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Purpose: To report outcomes of pars plana vitrectomy (PPV) with air tamponade for primary rhegmatogenous retinal detachment (RRD) and investigate the impact of vitreous cortex remnants (VCR) on surgical outcomes., Methods: A retrospective review of 900 patients treated for uncomplicated primary RRD between 2007 and 2020. Exclusion criteria included axial length > 26 mm, prior retinal surgery, giant retinal tear, PVR grade > B, and inadequate follow-up. Primary outcomes were retinal reattachment rate and best-corrected visual acuity (BCVA)., Results: Of 900 patients, 397 met inclusion criteria. Primary reattachment rate was 88.4%, with significant BCVA improvement. Forty-six eyes experienced RRD recurrence. Complications included cataracts (38.8%), IOP rise (11.4%), and macular edema (8.3%). Better final BCVA was associated with preoperative macular non-involvement and absence of reinterventions. No significant association was found between RRD recurrence and various factors, including VCR removal., Conclusion: Air tamponade is a safe and effective option for primary RRD treatment. It has no negative effect on the environment and creates less discomfort for patients. VCR removal did not significantly reduce RRD recurrence in the overall number of cases. Further research will help determine the role of VCR in RD recurrence and define in which cases their removal might be beneficial., Competing Interests: Declarations Competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (© 2024. The Author(s).)

Background: Vitreoretinal lymphoma (VRL) still represents a diagnostic challenge for retinal specialists. Early diagnosis and treatment are critical for a better prognosis. Several diagnostic tools have proven helpful in the identification of VRL abnormalities. However, swept-source OCT angiography (SS-OCT-A) findings and their long-term follow-up are yet to be explored., Case Presentation: a 42-year-old man presented with blurred vision in his left eye for 2 weeks. He denied any systemic symptoms. A multimodal imaging examination was performed, raising the clinical suspicion of VRL and guiding the ensuing diagnostic procedures. The patient underwent treatment and at the last FU visit three years later, no disease signs were present on fundus examination, nor on oncologic evaluation. Some novel SS-OCT-A features were identified, and uncommonly reported findings were examined over a long-term follow-up. At baseline multiple hyperreflective alterations were detected on the enface outer retina slabs and choriocapillary analysis revealed low reflectance areas in the foveal and parafoveal areas. One month after the first presentation, multiple hyperreflective retinal lesions in a vertical shape were detected on OCT which appeared on midretinal slabs of enface SS-OCT-A as hyperreflective spots mainly located near second-order retinal vessels. These alterations remarkably reduced after treatment., Conclusion: SS-OCT-A may be a useful imaging technique in the detection of VRL, providing ophthalmologists additional findings that assist the diagnosis and follow-up of this disease. This may prove useful for a more timely and precise diagnosis, prompt therapy, and treatment response monitoring. The original aspects found in this case may provide grounds for future studies, ultimately fostering a better understanding of the disease., (© 2024. The Author(s).)

To study the long-term outcomes of standard ILM peeling and fovea sparing with inverted flap (FSIF) peeling for symptomatic myopic foveoschisis (MF). This retrospective observational study included 36 eyes of 34 consecutive patients who underwent vitrectomy with standard ILM peeling and FSIF peeling for MF between April 2012 and march 2020. The primary outcome measures included best-corrected visual acuity (BCVA) and central foveal thickness (CFT) at 1 month and final visit and postoperative development of macular hole. There were 14 eyes in the standard ILM peeling group and 22 eyes and in the FSIF peeling groups with a mean FU of 34.2 months (SD 23.3; min. 12-max. 96) and 27.7 months (SD 14.9; min. 12-max. 63), respectively. In both groups BCVA was not significantly improved at 1 month but improved at last visit from 0.55 ± 0.21 to 0.37 ± 0.29 in the standard ILM peeling group (P = 0.0154) and from 0.57 ± 0.27 to 0.28 ± 0.23 in the FSIF peeling group (P < 0.0001). At 1 month and final visit CMT decreased from 572 ± 183.5 µm to 277.5 ± 95.2 µm and to 250.4 ± 96.1 µm, respectively, in the standard ILM peeling group and from 589.9 ± 189.8 µm to 383 ± 110.1 µm and 162.3 ± 74.8 µm in the FSIF peeling group (P < 0.001 for both groups at both time-points). The preoperative and postoperative BCVA and CMT showed no significant differences between groups. Three of the eyes in the standard ILM peeling group developed postoperative macular hole at 1, 10, 24 months, respectively, and none of the eyes in the FSIF peeling group. Multivariate analysis revealed that a better BCVA was the only independent factor correlated with the final BCVA. In this study, standard ILM peeling and FSIF peeling were both beneficial in improving the anatomy and function of eyes with MF. Postoperative MH may occur up to 2 years after standard peeling and seem effectively prevented by FSIF peeling., (© 2024. The Author(s).)

