Faculty Bibliography

PURPOSE/OBJECTIVE:To characterize the topographic relationships among vitreous structures, including the premacular bursa, prevascular vitreous fissures, cisterns, and lacunae, in healthy participants using en face and cross-sectional swept-source (SS) OCT. DESIGN/METHODS:Prospective, comparative study. PARTICIPANTS/METHODS:Sixty eyes of 60 healthy participants (age range, 4-35 years). Eyes of individuals younger than 20 years (n = 29) were compared with eyes of individuals 20 years of age or older (n = 31). METHODS:From each study eye, 12 × 12-mm SS OCT volume scans comprising 1024 × 1024 A-scans centered at the fovea were acquired. MAIN OUTCOME MEASURES/METHODS:En face and cross-sectional data were analyzed to characterize topographic relationships between hyperreflective spaces anterior to the vitreoretinal interface. RESULTS:Prevascular vitreous fissures are an almost universal feature of human eyes. Cisterns became more prevalent over the course of the first 20 years (r = 0.49; P = 0.002). In 97% of eyes in individuals older than 20 years, en face and cross-sectional SS OCT showed the premacular bursa and prepapillary gap merge at a distance superior to the optic nerve and then follow a superonasal course anteriorly. However, only 69% of individuals younger than 20 years demonstrated such a connection (P = 0.01). A close topographic relationship of vitreous fissures and cisterns to the underlying vasculature of the posterior pole was visible on en face projections. En face imaging readily distinguished these spaces. Degenerative, eyewall-parallel fissure planes and their course were described for the first time in a 3-dimensional manner. The fissure planes were rare in younger eyes (12%) and significantly more common in older eyes (42%; P < 0.001). CONCLUSIONS:En face SS OCT demonstrated that (1) premacular bursa and Cloquet's canal are not connected in younger patients, but are connected in older patients; (2) prevascular vitreous fissures overly the retinal vessels; and (3) cisterns are continuous with prevascular fissures.

PURPOSE/OBJECTIVE:Cutaneous melanoma metastatic to the vitreous is very rare. This study investigated the clinical findings, treatment, and outcome of patients with metastatic cutaneous melanoma to the vitreous. Most patients received checkpoint inhibition for the treatment of systemic disease, and the significance of this was explored. DESIGN/METHODS:Multicenter, retrospective cohort study. PARTICIPANTS/METHODS:Fourteen eyes of 11 patients with metastatic cutaneous melanoma to the vitreous. METHODS:Clinical records, including fundus photography and ultrasound results, were reviewed retrospectively, and relevant data were recorded for each patient eye. MAIN OUTCOME MEASURES/METHODS:Clinical features at presentation, ophthalmic and systemic treatments, and outcomes. RESULTS:The median age at presentation of ophthalmic disease was 66 years (range, 23-88 years), and the median follow-up from diagnosis of ophthalmic disease was 23 months. Ten of 11 patients were treated with immune checkpoint inhibition at some point in the treatment course. The median time from starting immunotherapy to ocular symptoms was 17 months (range, 4.5-38 months). Half of eyes demonstrated amelanotic vitreous debris. Five eyes demonstrated elevated intraocular pressure, and 4 eyes demonstrated a retinal detachment. Six patients showed metastatic disease in the central nervous system. Ophthalmic treatment included external beam radiation (30-40 Gy) in 6 eyes, intravitreous melphalan (10-20 μg) in 4 eyes, enucleation of 1 eye, and local observation while receiving systemic treatment in 2 eyes. Three eyes received intravitreous bevacizumab for neovascularization. The final Snellen visual acuity ranged from 20/20 to no light perception. CONCLUSIONS:The differential diagnosis of vitreous debris in the context of metastatic cutaneous melanoma includes intravitreal metastasis, and this seems to be particularly apparent during this era of treatment with checkpoint inhibition. External beam radiation, intravitreous melphalan, and systemic checkpoint inhibition can be used in the treatment of ophthalmic disease. Neovascular glaucoma and retinal detachments may occur, and most eyes show poor visual potential. Approximately one quarter of patients demonstrated ocular disease that preceded central nervous system metastasis. Patients with visual symptoms or vitreous debris in the context of metastatic cutaneous melanoma would benefit from evaluation by an ophthalmic oncologist.

