eyes underwent vitrectomy for epiretinal membrane removal (VT-group), and the control group consisted of 26 corresponding fellow eyes (F-group). All patients were evaluated at baseline, 30 and 90 days postsurgery. Using a modified image binarization algorithm for SS-OCT scans, the subfoveal choroidal area was segmented into the luminal and stromal areas, and the CVI was measured by calculating the proportion of the luminal area (LA) to the cross-sectional choroid area.

RESULTS

The mean CVI in the VT-group was 63.86 ± 4.04% at the baseline, 62.45 ± 4.21% at 30 days postsurgery and 61.06 ± 3.79% at 90 days (p < 0.001). The F-group had a mean CVI of 61.12 ± 2.29% at the baseline, 60.91 ± 2.25% at 30 days postsurgery and 61.05 ± 2.28% at 90 days (p = 0.29).

CONCLUSION

The CVI decreases following epiretinal membrane removal when compared to the fellow eyes, which suggests structural changes in the vascular layers of the choroid. The implication of these results may be that secondary inflammation resulting from mechanical traction induces choroidal thickness by way of increased vascularization of the choroid.

New Vital Dye Injection Technique With Vitrectomy Probe

BACKGROUND AND OBJECTIVE

To evaluate a new, safer way to inject vital dye during chromovitrectomy for dye-assisted macular peeling.

PATIENTS AND METHODS

Prospective consecutive case series. Enrolled patients underwent macular surgery with a new technique of staining the epiretinal membrane and the internal limiting membrane with vital dyes. Twenty eyes of 20 patients (eight men, 12 women) were affected by idiopathic epiretinal membrane and underwent 25-gauge via pars plana vitrectomy for epiretinal membrane removal. Ten eyes were stained with Membrane Blue-Dual (Brilliant Blue G + trypan blue; DORC, Zuidland, The Netherlands) and 10 eyes were stained with Brilliant Peel (Brillant Blue G; Fluoron GmbH, Ulm, Germany). Preoperatively and postoperatively (1, 3, and 6 months) all patients received a complete ophthalmologic examination with best-corrected visual acuity (BCVA) assessment, swept-source optical coherence tomography, and multifocal electroretinography (mfERG).

RESULTS

The mean age of the patients was 67.0 years ± 8.6 years (range: 55 years to 78 years). No statistically significant difference in BCVA improvement or central foveal thickness decrease was observed in either group (P > .05). The mfERG showed an increase in electrical response densities 3 months after surgery.

CONCLUSION

The authors describe a new technique to inject vital dye during chromovitrectomy for dye-assisted macular peeling that may help to improve the overall safety of macular surgery. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:528-533.].

Evaluation of ocular perforation during retrobulbar block using high-resolution spectral domain–optical coherence tomography and optical coherence tomography angiography

Introduction:

This article reports a case of ocular perforation during a retrobulbar block in a patient who underwent scleral buckle for retinal detachment.

Methods:

Sterile air was immediately injected into the vitreous cavity to restore intraocular pressure and the scleral buckle operation was quickly finished. One week later, a laser retinopexy was performed on the two retinal holes that were outside the foveal area. After 6 months, spectral domain–optical coherence tomography and optical coherence tomography angiography were performed on the perforated wall centered on the exit hole area.

Results:

The visual acuity was maintained 20/20 and the retina was totally attached. Spectral domain–optical coherence tomography showed a localized interruption of inner retina, retinal pigment epithelium, and choroid, with a higher posterior reflectivity in correspondence with the sclera. Optical coherence tomography angiography was able to detect atrophic alterations in the choroidal slab with a good visualization of large and rarefied choroidal vessels due to lack of retinal pigment epithelium and choriocapillaris.

Conclusion:

When ocular perforation by a needle is outside the foveal area and when there is an early awareness of the perforation, the complications may be avoided, and we could observe a good final visual acuity result. Furthermore, using spectral domain–optical coherence tomography and optical coherence tomography angiography, we could observe the perforated eyeball wall and study the effects of a 25-gauge needle perforation in the retinal and choroidal blood stream.

Relationship between ocular surface temperature and peripheral vasoconstriction in healthy subjects: A thermographic study

An impairment of ocular blood flow regulation is commonly considered one of the main pathogenetic mechanisms involved in the development of several eye diseases, like glaucoma. The aim of this study was to investigate whether an alteration of ocular blood supply induced by peripheral vasoconstriction might be detected by measuring the ocular surface temperature. The ocular surface temperature was evaluated in a group of 38 healthy young subjects (28 males and 10 females; mean age: 25.4 ± 4.1 years) by infrared thermography. For each subject, the experimental procedure consisted of two thermographic acquisitions both lasting 10 s, recorded before and during the immersion of both hands in a mixture of ice and water (1.6 °C ± 0.4 °C). Specifically, the second acquisition began 20 s after the hand immersion. Analysis of variance was used to compare the ocular surface temperature of the two profiles. The analysis of infrared images was carried out every 2 s: at the eye opening (t0) until 10 s (t5), for both profiles. Data showed that ocular surface temperature increased significantly ( p-value < 0.05), especially near the sources of ocular blood supply, that is, temporal and nasal areas (mean increasing temperature at t0 for P1 = 0.12 °C ± 0.13 °C). Therefore, these results suggest a response of the ocular hemodynamic to the peripheral vasoconstriction. The ocular surface temperature may represent a cheap, non-invasive and non-time-consuming test to evaluate ocular vaso-regulation.

Community health workers: integral members of the health care work force

As the US health care system strives to function efficiently, encourage preventive and primary care, improve quality, and overcome nonfinancial barriers to care, the potential exists for community health workers to further these goals. Community health workers can increase access to care and facilitate appropriate use of health resources by providing outreach and cultural linkages between communities and delivery systems; reduce costs by providing health education, screening, detection, and basic emergency care; and improve quality by contributing to patient-provider communication, continuity of care, and consumer protection. Information sharing, program support, program evaluation, and continuing education are needed to expand the use of community health workers and better integrate them into the health care delivery system.