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Purpose: To investigate the changes in aqueous humor cytokine levels in response to short-term aflibercept therapy in treatment-naive patients with center-involving diabetic macular edema (DME). Me...

PURPOSE To evaluate the ectopic inner foveal layer (EIFL) staging scheme as a visual prognostic factor for patients undergoing epiretinal membrane (ERM) surgery. METHODS Retrospective study of 88 pseudophakic patients with diagnosis of idiopathic ERM who underwent ERM surgery with a minimum follow-up of 12 months. Preoperative and postoperative EIFL staging was correlated with the final best-corrected visual acuity (BCVA). As a secondary outcome, evaluation of the proportion of patients achieving final best-corrected visual acuity ≥20/40 in each stage was assessed. RESULTS Based on the EIFL staging scheme, of 88 pseudophakic eyes analyzed, 24 (27.4%) were diagnosed as Stage 2 ERM, 45 (51.1%) as Stage 3 ERM, and 19 (21.5%) as Stage 4 ERM preoperatively. At the final follow-up visit, 70.8% of eyes with Stage 2 showed an improvement in EIFL staging scheme, while 68% of eyes in Stage 3 and 4 remained the same. The final best-corrected visual acuity significantly improved with all EIFL stages (P = Stage 3 > Stage 4 P < 0.001). Final best-corrected visual acuity ≥20/40 was reached in 91.7% of eyes with Stage 2, 42.3% with Stage 3, and 5.2% with Stage 4. CONCLUSION The EIFL staging scheme is an easy, fast, and reproducible method to evaluate visual prognosis with ERM surgery. Surgery on Stage 2 ERM results in significantly better visual outcomes and a greater chance of reversibility in anatomical changes.

PURPOSE Retinal displacement is common following rhegmatogenous retinal detachment (RRD) repair. A computer simulation was developed to assess forces applied by a gas tamponade of various sizes in the setting of pneumatic retinopexy (PnR) versus pars plana vitrectomy (PPV). DESIGN Computer simulation model. METHODS The contact angle and pressure between the tamponade and the retina were calculated using interfacial tension and the densities of gas and vitreous. A simulation determined the dynamics of fluid motion in the subretinal space and calculated deformations of the retina. RESULTS Bulk flow of fluid away from the tamponade in a direction along gravity stretched the retina and caused displacement in the simulations. Extent of displacement is attributable to the subretinal fluid layer thickness, and area of contact and contact pressure applied by the tamponade. Larger gas tamponades have greater contact pressure applied to the retina. Reducing gas bubble size from 93% to 6.25% with PPV versus PnR, there was a 79% reduction in the mean contact pressure (1.4 mmHg-0.29 mmHg), and a 93% reduction in the surface area of contact (11 cm2 -0.8 cm2 ). Therefore, the contact force applied to the entire retina decreases by 97% from 83 mN (PPV) to 2.9 mN (PnR). The model resembling PnR had more than three times less displacement compared to PPV. CONCLUSIONS This model provides a framework to study retinal displacement. Our findings suggest that proportional to their size, gas tamponades stretched the retina by displacing subretinal fluid following RRD repair.

