Diagnostic and Therapeutic Challenge
ASSESSING THE ABILITY OF PREOPERATIVE QUANTITATIVE SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHY CHARACTERISTICS TO PREDICT VISUAL OUTCOME IN IDIOPATHIC MACULAR HOLE SURGERY
PURPOSE/OBJECTIVE:To determine which spectral domain optical coherence tomography biomarkers of idiopathic macular hole (MH) correlate with the postoperative best-corrected visual acuity (BCVA) in anatomically closed MH. METHODS:Retrospective analysis of spectral domain optical coherence tomography scans of 44 patients presenting with MH followed for a mean of 17 months. Widths of MH aperture, base, and ellipsoid zone disruption were calculated from presenting foveal spectral domain optical coherence tomography B-scans. Macular hole base area and ellipsoid zone disruption area were calculated through the custom in-house software. RESULTS:Poorer postoperative BCVA correlated with increased preoperative choroidal hypertransmission (r = 0.503, P = 0.0005), minimum diameter (r = 0.491, P = 0.0007), and base diameter (r = 0.319, P = 0.0348), but not with preoperative ellipsoid zone width (r = 0.199, P = 0.2001). Applying en-face analysis, the BCVA correlated weakly with preoperative ellipsoid zone loss area (r = 0.380, P = 0.013), but not with preoperative MH base area (r = 0.253, P = 0.1058). CONCLUSION/CONCLUSIONS:Increased MH minimum diameter, base diameter, base area, and choroidal hypertransmission are correlated with a poorer postoperative BCVA. Ellipsoid zone loss measurements were not consistently correlated with a BCVA. Choroidal hypertransmission width may be an easy-to-visualize predictive imaging biomarker in MH surgery.
Risk Factors for Endophthalmitis Following Open Globe Injuries: A 17-Year Analysis
Background/Aims/UNASSIGNED:To determine the rate of endophthalmitis and assess risk factors for development of endophthalmitis following open globe injury (OGI). Methods/UNASSIGNED:A retrospective chart review of all patients treated for OGI at the University of Michigan from January 2000 to July 2017 was conducted. Exclusion criteria included intravitreal injection or intraocular surgery in the 30 days prior to injury or less than 30 days of follow-up. A total of 586 out of 993 open globe injuries were included in the study. The main outcome measure was the rate of endophthalmitis. Results/UNASSIGNED:In this study, 25/586 eyes (4.3%) had endophthalmitis. Of these, 12/25 eyes (48.0%) presented with endophthalmitis and 13/25 eyes (52.0%) developed endophthalmitis after globe closure. Multivariate analysis identified time to globe repair (OR 4.5, CI 1.9-10.7, p = 0.0008), zone I injury (OR 3.6, CI 1.1-11.0, p = 0.0282), and need for additional surgery (OR 5.5, CI 1.5-19.7, p = 0.0092) as factors associated with increased risk of developing endophthalmitis. Subconjunctival antibiotic injection at the time of globe closure (OR 0.3, CI 0.1-0.7, p = 0.0036) was associated with decreased risk of developing endophthalmitis. Conclusion/UNASSIGNED:Prompt globe closure and subconjunctival antibiotics may reduce the risk of endophthalmitis in OGI. Furthermore, our practice of a one-time dose of systemic prophylactic antibiotics, and intravitreal antibiotics if intraocular foreign body (IOFB) removal is delayed, was not found to increase the rate of endophthalmitis.
Paracentral Acute Middle Maculopathy Associated with Hypercoagulability in Pregnancy
PURPOSE/OBJECTIVE:To report a case of paracentral acute middle maculopathy (PAMM) in an otherwise healthy young, multiparous woman in her second trimester of pregnancy. METHODS:Case report RESULTS:: A 38-year-old woman in her twentieth week of pregnancy presented with a four-day history of an acute paracentral scotoma in her left eye. Fundoscopic examination of the left eye was significant for a white-gray lesion inferonasal to the fovea which corresponded with spectral domain-optical coherence tomography (SD-OCT) hyperreflectivity at the outer plexiform layer-inner nuclear layer junction and optical coherence tomography angiography (OCTA) non-perfusion. A diagnosis of paracentral acute middle maculopathy was made. The patient was sent for a hypercoagulability work-up that revealed elevated factor VIII activity, which has been associated with increased risk of complications during pregnancy. CONCLUSION/CONCLUSIONS:PAMM in pregnancy may be secondary to an underlying hypercoaguable condition. We recommend systemic evaluation and referral to a high-risk pregnancy specialist if PAMM is diagnosed during pregnancy. Additionally, OCTA in PAMM may demonstrate reperfusion of the affected vessels.