BACKGROUND AND OBJECTIVE/OBJECTIVE:To describe a two-forceps bimanual approach for complex diabetic detachments. PATIENTS AND METHODS/METHODS:Curved scissors were used to create a zone of decreased resistance within a thick fibrovascular membrane in a previously vitrectomized patient. Using two forceps, the linear defect was propagated into the periphery in a direction tangential to the retina. The tissue was repeatedly regrasped at the leading edge of the propagating tear, allowing for progressive separation of the hyaloid from the retinal surface. RESULTS:Separation of the diabetic membrane and hyaloid from the retinal surface in a previously vitrectomized patient. CONCLUSION/CONCLUSIONS:The authors describe a two-forceps approach for dense fibrovascular proliferation in the setting of persistently attached cortical vitreous that may be employed in cases of severe diabetic retinopathy with traction and fibrovascular membranes, even after previous vitrectomy. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e176-e178.].

PURPOSE/OBJECTIVE:To describe the fibrillar architecture of the posterior cortical vitreous and identify variations across eyes of different axial lengths in vivo. METHODS:Sixty-four eyes of 32 subjects were examined with swept-source optical coherence tomography (SS-OCT). Grading of vitreous degeneration, presence of vitreous cisterns/lacunae, posterior hyaloid status, directionality of vitreous fibers and their relations to vitreous spaces, and lamellar reflectivity of the posterior vitreous were assessed. RESULTS:A consistent pattern of fibrillar organization was discovered. Eyewall parallel fibers formed a dense meshwork over the retinal surface and fibers oriented in a perpendicular fashion to this meshwork were found to envelop the various vitreous spaces, intersecting at variable angles of insertion to the eyewall parallel fibers. Lamellar reflectivity suggestive of splitting of the cortical fibrillar meshwork was detected in 27 eyes (42%) with 56% of these eyes demonstrating perpendicularly oriented intersecting fibers. Fifty-six percent of eyes with lamellar reflectivity had an axial length > 25 mm. CONCLUSION/CONCLUSIONS:SS-OCT imaging revealed fibrillar organization of the posterior vitreous. Eye wall parallel hyperreflectivity of cortical vitreous was a universal finding. This pattern is suggestive of a splitting of cortical vitreous tissue and may represent a precursor to vitreoschisis. Perpendicular fibers appear to be important constituents of the walls of the various liquid vitreous spaces.

Purpose: Blood is one of the main absorbers in the near-infrared spectrum and therefore retinal vessels appear dark in near-infrared reflectance (NIR) images. Proliferative diabetic retinopathy (PDR) is characterized by the growth of abnormal vessels which also absorb light and appear dark against a lighter fundus background. We aim to study the usefulness of NIR imaging in the detection and follow-up of neovascular complexes (NVCs) in PDR.
Method(s): Retrospective study of 20 eyes of 17 patients with PDR who underwent NIR imaging with optical coherence tomography (OCT) using the Spectralis System as part of routine clinical examination. NVCs presence and activity was determined using clinical, tomographic and angiographic criteria.
Result(s): Twenty-seven NVCs were imaged, of which, 48% were neovascularization of the disc (NVD) and 52% were elsewhere (NVE). Mean patient follow-up was 3.7 years. Consecutive images were obtained from 3 to 5 time-points. All patients underwent laser treatment and 7 had additional intravitreal therapy. At baseline, NVCs were absent, present and active and present and inactive, respectively in 11%, 85% and 4% of cases. NIR identified active NVCs as hyporreflective irregular dark vessels originating from the retinal venules in NVE or from the disc in NVD. Associated hyperreflective fibrotic tissue was seen at baseline in 26%. NIR regression shown by reduced dark perfusion was observed in the 1 follow-up visit in 33% of cases and in 70% of cases in the 4 visit, consistent with various laser sessions. Progression with new vascular dark fronds was documented in about 40% scans in all time points. Four eyes developed a wolf's jaw configuration with vascular hyporreflective new vessels and hyperreflective tissue from extensive fibrosis. Fibrosis was more apparent in later images, reaching 77%. In a minority of cases (7%) the NVC was no longer seen in NIR, although was still identifiable on OCT over the NVC area.
Conclusion(s): NIR is a non-invasive imaging modality commonly performed alongside OCT and frequently overlooked which can be useful to evaluate NVCs in PDR. Blood is one of the main absorbers in the NIR spectrum and therefore changes in NVC contrast and reflectivity due to blood perfusion can help in the detection and monitoring of diabetic proliferative disease and aid clinicians in daily practice

