Journal of VitreoRetinal Diseases

This work evaluates the effect of antiplatelet and anticoagulant agents on clinical outcomes, optical coherence tomography (OCT) parameters, and macular ischemia in eyes with central retinal vein occlusion (CRVO).

A retrospective longitudinal cohort study was performed to evaluate patients with CRVO. Demographics, OCT parameters before and after treatment, macular ischemia on fluorescein angiography, and clinical outcomes including the number of injections received were analyzed.

A total of 365 patients with CRVO were identified. The average follow-up was 36 months. Antiplatelet or anticoagulant agent use was not associated with a significant difference in visual acuity (VA), prevalence of macular edema, or central subfield thickness on OCT at presentation or final visit. The use of 81-mg aspirin alone was associated with an increased prevalence of foveal hemorrhage at presentation. Patients who were taking an antiplatelet agent, an anticoagulation agent, or both and had an ischemic CRVO with logMAR VA of less than 1.0 experienced improved VA at the final study visit. Patients given antiplatelet or anticoagulant agents had a similar incidence of neovascular sequelae compared with patients not administered these agents.

In eyes with CRVO, the use of antiplatelet or anticoagulant agents at CRVO onset was not associated with significantly different functional outcomes, except in ischemic CRVO eyes with VA of less than 20/200. The use of 81-mg aspirin was associated with foveal hemorrhage at CRVO presentation. Otherwise, the use of any antiplatelet agent or anticoagulation was not associated with any CRVO structural outcomes.

This work describes characteristics of pentosan polysulfate sodium (PPS)–associated maculopathy and its similarities with common maculopathies in a retina practice cohort.

Thirty-two patients were identified through electronic medical record query who were exposed to PPS. One patient was excluded for lack of retinal imaging. Thirty-one patients (62 eyes) were included. A retrospective review was used to obtain patient characteristics, examination findings, and retinal imaging of the study patients. Classification into “likely,” “unlikely,” or “possible” to have PPS-associated maculopathy groups was based on the fundus photography and retinal imaging. Main outcome measures were best-corrected visual acuity, age, sex, diagnosis of reason for referral, allocation into designated maculopathy group, and presence of choroidal neovascularization.

Of 31 patients (62 eyes), the median age was 70 years (range, 24-104 years) and the majority were women (87%). Mean best-corrected visual acuity was 0.3 ± 0.4 logMAR at presentation. The most common reason for referral was age-related macular degeneration (29%). Maculopathy grades were “likely” (29%, 9 total patients), “possible” (26%, 8 total patients), or “unlikely” (45%, 14 total patients). Choroidal neovascularization was noted in 9.7% of all eyes and 11% of eyes in the “likely” group. The “possible” and “likely” groups had older ages of presentation (P < .05) compared with the “unlikely” group.

A high percentage (55%) of patients with a history of chronic PPS exposure showed features of “likely” or “possible” maculopathy. Similarities with common maculopathies such as age-related macular degeneration and the importance of screening and recognizing at-risk patients are highlighted.

This work describes a stepwise surgical approach to draining choroidal detachments and 2 cases for which this approach was used.

The first step involves insertion of an anterior chamber maintainer and a nonvalved 23- or 25-gauge trocar cannula at the highest peak of hemorrhagic choroidal detachment (as determined using B-scan ultrasonography), 6 to 8 mm from and angled 20° to 30° toward the limbus. The second step involves removal of the trocar to expose the sclerotomy. Alternatively, the second step can be insertion of a second trocar. The third step involves the creation of a small focal peritomy around the preexisting sclerotomy and enlargement of the preexisting sclerotomy into a radial sclerotomy. Progression between steps only occurs if prior steps did not provide adequate drainage.

Two cases of appositional hemorrhagic choroidal detachments in hypotonic eyes were successfully resolved by this stepwise approach. In case 1, a choroidal detachment developed after a corneal ulcer perforation. The hemorrhagic choroidal detachment in case 1 was resolved with steps 1 and 2, and an unnecessary scleral cutdown was avoided. In case 2, a choroidal detachment developed after a trabeculectomy. The detachment in case 2 required progression to step 3, extension of the trocar insertion site into a radial sclerotomy.

This stepwise approach should be considered to reduce excessive manipulation of the globe and conjunctiva in hemorrhagic and serous choroidal detachments that warrant surgical intervention.

This work investigates associations between physician qualifications and the risk of postintravitreal injection endophthalmitis.

This retrospective analysis of data from medical claims studied Medicare beneficiaries undergoing 1 or more intravitreal injections between January 1, 2013, and December 31, 2017. Logistic regression analysis was performed to assess whether board certification status or retina subspecialty training was associated with lower risk of postinjection endophthalmitis, controlling for patient's age, race, and sex, type of agent injected, diagnosis, and year of injection. The main outcome measure was odds ratio (OR) of receiving a diagnosis of endophthalmitis in the 14 days after intravitreal injection. Clinical outcome and quality of care were not evaluated in this study.