To determine the association of aqueous humor cytokine concentrations with long-term treatment response to anti-vascular endothelial growth factor (VEGF) agents in diabetic macular edema (DME).Retrospective case series.Pooled data of aqueous humor cytokine concentrations collected at baseline and 2-month follow-up (2 injections) for treatment-naïve eyes with center-involving DME previously enrolled in a prospective study were reviewed. Subjects receiving intravitreal anti-VEGF injections outside of study protocol as per standard of care were classified into Responders versus Nonresponders based on qualitative assessment of optical coherence tomography for persistence of DME at longitudinal follow-up visits.Of the 41 eyes, 85% were classified as Responders with a significant decline in baseline central subfield thickness and macular volume (P values.001), and 15% were identified as Nonresponders to anti-VEGF therapy over 51.4 ± 18.7 months of follow-up. No significant difference in baseline aqueous humor VEGF concentration was noted, while at the 2-month follow-up the Nonresponder group had a significantly higher VEGF concentration compared with the Responder group (451.5 ± 690.9 pg/mL vs 113.7 ± 211.4 pg/mL; P = .02). The Responder group also demonstrated a significant decline from baseline to 2-month follow-up in concentration of intercellular adhesion molecule-1 (P.001), interleukin-10 (P = .041), monocyte chemotactic protein-1 (P = .046), placental growth factor (P = .027), and transforming growth factor-β2 (P = .017).Aqueous humor cytokine concentrations serve as an early biomarker for long-term response to anti-VEGF therapy and may enable more effective treatment regimens that improve anatomical outcomes in eyes with DME.

Purpose: Recent publications have reported that the deep capillary plexus (DCP) area of the foveal avascular zone (FAZ) is significantly larger in eyes following pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) repair when compared with controls. To the best of the authors’ knowledge, there have been no publications on the evaluation of the macular microvasculature using optical coherence tomography angiography (OCTA) in post–pneumatic retinopexy (PnR) eyes. Therefore, the purpose of this study was to investigate FAZ-area changes following PnR. Methods: This retrospective cohort included 19 patients with macula-off RRD who underwent PnR repair. Each patient’s fellow eye was used as a control. The FAZ area in the superficial capillary plexus and DCP was investigated with OCTA and the areas were measured by 2 masked graders. Results: Both superficial (PnR: 0.22 [0.16-0.35] vs control: 0.24 [0.18-0.34] mm2; P = .715) and deep (PnR: 0.56 [0.51-0.76] vs control: 0.7 [0.59-0.89] mm2; P = .105) FAZ areas were not significantly different between eyes. Conclusions: Our results suggest that the lack of FAZ-area enlargement after PnR repair may indicate that there is less ischemic damage to the retinal capillary plexus in the fovea when compared with that described in the literature for PPV. The PIVOT trial demonstrated that PnR is associated with superior visual acuity and less metamorphopsia when compared with PPV at 1 year. The results of the current study may provide insight into the potential advantages of PnR. Further studies are needed to elucidate how the macular microvasculature is affected after RRD and to clarify how the FAZ area changes following PnR and PPV.

Purpose To present a novel technique, Minimal Gas Vitrectomy (MGV), as a means of potentially minimizing retinal displacement compared to standard vitrectomy for select cases. Methods A patient with a macula off retinal detachment and break at 12 o'clock underwent a 23-gauge pars plana vitrectomy, endodiathermy of the superior break in detached retina and endolaser of the inferior break in attached retina, without air-fluid exchange. Suturing of sclerotomies, anterior chamber paracentesis of 0.3 mL followed by intravitreal injection of 0.6 mL pure SF6 was then performed. Positioning was face down for 6 hours and then steamroll up with laser retinopexy to the superior break the following day. Results Post-operative fundus autofluorescence imaging demonstrated no retinal displacement. Conclusion The MGV technique has the potential to minimize retinal displacement by using a smaller gas tamponade compared to standard vitrectomy in certain cases with specific post-operative positioning instructions.