Antimicrobial guide to posterior segment infections
PURPOSE/OBJECTIVE:This review article is meant to serve as a reference guide and to assist the treating physician in making an appropriate selection and duration of an antimicrobial agent. METHODS:Literature review. RESULTS:Infections of the posterior segment require prompt medical or surgical therapy to reduce the risk of permanent vision loss. While numerous options exist to treat these infections, doses and alternative therapies, especially with contraindications for first-line therapy, are often elusive. Antimicrobial agents to treat posterior segment infections can be administered via various routes, including topical, intravitreal, intravenous, and oral. CONCLUSIONS:Although there are many excellent review articles on the management of endophthalmitis, we take the opportunity in this review to comprehensively summarize the appropriate antimicrobial regimen of both common and rare infectious etiologies of the posterior segment, using evidence from clinical trials and large case series.
DNA testing for inherited retinal disease: Initial experience with the SPARK/Invitae 248-gene panel [Meeting Abstract]
Purpose To evaluate the diagnostic yield and clinical impact of the SPARK/Invitae 248 gene panel in patients with known or suspected inherited degenerative retinal disease, in comparison with traditional clinical assessments including ERG testing. Methods Patients were drawn from the clinical practices of the authors. Genetic screening was provided by means of the SPARK/Invitae 248-gene panel at no charge to patients. Over the past year, results are available for 18 patients. Clinical diagnoses were Best vitelliform dystrophy (definite in one patient, suspected in three patients); retinitis pigmentosa (five affected patients, one likely female carrier); possible Stargardt disease (five patients); and one each with Leber congenital amaurosis, choroideremia, nyctalopia, and Norrie disease. Results Of the 18 studies returned, results were deemed by Invitae ''Positive'' in nine and ''Uncertain'' in nine. The genetic diagnosis agreed with the clinical diagnosis in eight cases (including two patients diagnosed with retinitis pigmentosa with homozygous mutations in USH2A, and one patient with the diagnosis of retinitis pigmentosa with compound heterozygotic mutations in NR2E3, which is also associated with enhanced S-cone syndrome). One patient with macular degeneration of uncertain etiology had a deletion in TPP1, which codes for ceroid lipofuscinosis. The remaining nine patients all returned heterozygous mutations considered ''variations of uncertain significance'' (VUS) ranging from two to eight different genes. Heterozygous VUS in ABCA4 were noted in two patients with the clinical diagnosis of Stargardt disease and in one with the clinical diagnosis of Best disease. Conclusion The SPARK/Invitae 248-gene panel provided a genetic diagnosis consistent with the clinical diagnosis in about half of cases and was diagnostic in one case where the clinical diagnosis was unclear. Retinitis pigmentosa and Stargardt disease were the most common genetic diagnoses. No cases of Leber congenital amaurosis were detected by genetic testing which had been misdiagnosed clinically.
Epinephrine in the Bottle: Intraoperative vascular changes seen with intravitreal epinephrine
TENON CAPSULE-VITREOUS CAVITY FISTULA AFTER HYDROGEL SCLERAL BUCKLE REMOVAL
PURPOSE/OBJECTIVE:To report a rare case of vitreous cavity-Tenon capsule fistula formation after removal of a symptomatic hydrogel scleral buckle. METHODS:Case report. RESULTS:A 43-year-old man presented with chronic headache and involuntary gaze deviation for over 1 year after hydrogel scleral buckle surgery 25 years prior. After removal of the scleral buckle, the patient developed a fluid-filled inflation of the buckle capsule, surrounding a previously noted area of severe scleral thinning. Ocular ultrasonography suggested a fistulous connection between the vitreous cavity and the sub-Tenon space in the area of scleral thinning. There was resolution of diplopia and headache postoperatively, with stability of the fluid collection on clinical examination. Because of high risk of further surgery and resolution of the patient's symptoms, conservative management was elected. CONCLUSION/CONCLUSIONS:This is the first report, to the best of our knowledge, of Tenon capsule-vitreous cavity fistula formation after scleral buckle explantation. Because of innate ability to expand, as well as tendency to become friable, hydrogel buckles have a higher risk of requiring removal and of complications from explantation, respectively. Our patient experienced relief of symptoms, without complication from the fistula, and was successfully managed conservatively.