Purpose: To investigate morpho-functional changes after surgical treatment for ERM foveoschisis or lamellar macular hole (LMH), and to evaluate whether the two entities are associated with different healing processes and long-term outcomes., Design: Retrospective interventional case series., Methods: A total of 56 eyes, treated for lamellar macular defects and followed up for 24 months, were enrolled. The eyes were divided into two groups: 34 with ERM foveoschisis and 22 with LMH. Changes in the following features were evaluated and compared between the two groups: best-corrected visual acuity (BCVA), external limiting membrane (ELM) and ellipsoid zone (EZ) defects, central foveal thickness (CFT), and autofluorescence (FAF) diameter and area., Results: After surgery, progressive BCVA improvement was observed with no significant difference between the two groups ( p -value: 0.06). An increased number of eyes with intact outer-retinal layers was found both in the ERM foveoschisis and LMH groups. FAF diameter and area decreased significantly throughout the FU with no significant difference between the two groups ( p -value: 0.2)., Conclusion: In the present study, significant functional and microstructural improvements were observed after surgery for both ERM foveoschisis and LMH, demonstrating considerable repair potential in both types of lamellar defects. These findings question the true "degenerative" nature of LMH., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Pertile, Iacovello, Maraone, Bottega, Guerriero and Maggio.)

Introduction: This is a multicentric study on the use of heavy silicon oil (HSO) as an intraocular tamponade for inferior retinal detachment (RD) complicated by proliferative vitreoretinopathy (PVR)., Methods: 139 eyes treated for RD with PVR were included in the study. 10 (7.2%) were affected by primary RD with inferior PVR, while 129 (92.8%) were affected by recurrent RD with inferior PVR. 102 eyes (73.9%) had received a silicon oil (SO) tamponade in a previous intervention prior to receiving HSO. Mean follow-up was 36.5 (standard deviation = 32.3) months., Results: The median interval between HSO injection and removal was 4 months (interquartile range: 3). At the time of HSO removal, the retina was attached in 120 eyes (87.6%), whereas in 17 eyes (12.4%), it had re-detached while the HSO was in situ. 32 eyes (23.2%) showed recurrent RD. A subsequent RD relapse was observed in 14.2% of cases with no RD at the time of HSO removal, and in 88.2% if an RD was present at the time of HSO removal. Advancing age showed a positive association with retinal attachment at the end of follow-up, while the risk of RD relapse at the end of the follow-up showed a significant negative association with HSO tamponade duration and with the use of SO rather than air or gas as post-HSO tamponade materials. Mean best corrected visual acuity was 1.1 logarithm of minimum angle of resolution at all follow-up time points. 56 cases (40.3%) needed treatment for elevated intraocular pressure (IOP), with which no clinically relevant variables were associated during follow-up., Conclusion: HSO represents a safe and effective tamponade in cases of inferior RD with PVR. The presence of RD at the time of HSO removal is a negative prognostic factor for the development of a subsequent RD relapse. According to our findings, in cases of RD at the time of HSO removal, a short-term tamponade should definitely be avoided, in favor of SO. Special attention must be paid to the risk of IOP elevation, and patients should be closely monitored., (© 2023 S. Karger AG, Basel.)

The efficacy of intravitreal anti-VEGF may be reduced in vitrectomized eyes due to accelerated drug clearance. Given its longer durability, brolucizumab may represent a suitable therapeutic option. However, its efficacy in vitrectomized eyes remains to be explored. Herein, we describe the management of a macular neovascularization (MNV) in a vitrectomized eye with brolucizumab after unsuccessful treatment with other anti-VEGF. A 68-year-old male was treated with pars plana vitrectomy for epiretinal membrane in his left eye (LE) in 2018. After surgery, best corrected visual acuity (BCVA) improved to 20/20 with a remarkable reduction of metamorphopsia. After 3 years, the patient returned, presenting visual loss in the LE due to MNV. He was treated with intravitreal bevacizumab injections. However, after the loading phase, an increased lesion size and exudation with worsening BCVA were detected. Therefore, the treatment was switched to aflibercept. However, after three monthly intravitreal injections, further worsening was recorded. Treatment was then switched to brolucizumab. Anatomical and functional improvement was noticed 1 month after the first brolucizumab injection. Two additional injections were performed, and further improvement was recorded with BCVA recovery to 20/20. At the last follow-up visit 2 months after the third injection, no recurrence was detected. In conclusion, determining whether anti-VEGF injections are efficacious for vitrectomized eyes would be helpful for ophthalmologists managing such patients, as well as when considering pars plana vitrectomy in eyes at risk of MNV. In our case, brolucizumab was found to be effective after unsuccessful treatment with other anti-VEGF. Additional studies are required to evaluate the safety and efficacy of brolucizumab for MNV in vitrectomized eyes., Competing Interests: The authors declare that they have no financial disclosures., (Copyright © 2022 by The Author(s). Published by S. Karger AG, Basel.)