To identify the proportion of patients with primary rhegmatogenous retinal detachment (RRD) presenting to a retina practice that meet 'Pneumatic Retinopexy versus Vitrectomy for the Management of Primary RRD' (PIVOT) trial criteria and to assess anatomic and functional outcomes of pneumatic retinopexy (PnR) in this population.Retrospective consecutive case series.Patients with primary RRD treated between October 2009 and November 2017 at an academic vitreoretinal practice in Canada.Medical records of all cases18 years old with primary RRD were reviewed and the proportion of patients meeting PIVOT criteria was determined. Patients that met PIVOT criteria who underwent PnR with a follow-up3 months were included for further analysis.The primary outcome was the primary retinal reattachment rate at 12 months among patients meeting PIVOT criteria undergoing PnR.A total of 1,091 patients were identified, of which 577 (52.9%) met PIVOT criteria. Of these, 482/577 (83.5%) underwent PnR, but 54/482 (11.2%) were excluded as these had been enrolled in the PIVOT trial, and another 40/482 (8.3%) were excluded due to short follow-up (3 months). Therefore, data pertaining to 388 patients is included in our analysis. 79.4% (308/388), 78.2% (280/358), 76.5% (241/315) and 73.9% (178/241) of patients who followed up at 3, 6, 12, and 24 months, respectively, had primary anatomic reattachment. A total of 20.6% (80/388) of patients did not reattach with the initial PnR or re-detached in the early post-procedure period (3 months), 2.1% (8/388) of patients re-detached between 3-12 months, and 1.3% (5/388) re-detached after 1 year. Phakic lens status was the only significant predictor of PnR success at 12 months in a multivariate logistic regression analysis (P = 0.006). Mean logMAR VA improved from 0.90 ± 0.90 (Snellen 20/159) at baseline t 0.34 ± 0.40 (Snellen 20/44) at 12 months (P0.001).Over 50% of patients presenting to an academic tertiary retina practice with primary RRD met PIVOT criteria and were eligible for PnR. Evidence from this study demonstrates a durable primary anatomic retinal reattachment rate with PnR in patients fulfilling PIVOT criteria, with similar results to those encountered in the PIVOT trial.

Purpose: Report a case of a recurrent macular hole which completely resolved with a non-surgical approach with steroid drops. Observations: While traction is considered the mayor contributor to full thickness macular hole formation, retinal hydration as that in cystoid macular edema also plays an important role. Conclusions and Importance: Topical corticosteroid drops can be considered as an alternative therapy for small recurrent macular holes that lack tractional components and have an appearance of cystoid changes on the edges of the hole. Keywords: Macular hole, Topical drops, Corticosteroid drops, Macular hole closure

Importance Pneumatic retinopexy (PnR) is associated with superior visual acuity and reduced vertical metamorphopsia compared with pars plana vitrectomy (PPV) for primary rhegmatogenous retinal detachment (RRD). It is important to determine postoperative photoreceptor integrity with both surgical techniques. Objective To compare photoreceptor integrity on spectral domain-optical coherence tomography (SD-OCT) between PnR and PPV at 12 months postoperatively. Design, setting, and participants Post hoc analysis of the Pneumatic Retinopexy Versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT) conducted between August 2012 and May 2017 at St Michael's Hospital, Toronto, Ontario, Canada. Primary RRDs with specific criteria were included. Data were analyzed between April and August 2020. Intervention Randomization to PnR vs PPV stratified by macular status. Main outcomes and measures Difference in proportion of patients with discontinuity of the ellipsoid zone (EZ) and external limiting membrane (ELM) between groups assessed independently by 2 masked graders at an external masked image reading center. Results A total of 150 participants completed the 12-month follow-up visit. A total of 145 patients (72 PPV and 73 PnR) had gradable spectral-domain optical coherence tomography at 12 months. Analysis of the central 3-mm (foveal) scans found that 24% (n = 17 of 72) vs 7% (n = 5 of 73) displayed EZ discontinuity (difference, 17%; odds ratio [OR], 4.204; 95% CI, 1.458-12.116; P = .005) and 20% (n = 14 of 71) vs 6% (n = 4 of 73) displayed ELM discontinuity (difference, 14%; OR, 4.237; 95% CI, 1.321-13.587; P = .01) in the PPV and PnR groups, respectively. Analysis of the 6-mm (foveal and nonfoveal) scans revealed that EZ and ELM discontinuity was greater in the PPV vs PnR groups (EZ, 32% [n = 23 of 72] vs 11% [n = 8 of 73]; difference, 21%; OR, 3.814; 95% CI, 1.573-9.249; P = .002; ELM, 32% [n = 23 of 71] vs 18% [n = 13 of 73]; difference, 14%; OR, 2.211; 95% CI, 1.015-4.819; P = .04). Conclusions and relevance Discontinuity of the EZ and ELM was more common at 12 months postoperatively following PPV vs PnR for RRD repair. The findings of this post hoc analysis suggest that less discontinuity of the EZ and ELM may provide an anatomic basis for the previously reported superior functional outcomes with PnR, although the analysis does not prove a cause-and-effect relationship. Trial registration ClinicalTrials.gov Identifier: NCT01639209.