PURPOSE/OBJECTIVE:To report a giant retinal pigment epithelium rip in a patient with a bullous retinal and choroidal detachment. METHODS:Case report with widefield imaging, fundus autofluorescence, and optical coherence tomography of the retina. RESULTS:This 62-year-old patient had a history of advanced glaucoma, trabeculectomy, blebitis, and endophthalmitis. He had cataract surgery 6 weeks before presentation. He was found to have a large bullous retinal and choroidal detachment with a large retinal pigment epithelium tear at the limit of the choroidal detachment. After vitrectomy for retinal detachment repair, the tear was observed to extend inferiorly at the margins of the choroidal detachment. CONCLUSION/CONCLUSIONS:This case report demonstrates that large retinal pigment epithelium rips can be found associated with large bullous choroidal and retinal detachments. These tears seem similar to tears that have been observed after trabeculectomy.

Purpose: A macular hole (MH) is a pathological full thickness retinal defect in the macular region (MR). Interestingly, a MH always possesses a circular shape in the retinal plane. Present assumptions on MH etiology refer to tangential or anterior-posterior tensile forces at the foveal region. Using biomechanical models, we investigated the impact of biomechanical factors in macular region on the MH formation and its circular shape. Methods: 2D-and 3D-finite-element models of MR were developed based on optical coherence tomography (OCT) volume scans of a healthy eye. The models consist of two elastic layers: the internal limiting membrane (ILM: E=0.147MPa) and the retina (E=0.431MPa). Both materials were modeled as linearly elastic and incompressible. In the ILM in MR a small ellipsoidal slit was constructed as a precursor to a macular hole. In the 3D model, the axial ratio (minor d /major axis b, see Figure) of the initial constructed slit was determined assuming physiological intraocular pressure (IOP) range. In the 2D model, tangential and anterior-posterior tensile forces were applied to the intact ILM at specific angular vitreal attachments (shearing angle ranged 0degree-90degree). Maximal principal strains were computed, which are likely candidates of causing failure in the tissue and thus MH formation. Results: Under physiological IOP-conditions, the 2D model of MR without an initial slit shows high strains exactly in the area, where the MH formation is observed clinically. Using the 3D model further simulations under the same conditions show that an initial slit turns into an oval shape with a tendency to become round. When additional forces were considered in the attachment region of the vitreous it was observed that maximal principal strains in MR become larger with smaller shearing angle under predominant tangential forces. Tangential forces become greater than tensile forces hence being potentially riskier for MH progression. Conclusions: The IOP as single factor is not alone responsible for the circular formation of a MH from an initial slit. However, forces, especially tangential ones, transferred by the detaching vitreous result in high principal strains in MR. This aspect in combination with weakened tissue might lead to MH formation. Biomechanical modelling can be a useful tool for the investigation of MH etiology as well for the early MH diagnostics and the prediction of its progression