Purpose: To report a rare case of pachychoroid neovasculopathy in retinitis pigmentosa (RP) and to describe its features and changes after treatment with bevacizumab as documented by swept-source optical coherence angiography., Methods: A case report of a 69-year-old man with a history of RP who presented at our clinic with an acute decrease in visual acuity (Best corrected visual acuity) in his left eye., Results: Upon the first examination, best-corrected visual acuity in the left eye was 20/50. Fundus examination and fundus autofluorescence showed bilaterally typical features of RP, and enhanced depth imaging-optical coherence tomography revealed a pachychoroid pattern. Fluorescein angiography and indocyanine green angiography suggested the presence of a choroidal neovascularization in the left eye, although no clear evidence of any neovascular network could be identified. Swept-source optical coherence angiography was performed, confirming the presence of a choroidal neovascularization network. The patient was treated with 2 monthly intravitreal injections of bevacizumab. After treatment, BVCA improved to 20/25, and no evidence of the vascular network was detectable on swept-source optical coherence angiography., Conclusion: Our case reports the uncommon association of RP with pachychoroid neovasculopathy. Swept-source optical coherence angiography proved to be a useful imaging technique for the diagnosis and follow-up of this condition. Intravitreal bevacizumab represents an effective treatment for choroidal neovascularization associated with RP.

Purpose: To report a longitudinal analysis of specific optical coherence tomography (OCT) features in eyes with diabetic macular edema (DME) treated with anti-VEGF., Methods: A total of 133 eyes of 103 consecutive patients with center-involving DME were included in the study. The eyes were treated between August 2008 and April 2019 with three monthly intravitreal anti-VEGF injections, either with or without prompt or deferred laser, followed by pro re nata (PRN) re-treatment. The following OCT biomarkers were evaluated: subfoveal neuroretinal detachment (SND) (defined as present (SND+) or absent (SND-)), hyperreflective retinal foci (HRF) number (defined as: absent/few(HRF-) or moderate/many (HRF+)), external limiting membrane (ELM) integrity, central macular thickness (CMT), and central retinal thickness (CRT). Changes in SND status and in the number of HRF were evaluated at each DME recurrence throughout the follow-up(FU) period. Mutual correlation among OCT biomarkers and their relationship with visual and anatomic outcomes were assessed both at baseline and over the FU period., Results: The mean FU was 71.2 months (SD 28.4; min. 12-max. 111). At baseline, the prevalence of SRD+ was 27.8% and a high number of HRF were detected in 41.4% of the eyes. A significant reduction in the number of HRF, CMT, CRT, and in the prevalence of SND was recorded in the post-loading phase (p-value <0.0001). In DME recurrences, the presence of SND+ and HRF+ was significantly more frequent in eyes with baseline SND+ and HRF+ compared to eyes presenting baseline SND- and HRF- (p-value <0.0001). No role of SND (p-value: 0.926) and HRF (p-value: 0.281) as baseline predictors of visual and anatomic outcomes was demonstrated, while a worse visual outcome was significantly correlated with a higher incidence of relapsing SND+ (p-value <0.0001) and HRF+ (p-value <0.0028) throughout the FU period., Conclusion: In this study, SND and HRF were frequently present in DME recurrences with the same pattern exhibited at baseline, suggesting that these OCT biomarkers may characterize a specific pattern of DME that repeats over time. Moreover, the results suggested that the persistence and recurrence of SND and HRF may account for a decrease in visual function more than the baseline prevalence of these biomarkers. Further studies are required to confirm these findings., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To assess the prevalence of vitreomacular adhesion (VMA) in consecutive naïve eyes diagnosed with macular oedema (ME) secondary to retinal vein occlusion (RVO) and to longitudinally evaluate the incidence of vitreomacular interface changes over time and the influence on response to treatment., Design: Retrospective cross-sectional analysis and longitudinal cohort study conducted at two Italian tertiary referral centres., Methods: A total of 295 eyes, treated with intravitreal ranibizumab and/or dexamethasone for ME secondary to RVO between June 2008 and May 2018, were enrolled in the study. 280 fellow eyes met the inclusion criteria and were included as control group. The vitreomacular interface status was evaluated by spectral domain optical coherence tomography (OCT) and graded according to the OCT-based International Classification System developed by the International Vitreomacular Traction Study (IVTS) group., Results: At baseline, VMA was present in 130 (44.07%) RVO eyes and 142 (50.7%) control eyes (no statistically significant difference was found; p = 0.455). Mean follow-up (FU) was 35.98 months (min 6 - max 112). Throughout the FU, the incidence of spontaneous release of VMA (RVMA) in RVO eyes was significantly higher in comparison with that of the control group [59 (41.84%) RVO eyes versus 18 (12.33%) control eyes; p < 0.0001]. The number of injections in VMA+ eyes was significantly higher when compared with VMA- eyes. No significant difference was found between VMA+ and VMA- eyes regarding their mean best-corrected visual acuity (BCVA) at baseline and at each annual time point (p = 0.2). Differences in central macular thickness (CMT) were significant only at the baseline evaluation (p = 0.0303)., Conclusions: Vitreomacular adhesion (VMA) was not found to be more prevalent in eyes with RVO compared to healthy fellow eyes, and RVO, in turn, did not result in a higher persistence of VMA over time. This suggests that VMA and RVO might be two independent retinal phenomena, with no mutual pathogenetic influence. Vitreomacular adhesion (VMA) might have an impact on the response to treatment, since it was found to result in a more intensive treatment regimen; however, it did not affect visual and anatomic outcomes. These results do not support vitrectomy or PVD induction in the prevention, nor the treatment, of RVO., (© 2021 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: This study aimed to describe foveal microstructural changes after pars plana vitrectomy (PPV) with air tamponade for rhegmatogenous retinal detachment (RRD)., Methods: External limiting membrane (ELM) and ellipsoid zone (EZ) integrity, cystoid macular edema (CME), and subretinal fluid bleb (SB) development were analyzed using optical coherence tomography in 59 eyes over a 6-month follow-up period after PPV surgery for RRD. Eyes were grouped as macula-on (n = 30) or macula-off (n = 29), and the association between ELM and EZ recovery and best-corrected visual acuity (BCVA) was investigated. Predictive factors for ELM and EZ recovery were also identified., Results: The interval between symptom onset and surgery did not significantly differ between the macula-on and macula-off groups. Macula-on patients showed ELM and EZ integrity throughout, whereas macula-off patients had ELM and EZ integrity restored in 89.7% and 86.2% cases, respectively, with a resultant increase in final BCVA. Significant associations were found between preoperative macular involvement and ELM/EZ restoration. ELM/EZ recovery was also inversely associated with CME development. Significant associations were also found between final BCVA and preoperative BCVA and EZ recovery. CME and SB development were equally distributed between the 2 groups., Conclusion: Prompt surgery for macula-off RRD allows the progressive recovery of outer retinal layers and significant visual gain., (© 2021 S. Karger AG, Basel.)