A total of 2 907 324 intravitreal injections were performed on 219 640 patients by 4315 ophthalmologists, 3196 (74%) of whom were retina specialists and 4021 (92%) of whom were certified by the American Board of Ophthalmology (ABO). Overall, there were 1088 (0.037%) cases of postinjection endophthalmitis, of which 1024 (0.037%) were injected by ABO-certified ophthalmologists and 64 (0.050%) by non–board-certified ophthalmologists. Injections by ABO-certified ophthalmologist had 28% reduced odds of endophthalmitis (OR = 0.72; 95% CI, 0.523-0.996, P = .05). Higher odds of endophthalmitis were observed for corticosteroid injections (OR = 3.91; 95% CI, 2.75-5.56, P < .001) and aflibercept injections (OR = 1.47; 95% CI, 1.19-1.80, P < .001). Patients' sex and race, the diagnosis associated with the injection, and providers' retina subspeciality training were not associated with the rate of endophthalmitis (P < .20 for all comparisons).

We found evidence that endophthalmitis may be reduced when ABO-certified physicians perform an intravitreal injection.

This work compares best-corrected visual acuity (BCVA) and central retinal thickness (CRT) outcome measures following pars plana vitrectomy (PPV) with and without internal limiting membrane (ILM) peel for epiretinal membrane (ERM).

A retrospective cohort study was conducted of 114 eyes of 114 patients with visually significant ERM undergoing PPV with membrane peel (PPV/MP) at a single institution. CRT measurements were collected from Heidelberg and Zeiss spectral-domain optical coherence tomography imaging units. Results compared preoperative and postoperative CRT and BCVA among patients with at least 60 days of follow-up.

A total of 114 eyes with ERM met the inclusion criteria. Eighty-one eyes (71%) underwent PPV/MP with ILM peel and 33 eyes (29%) underwent PPV/MP without ILM peel. There was no statistically significant difference between preoperative CRT between the 2 study groups (P = .95). The mean follow-up time of eyes undergoing PPV/MP without ILM peel and with ILM peel was 391 days and 319 days, respectively. There was no statistical difference in the mean reduction of CRT between the 2 groups (P = .470). Both groups had improvement of BCVA following surgery and there was no statistical difference in final logMAR visual acuity when comparing the 2 groups (P = .738).

There was an overall improvement of CRT and BCVA among patients undergoing PPV/MP for ERM with or without ILM peel. There was no statistically significant difference in the final BCVA or CRT between the 2 groups.

This work assesses bilateral ganglion cell layer–inner plexiform layer (GCL-IPL) thickness changes in patients with unilateral neovascular age-related macular degeneration (nAMD) treated with antivascular endothelial growth factor (anti-VEGF).

In this single-center, retrospective, cohort study, the medical records of patients with unilateral nAMD treated with anti-VEGF were reviewed. The treated group included eyes with newly diagnosed nAMD that subsequently underwent treatment with intravitreal anti-VEGF injections. The control group was the fellow eye with dry AMD. Eyes receiving at least 10 intravitreal injections were included. Measurement of GCL-IPL thickness was performed at different time points using spectral domain–optical coherence tomography.

A total of 216 eyes of 108 patients met the inclusion criteria. The mean age ± SD was 80.1 ± 10.7 years. Eyes in the treated group underwent a mean ± SD of 20.2 ± 7.2 injections in 21.3 ± 6.8 months. At baseline, average mean ± SD of GCL-IPL thickness was 73.71 ± 8.81 µm and 73.84 ± 8.26 µm in the treated and fellow eye, respectively (P = .795). After 10 injections the average thickness was 65.41 ± 14.08 µm and 68.77 ± 13.24 µm in the treated and fellow eye, respectively (P = .007). The absolute decrease in thickness was significantly greater in the treated eye than the fellow eye (mean ± SD, 8.31 ± 11.19 µm vs 5.07 ± 10.83 µm, respectively; P = .002).

GCL-IPL thickness decreased significantly in the treated group more than in the control group after 10 anti-VEGF injections. The mechanism and clinical significance of this observation warrants further study.

An alternative ocular antiseptic is needed for patients who do not tolerate povidone-iodine (PI). The purpose of this study is to compare the antimicrobial effect of hypochlorous acid (HA) 0.01% with PI 5% applied topically to the ocular surface.

Swabs of the inferior conjunctiva and posterior lower eyelid margin of 40 patients were taken from both eyes and plated onto blood agar plates. One eye was treated with HA and the other with PI, and swabs were taken after 1-minute exposure. The eye treated with PI was rinsed with sterile saline and another swab was taken. Colony-forming units (CFUs) were recorded after 2 days. Patients rated the level of irritation after treatment in each eye.

HA and PI both gave significant reduction in CFUs from baseline (P < .001 for HA and P = .002 for PI). The mean reduction in logCFU ± 95% CI was 0.850 ± 0.387 or greater for HA and 0.749 ± 0.385 or greater for PI; this was equivalent to a mean reduction of 7.1-fold or greater or 86% or greater (95% CI, 66%-94%) for HA and 5.6-fold or greater or 82% or greater (95% CI, 57%-93%) for PI. CFUs increased in 17 eyes after saline rinse. PI caused substantial irritation in 31 of the 40 participants, whereas no individuals had any irritation from topical HA.