IMPORTANCE: Retinal displacement following rhegmatogenous retinal detachment repair may have consequences for visual function. It is important to know whether surgical technique is associated with risk of displacement. OBJECTIVE: To compare retinal displacement following rhegmatogenous retinal detachment repair with pneumatic retinopexy (PR) vs pars plana vitrectomy (PPV). INTERVENTIONS OR EXPOSURES: Fundus autofluorescence images were assessed by graders masked to surgical technique. DESIGN, SETTING, AND PARTICIPANTS: A multicenter retrospective consecutive case series in Canada and the UK. A total of 238 patients (238 eyes) with rhegmatogenous retinal detachments treated with PR or PPV who underwent fundus autofluorescence imaging from November 11, 2017, to March 22, 2019, were included. MAIN OUTCOMES AND MEASURES: Proportion of patients with retinal displacement detected by retinal vessel printings on fundus autofluorescence imaging in PR vs PPV. RESULTS: Of the 238 patients included in the study, 144 were men (60.5%) and 94 were women (39.5%); mean (SD) age was 62.0 (11.0) years. Of the 238 eyes included in this study, 114 underwent PR (47.9%) and 124 underwent PPV (52.1%) as the final procedure to achieve reattachment. Median time from surgical procedure to fundus autofluorescence imaging was 3 months (interquartile range, 1-5 months). Baseline characteristics in both groups were similar. The proportion of eyes with retinal vessel printing on fundus autofluorescence was 7.0% for PR (8 of 114) and 44.4% for PPV (55 of 124) (37.4% difference; 95% CI, 27.4%-47.3%; P

To report the anatomical and visual outcomes of patients with thick submacular hemorrhage (SMH) treated with pars plana vitrectomy (PPV), subretinal tissue plasminogen activator (t-PA), and pneumatic displacement.Single-centre, retrospective case series.A total of 99 eyes of 99 consecutive patients with thick SMH secondary to any underlying etiology treated with PPV with subretinal t-PA and pneumatic displacement by 6 vitreoretinal surgeons at St. Michael's Hospital, Toronto, between July 2004 and August 2016.All medical records and colour fundus photographs were reviewed for data collection. Blood displacement was evaluated at follow-up visits and classified as complete, partial, or none. Main outcome measures included blood displacement at final follow-up, postoperative Snellen best-corrected visual acuities (BCVA), and complication and recurrence rates.Patients had a mean age of 77.7 ± 12.3 years and were followed up for an average of 18.4 ± 22.3 months. Wet age-related macular degeneration was the most common etiology associated with thick SMH (80.8%). Complete blood displacement was observed by final follow-up in 85.9% of the cases, partial displacement in 12.1%, and none in 2.0%. Mean logMAR BCVA improved from 2.03 ± 0.81 (Snellen 20/2143) at baseline to 1.80 ± 1.00 (Snellen 20/1262; p = 0.009) at final follow-up, and baseline BCVA was a significant predictor of final BCVA (p0.001). Early postoperative complications included vitreous hemorrhage in 13 eyes and rhegmatogenous retinal detachment in 8. Recurrent SMH was observed in 12 cases.Vitrectomy with subretinal t-PA and pneumatic displacement seems to be an effective treatment for SMH in terms of blood displacement and visual outcomes.