Background: Choroidal neovascularization (CNV) in pregnancy has rarely been described. A differential diagnosis between inflammatory, idiopathic, and myopic CNV may be challenging. Moreover, there is no consensus on management, and therapeutic options may be further limited by patient and physician concerns about potential risk to the fetus. Herein, we report a case of inflammatory CNV during pregnancy and describe a previously unreported management approach with retrobulbar triamcinolone injections., Case Presentation: A 36-year-old woman presented with vision loss and metamorphopsia in her right eye while 21 weeks pregnant. She was diagnosed with an inflammatory CNV based on the following multimodal imaging findings: a type 2 lesion with the "pitchfork sign" on OCT, along with the absence of tomographic signs of myopic CNV, and the presence on autofluorescence of multiple hyper-autofluorescent spots, interpreted as focal areas of inflammation at the level of the outer retina and inner choroid. The patient refused oral corticosteroids and any intravitreal injection therapies. Therefore, she was treated with two trans-Tenon's retrobulbar injections of triamcinolone acetonide after explaining the procedure and acquiring consent. The treatment resulted in a regression of inflammatory signs and a reduction of neovascular activity. No adverse events occurred for the mother or the baby, neither during the pregnancy nor after delivery., Conclusion: Inflammatory CNV may be rarely associated with pregnancy. The correct diagnosis is crucial to allow the consideration of all possible management options. To the best of our knowledge, this is the first reported case of treatment with retrobulbar triamcinolone injections. This may represent a suitable therapeutic option in the absence of any other therapeutic approaches.

Background: Bullous serous retinal detachment (RD) with retinal pigment epithelial (RPE) tear is a rare and severe variant of chronic central serous chorioretinopathy (CSC). Due to its atypical presentation, it may raise diagnostic issues, leading to inappropriate therapeutic procedures. The optimum treatment for this CSC variant is still uncertain., Case Presentation: A 65-year-old male was referred for vitreo-retinal surgery with a provisional diagnosis of rhegmatogenous RD in his right eye. Dilated fundus examination showed an inferior bullous RD with no evidence of retinal breaks, while a large RPE tear was detected in the temporal quadrant. Ocular ultrasound showed no mass lesion. The axial length was 23.63 mm. Enhanced depth imaging optical coherence tomography (EDI-OCT) revealed a pachychoroid pattern in both eyes. The patient referred a history of CSC in the right eye and the recent use of intravenous corticosteroids for bronchitis. Laser therapy and photodynamic therapy were not applicable due to the extension and elevation of the RD. Two months after oral treatment with eplerenone, the subretinal fluid increased significantly. The patient underwent two 4 × 4 mm deep lamellar sclerectomies in the inferior quadrants. The surgical treatment resulted in complete RD resolution., Conclusion: A correct diagnosis of bullous variant of chronic CSC with RPE tear is critical to avoid inappropriate procedures and to prevent severe visual loss as a result of neuroretinal damage. Scleral thinning surgery may be considered a valid option, resulting in rapid and long-lasting resolution of RD.