Both HA and PI were effective in reducing ocular bacterial load. Unlike PI, HA was not irritating to the eye. Saline rinse after topical PI may increase bacterial counts in some individuals.

To report an unusual case of intraocular cysticercosis in a 11-year-old boy that presented with chronic posterior uveitis and associated recalcitrant subfoveal and multifocal subretinal fluid blebs. The patient was later found to have a subsequent free-floating vitreous cyst that had been concealed from examination for years.

Case report.

A diagnostic and therapeutic vitrectomy and cyst extraction revealed eosinophilic material suggestive of cysticercosis. Brain magnetic resonance imaging revealed suggestive neurocysticercosis and serological titers for cysticercosis immunoglobulin G were positive. After antihelminthic therapy and surgical removal of the cyst, the patient did well with complete resolution of multifocal subretinal fluid blebs and visual acuity improvement to 20/25.

Ocular cysticercosis is a sight-threatening parasitic disease that can cause visually threatening manifestations if not identified and treated in a timely manner. Awareness of atypical presentations such as seen in this case in a pediatric patient is paramount.

To report a case of Mycobacterium chelonae endogenous endophthalmitis in a 28-year-old man with recent intravenous drug use that presented as an intraretinal peripapillary granuloma extending from the optic nerve head with an associated macular tractional retinal detachment.

Case report.

Anterior chamber tap yielded aqueous cultures positive for M chelonae. A diagnostic and therapeutic vitrectomy was performed after inpatient hospitalization for 3 weeks to relieve a progressively worsening tractional retinal detachment.

Atypical causes of endophthalmitis, including nontuberculous mycobacterium, in the population of individuals addicted to intravenous drugs may present with intraretinal peripapillary granuloma associated with a macular tractional retinal detachment. Surgical debulking to relieve anteroposterior traction is an effective treatment option to improve long-term visual outcomes.

This report describes a case of acute occlusive hemorrhagic complication after intravitreal melphalan for vitreous seeds in retinoblastoma.

A case report is presented.

Intravitreal melphalan has been used extensively for vitreous seeds in retinoblastoma. Although melphalan is relatively safe at optimal doses, it can sometimes cause inadvertent complications like hemorrhagic events if the drug is administered close to the retina or in more pigmented eyes. We report a case of a 5-month-old patient with bilateral retinoblastoma who underwent enucleation of the right eye and 2 intravitreal melphalan injections in the left eye (20 µg/0.02 mL) at a 1-month interval for persistent vitreous seeds. After the second injection, there was a sudden decrease in the child’s visual acuity in the left eye, and the retina showed multiple intraretinal hemorrhages and diffuse chorioretinal atrophy.

Intravitreal melphalan may cause acute hemorrhagic complications after intravitreal use for retinoblastoma seeds, especially in pigmented eyes.

This work describes a case of Waldenström macroglobulinemia (WM) relapse presenting with unilateral blurred vision.

A case report is presented.

A 60-year-old woman with a history of WM in remission was referred for suspicious peripheral choroidal lesions and left optic disc swelling. Magnetic resonance imaging revealed optic nerve and cranial nerve infiltration consistent with central nervous system invasion from WM relapse, called Bing-Neel syndrome. Irradiation of the optic nerve and systemic targeted therapy were successful in addressing the ocular features as well as reducing immunoglobulin M paraprotein levels and lymphoproliferative disease burden.

We described the first documented case to our knowledge of intraocular involvement as the earliest sign of relapse of WM. Ophthalmology assessment is warranted in patients with a history of WM who present with new ocular symptoms to aid early detection and treatment of this disease.

This is the first report to our knowledge of ischemic retinopathy in a pediatric patient with Upshaw-Schulman syndrome (USS).

A 6-year-old girl previously diagnosed with USS was referred to our clinic with exodeviation of the left eye and a 2-month-long decrease in vision of both eyes. A dilated fundus examination showed a total vitreous hemorrhage in both eyes. The first course of action was conservative treatment, with the patient experiencing visual-acuity improvement in her right eye.

An ischemic retina and optic nerve atrophy was found once the left eye was cleared of the hemorrhage.

We present a case of a vitreous hemorrhage, possibly secondary to an episode of severe thrombocytopenia. Following USS diagnosis, providers should perform dilated ophthalmologic examinations as part of initial and follow-up general evaluations. This case exemplifies that, in understudied and underdescribed pediatric retinal diseases, extreme therapeutic decisions—such as surgery—should not be rushed.

This work reports on the management of a large subretinal gas bubble after pneumatic retinopexy.

A case report is discussed.

We report a case of subretinal gas after pneumatic retinopexy for rhegmatogenous retinal detachment that was managed with a series of head-positioning maneuvers to allow the subretinal gas to migrate into the vitreous cavity through the retinal break. Despite the subretinal bubbles being larger than the retinal break, this approach eliminated the subretinal gas and averted surgical intervention.

Subretinal gas after pneumatic retinopexy can be successfully managed by head-positioning maneuvers in some cases, even if the subretinal gas bubble is larger than the retinal break.