Use of Bevacizumab and Ranibizumab for Wet Age-Related Macular Degeneration: Influence of CATT Results and Introduction of Aflibercept
PURPOSE/OBJECTIVE:To assess whether publication of Comparison of Age-related macular degeneration Treatment Trial (CATT) results and introduction of aflibercept to the marketplace affected intravitreal bevacizumab and ranibizumab utilization. DESIGN/METHODS:Retrospective analysis of treatment patterns. METHODS:We calculated weekly bevacizumab and ranibizumab utilization during 3 timeframes: (1) before CATT publication, (2) between CATT publication (4/28/2011) and assignment of a unique aflibercept billing code (1/1/2013), and (3) afterwards for 164188 Medicare beneficiaries with neovascular macular degeneration receiving â‰¥1 anti-Vascular Endothelial Growth Factor injections from 1/1/2008 to 12/31/2014. We identified ophthalmologists who predominantly (â‰¥80%) administered bevacizumab or ranibizumab, and evaluated changes in preferences over the 3 periods. We replicated analyses on 881381 commercially-insured beneficiaries. RESULTS:Among 317 ophthalmologists administering predominantly ranibizumab to Medicare beneficiaries pre-CATT, 221 (69.7%) reduced ranibizumab utilization post-CATT, whereas 96 (30.3%) continued using ranibizumab â‰¥80% of the time. Findings were reversed among 1041 ophthalmologists who predominantly administered bevacizumab pre-CATT-777 (74.6%) continued bevacizumab-predominant use while 264 (25.4%) reduced bevacizumab utilization post-CATT. Among the 145 ophthalmologists who predominantly administered ranibizumab before aflibercept's availability, 77 (53.1%) reduced ranibizumab utilization and 68 (46.9%) continued using ranibizumab â‰¥80% of the time after aflibercept became available. Corresponding numbers among the 909 ophthalmologists who predominantly administered bevacizumab pre-aflibercept were 381 (41.9%) reducing and 528 (58.1%) continuing bevacizumab-predominant use. Similar results were observed for commercially-insured patients. CONCLUSIONS:Many ophthalmologists who favored ranibizumab switched to bevacizumab after CATT publication while most who favored bevacizumab prior to CATT publication continued favoring it afterwards. Aflibercept's introduction had little impact on preferences for ranibizumab or bevacizumab.
Smartphone-based fundus photography for screening of plus-disease retinopathy of prematurity
BACKGROUND:Inadequate screening of treatment-warranted retinopathy of prematurity (ROP) can lead to devastating visual outcomes. Especially in resource-poor communities, the use of an affordable, portable, and easy to use smartphone-based non-contact fundus photography device may prove useful for screening for high-risk ROP. This study evaluates the feasibility of screening for high-risk ROP using a novel smartphone-based fundus photography device, RetinaScope. METHODS:Retinal images were obtained using RetinaScope on a cohort of prematurely born infants during routine examinations for ROP. Images were reviewed by two masked graders who determined the image quality, the presence or absence of plus disease, and whether there was retinopathy that met predefined criteria for referral. The agreement between image-based assessments was compared to the gold standard indirect ophthalmoscopic assessment. RESULTS:Fifty-four eyes of 27 infants were included. A wide-field fundus photograph was obtained using RetinaScope. Image quality was acceptable or excellent in 98% and 95% of cases. There was substantial agreement between the gold standard and photographic assessment of presence or absence of plus disease (Cohen's Îºâ€‰=â€‰0.85). Intergrader agreement on the presence of any retinopathy in photographs was also high (Îºâ€‰=â€‰0.92). CONCLUSIONS:RetinaScope can capture digital retinal photographs of prematurely born infants with good image quality for grading of plus disease.