Purpose: To report the long-term visual and anatomic outcomes of intravitreal injections for macular edema (ME) secondary to retinal vein occlusion (RVO) in a real-life clinical setting., Design: Retrospective interventional case series., Methods: A total of 223 consecutive eyes with ME secondary to RVO, treated with the first three intravitreal Ranibizumab or dexamethasone injections between August 2008 and September 2018, were enrolled in the study. Subsequent retreatment was guided by best-corrected visual acuity (BCVA) and central macular thickness (CMT) measurements, aimed at achieving macular fluid regression and BCVA stability. BCVA and CMT were recorded at baseline and at subsequent annual time points. The mean number of injections administered each year and the incidence of adverse events were recorded., Results: The mean BCVA and CMT at baseline were 0.79 logMar (SD 0.71) and 615.7  μ m (SD 257.5), respectively. The mean follow-up (FU) period was 47.8 months (min 12-max 120). At 12 months, the mean BCVA and CMT had significantly improved to 0.62 logMar (SD 0.68; p < 0.0001) and 401.04  μ m (SD 257.5), respectively. The mean follow-up (FU) period was 47.8 months (min 12-max 120). At 12 months, the mean BCVA and CMT had significantly improved to 0.62 logMar (SD 0.68; p < 0.0001) and 401.04 ., Conclusion: Intravitreal Ranibizumab and/or dexamethasone injections were found to be effective at inducing a long-lasting improvement of BCVA and CMT in a real-life clinical setting. A safety profile similar to that already well-established in Ranibizumab and dexamethasone treatment was observed, as well as a steady decrease in the number of intraocular injections required. The results support intravitreal treatments for BRVO and CRVO in patient populations with similar characteristics in similar settings., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Emilia Maggio et al.)

Purpose: To evaluate the effectiveness of recombinant tissue plasminogen activator (rtPA) and sulphur hexafluoride gas (SF6) intravitreal injection for the displacement of large submacular haemorrhages (SMH) secondary to neovascular age-related macular degeneration and for guiding the selection of additional treatments or observations for choroidal neovascularization (CNV)., Methods: The medical records of consecutive patients with recent-onset, large SMH, treated at Sacro Cuore Hospital from January 2004 to May 2016, were retrospectively analysed. All eyes underwent a 0.05-mL intravitreal injection of 50 μg rtPA, 0.3 mL of 100% SF6, and then face-down positioning. Afterwards, the eyes received additional treatments for CNV or observation, based on the severity and extent of the underlying pathology. The multimodal imaging features revealed after blood displacement were analysed and then correlated to the treatment selected as a second therapeutic option., Results: A total of 96 eyes met the inclusion criteria and was evaluated in this study. SMH was displaced from the fovea in the majority of the eyes (76%), allowing several diagnostic tools to evaluate the underlying macular features. In 19 cases (19.8%) exhibiting severe macular damage, no additional treatment was applied. In the remaining eyes, subsequent treatments included anti-vascular endothelial growth factor injections (44.8%), photodynamic therapy (n = 2), and submacular surgery (35.4%). Statistically significant correlations were found between the macular findings revealed after blood displacement and the additional treatments or observations selected for the underlying disease. The mean follow-up was 35 months. Improvements in visual acuity were statistically significant up to 3 years., Conclusion: Intravitreal rtPA and gas injection was found to be effective for the displacement of large SMH, allowing postoperative diagnostic testing, and thus guiding the opportunity to apply further treatments. The addition of subsequent individualized treatments may allow long-term visual gain in selected cases., (© 2020 S. Karger AG, Basel.)

Objective: To investigate the influence of the inverted flap technique compared with traditional internal limiting membrane (ILM) peeling in the postoperative remodelling of outer retinal layers of idiopathic macular holes (MHs) >450 µm., Methods: We analyzed medical records and imaging studies of all patients with an idiopathic MH >450 µm who underwent vitrectomy at the Sacco University Hospital, Milan, and the Sacro Cuore Don Calabria Hospital, Verona, Italy, between January 2008 and December 2017. Out of 41 eyes evaluated, 17 were treated with traditional ILM peeling and 24 with the inverted ILM flap technique. All patients underwent follow-up examinations every 3 months and all of them completed a final visit 12 months after surgery. Best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) parameters were evaluated at each visit. The main outcome measures were the postoperative recovery rate of the external limiting membrane (ELM) and ellipsoid zone (EZ), and postoperative BCVA. Correlations between OCT measurements and visual outcome were analyzed., Results: The ELM recovery rate in the ILM peeling group (15/17 eyes, 88%) was higher than in the ILM flap group (14/24 eyes, 58%) (p = 0.079). The EZ recovery rate was similar in the 2 groups, 7/17 eyes (41%) in the ILM peeling and 8/24 eyes (33%) in the ILM flap group (p = 0.744). Eyes without a persistent hyper-reflective "plug" at the edges of the MH showed a significantly higher EZ recovery rate (11/18, 61%) compared with eyes showing a persistent plug (4/23, 17%) (p = 0.008). The mean BCVA improved significantly in both groups: from 0.93 logMAR (20/170) to 0.26 logMAR (20/36) in the ILM peeling and from 0.98 logMAR (20/190) to 0.37 logMAR (20/46) in the ILM flap group. The final BCVA tended to be better in the ILM peeling group (p = 0.085)., Conclusions: Given the limited information about the influence of ILM flap versus traditional ILM peeling in the postoperative remodelling of large idiopathic MHs, our data provides some new insights into the healing process of MHs >450 µm. This should be considered as part of the decision process about whether to perform an ILM flap in these patients., (© 2020 S. Karger AG, Basel.)

Background: Best vitelliform macular dystrophy (BVMD) is an autosomal dominant macular degeneration. The typical central yellowish yolk-like lesion usually appears in childhood and gradually worsens. Most cases are caused by variants in the BEST1 gene which encodes bestrophin-1, an integral membrane protein found primarily in the retinal pigment epithelium., Methods: Here we describe the spectrum of BEST1 variants identified in a cohort of 57 Italian patients analyzed by Sanger sequencing. In 13 cases, the study also included segregation analysis in affected and unaffected relatives. We used molecular mechanics to calculate two quantitative parameters related to calcium-activated chloride channel (CaCC composed of 5 BEST1 subunits) stability and calcium-dependent activation and related them to the potential pathogenicity of individual missense variants detected in the probands., Results: Thirty-six out of 57 probands (63% positivity) and 16 out of 18 relatives proved positive to genetic testing. Family study confirmed the variable penetrance and expressivity of the disease. Six of the 27 genetic variants discovered were novel: p.(Val9Gly), p.(Ser108Arg), p.(Asn179Asp), p.(Trp182Arg), p.(Glu292Gln) and p.(Asn296Lys). All BEST1 variants were assessed in silico for potential pathogenicity. Our computational structural biology approach based on 3D model structure of the CaCC showed that individual amino acid replacements may affect channel shape, stability, activation, gating, selectivity and throughput, and possibly also other features, depending on where the individual mutated amino acid residues are located in the tertiary structure of BEST1. Statistically significant correlations between mean logMAR best-corrected visual acuity (BCVA), age and modulus of computed BEST1 dimerization energies, which reflect variations in the in CaCC stability due to amino acid changes, permitted us to assess the pathogenicity of individual BEST1 variants., Conclusions: Using this computational approach, we designed a method for estimating BCVA progression in patients with BEST1 variants.

Purpose: To investigate the microstructural changes after successful myopic macular hole (MMH) surgery, comparing inverted ILM flap and complete ILM removal techniques, and their association with visual function., Methods: Spectral-domain optical coherence tomography (SD-OCT) was used to evaluate both external limiting membrane (ELM) and ellipsoid zone (EZ) recovery in 40 eyes of 39 patients who underwent pars plana vitrectomy with either inverted internal limiting membrane flap technique ( n =27) or complete ILM removal ( n =13) to achieve MH closure. The association between ELM and EZ recovery and visual acuity was also investigated. The patients were followed up at 1 year., Results: ELM and EZ was recovered in 72% and 62% of cases, respectively, regardless of the surgical techniques 1 year after surgery. A strong positive association between the ELM and EZ recovery and the mean BCVA was found: regardless of the surgical technique, this was statistically significant at each time point ( p < 0.05). None of the baseline variables were found to act as predictive factors for either ELM or EZ., Conclusion: The inverted ILM flap technique did not affect the MMH healing processes compared to complete ILM removal. Thus, the presence of the ILM plug did not interfere with the restoration of both ELM and EZ, which correlated with functional recovery.

Purpose: To report the long-term outcomes of intravitreal anti-vascular endothelial growth factor (VEGF) treatment for diabetic macular edema (DME) in a real-world clinical setting and to assess the efficacy of subsequent alternative treatments in eyes with suboptimal response to anti-VEGF., Design: Retrospective interventional case series., Methods: The medical records of consecutive eyes with center-involving DME, treated between August 2008 and June 2015 with 3 monthly intravitreal anti-VEGF injections-with or without prompt or deferred laser-followed by pro re nata re-treatment, were reviewed. A subgroup of eyes that were unresponsive to the treatment received subsequent alternative therapeutic options, including switching to another anti-VEGF drug, intravitreal injection of dexamethasone, and vitrectomy., Results: A total of 170 eyes of 129 patients were included in the study. The mean follow-up (FU) was 45.6 months (SD 18; minimum 12-maximum 81). The change in mean best-corrected visual acuity (BCVA) at 1-year FU was +5 ETDRS letters (P < .0001). Improvement in BCVA was statistically significant up to 5 years. Improvement in central macular thickness (CMT) was statistically significant up to the last FU visit. In eyes with suboptimal response, no significant visual improvement was found by switching to another anti-VEGF (P =.4347). Twenty-four eyes treated with intravitreal dexamethasone and 14 with vitrectomy exhibited a significant reduction in CMT with variable functional responses. In these eyes, better BCVA gain was found in cases with an early change of the treatment strategy., Conclusion: The results support treatment with intravitreal anti-VEGF for DME in real-world clinical settings and suggest that an early change of the therapeutic strategy should be considered for eyes unresponsive to the treatment., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Indocyanine Green Angiography (ICG-A) and Enhanced Depth Imaging Spectral-Domain Optical Coherence Tomography (EDI-OCT) are essential imaging techniques for diagnosis, management and understanding of the pathophysiology of many chorioretinal diseases. Herein, we report the ICG-A and EDI-OCT findings from a case of Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE), in which these imaging techniques enable the visualization of more diagnostic details than those observable with other widely used diagnostic tools., Case Presentation: A 60-year-old white female presented with bilateral blurred vision for few days. Fundus examination showed multiple, yellow-white placoid lesions at the posterior pole of both eyes. The placoid lesions were also evident on Spectral-Domain Optical Coherence Tomography (SD-OCT), Fluorescein Angiography (FA), Fundus Autofluorescence (AF), and ICG-A. A complete ophthalmologic examination was performed and the diagnosis of APMPPE was made based on imaging and clinical features. Notably, all the lesions detected by FA, AF and OCT corresponded to focal areas of hypofluorescence seen on ICG-A, whereas several additional hypofluorescent areas that were not associated with FA, AF or OCT abnormalities, were also detected with ICG-A. On follow-up, the regression of outer retinal abnormalities detected on OCT preceded the restoration of choroidal perfusion abnormalities in the corresponding locations on ICG-A. This long-standing choroidal perfusion defect could not be detected with OCT. EDI-OCT scans revealed characteristic choriocapillaris changes beneath the placoid lesions and an increase in choroidal thickness during the acute phase, with subsequent decrease in the inactive stage of the disease., Conclusion: Our findings show that ICG-A and EDI-OCT provide detailed morphologic information of choroidal abnormalities in APMPPE and allow accurate evaluation of definitive resolution of the lesions. Moreover, they support the acute choroidal hypoperfusion as the primary mechanism overlying the pathogenesis of the disease, and suggest that the non-perfused areas may extend beyond the damage of the outer retina.

Purpose: To assess the prevalence of vitreomacular adhesion (VMA) in consecutive naïve eyes diagnosed with exudative age-related macular degeneration (AMD) in comparison with eyes with nonexudative AMD and age-matched controls, and to evaluate prospectively the incidence of vitreomacular interface changes over time and their influence on choroidal neovascularization (CNV) development., Design: Retrospective cross-sectional analysis and longitudinal cohort study conducted at Sacrocuore Hospital, Negrar, Verona, Italy., Participants: A total of 1067 eyes examined at Sacrocuore Hospital between August 2008 and June 2015 met the inclusion criteria and were evaluated in this study., Methods: Eyes were classified into 3 groups: 403 eyes of 364 patients (mean [standard deviation; SD] age 77.8 [8.0] years) affected by exudative AMD; 350 eyes of 298 subjects (mean [SD] age 78.1 [8.2] years) with nonexudative AMD; and 314 eyes of 214 subjects (mean [SD] age 74.2 [8.2] years) with no signs of AMD enrolled as the control group. The vitreomacular interface status was evaluated by spectral-domain optical coherence tomography (OCT) and was graded according to the OCT-based International Classification System developed by the International Vitreomacular Traction Study Group by 2 independent masked observers., Results: VMA was present in 101 (25.1%) eyes with exudative AMD, 84 (24.0%) eyes with nonexudative AMD, and 84 (26.8%) eyes with no signs of AMD (no statistical difference was found; P = 0.3384). Spontaneous release of VMA (RVMA) was found in 15 (15.3%) eyes with exudative AMD, 21 (28.0%) eyes with nonexudative AMD, and 10 (24.4%) eyes with no signs of AMD over a mean follow-up of 25.5, 25.9, and 24.1 months, respectively. The incidence of RVMA in exudative AMD eyes was significantly lower compared with nonexudative (P = 0.0207) and lower, but not statistically significant, with respect to eyes with no signs of AMD (P = 0.1013). In eyes with nonexudative AMD, de novo development of CNV occurred in 91 eyes (30.6%). There was no significant difference regarding the rate of CNV development in the presence or absence of VMA (P = 0.0966)., Conclusions: The present study found no significant difference in the prevalence of VMA in eyes affected by AMD compared with age-matched controls and no difference in the rate of de novo CNV development in eyes with or without VMA. Conversely, a lower incidence of RVMA over time was found in eyes affected by exudative AMD. The results of this study suggest that VMA might be a consequence rather than a causative factor in the development of CNV., (Copyright © 2017 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the clinical findings and management of eyes affected by uveal effusion syndrome (UES) presenting with clinical features mimicking inflammatory ocular diseases, treated using individualized surgical approaches., Methods: We report a consecutive interventional case series of seven eyes of four patients affected by UES. On presentation in our clinic, all patients showed signs of steroid effects as a consequence of a presumptive diagnosis; one eye had undergone vitrectomy for retinal detachment (RD), without benefit. Diagnosis of UES was based on ophthalmic examination, ultrasonography, fluorescein angiography, biometry and magnetic resonance imaging. Five eyes with active disease were treated using scleral thinning surgical procedures based on the extent and characteristics of the disease: sclerectomy sites were ultrasound-guided to the area of maximal choroidal swelling, associated with evacuative puncture in the case of bilateral funnel-shaped RD., Results: One patient was diagnosed with type 1 UES, two with type 2, and one with type 3. Mean postoperative follow-up was 26 months. In all eyes, surgery resolved the ciliochoroidal and retinal detachment and improved visual acuity. In two eyes, visual restoration was limited by a prolonged disease course., Conclusion: UES may be mistaken for other sources of ciliochoroidal effusion. Early diagnosis and treatment is critical to avoid unnecessary procedures and to prevent severe visual loss as a result of neuroretinal damage. Surgical treatment based on the extent and characteristics of the disease may be effective for the resolution of ciliochoroidal effusion, even in type 3 UES, where conventional surgery has proved unsuccessful.

Background: Central Serous Chorioretinopathy (CSC) has been previously reported as an infrequent complication of pregnancy that usually resolves spontaneously after delivery, with minimal or no sequel. We report a case of a severe form of CSC in an uncomplicated pregnancy with extensive subfoveal exudates and severe permanent visual loss. Multimodal imaging techniques, including color and red-free photographs, near-infrared reflectance, fluorescein angiography, and spectral-domain optical coherence tomography, were performed and the findings were correlated to the changes in visual acuity., Case Presentation: A 35-year-old pregnant woman presented with loss of vision and metamorphopsia in her left eye. Fundus examination showed subfoveal severe exudation with a posterior pole serous detachment. Optical coherence tomography (OCT) showed macular neurosensory detachment with central highly reflective sub-retinal material. Multimodal fundus pictures and angiograms revealed distinct clinical features of the disease during both the acute and final phase. The disease spontaneously resolved after delivery with regression of the subretinal fluid and the disappearance of subfoveal exudates. Nevertheless, because of severe atrophic macular changes and subfoveal fibrosis, no improvement of visual acuity was noted., Conclusion: Severe variants of CSC may also present in cases of uncomplicated pregnancy and result in a poor prognosis. Recognising these presentations of CSC is critical to avoid improper management. Multimodal imaging may help to clarify the diagnosis and highlight the clinical features.

Purpose: To evaluate anatomical and visual outcomes following intravitreal dexamethasone implantation (Ozurdex) in eyes with visual loss due to macular edema (ME) secondary to retinal vein occlusion (RVO) and to identify predictive factors for improvement in best-corrected visual acuity (BCVA)., Methods: We retrospectively analyzed medical records of 43 consecutive eyes with treatment-naïve ME secondary to recent onset RVO treated with repeated Ozurdex injections on a pro re nata basis., Results: The mean follow-up (FU) duration was 14 months (min. 12, max. 22). Both mean BCVA and central macular thickness improved significantly at the end of the FU period (p = 0.0001), and more than 30% of the eyes gained ≥ 3 lines within 3 months of repeated injections. Presence of foveal serous retinal detachment and macular ischemia were negatively associated with visual outcomes. Improvements were significantly associated with baseline BCVA and the integrity of the ellipsoid zone. No serious adverse events were recorded., Conclusions: In our study population, Ozurdex was a safe and effective therapeutic option for the treatment of ME associated with RVO. The results suggest that a comprehensive approach in the examination of RVO eyes may help to predict which patients are most likely to benefit from the treatment., (© 2014 S. Karger AG, Basel.)

Background: Several surgical techniques have been described for the treatment of retinal detachment (RD) associated to myopic macular hole (MMH). In this retrospective study, the anatomical and functional outcomes of pars plana vitrectomy (PPV) with long-term tamponade, using either 1000 cSt silicone oil (SO) or heavy silicone oil (HSO), are compared., Methods: Forty-two eyes affected by RD associated with MMH were included. The surgical technique involved standard 3-port 20-gauge PPV with long-term tamponade. The patients were divided into two groups, according to the intraocular tamponade: SO in group 1 (n = 17), and HSO in group 2 (n = 25). Internal limiting membrane (ILM) removal was performed in 15 cases of group 1 and 20 cases of group 2. Tamponade removal was performed 2 to 5 months after primary surgery. The patients were assessed 1 week and 1 month after primary surgery, and then 1 week and 1 month after tamponade removal or after further surgery if macular redetachment had occurred. The patients were also visited every 2 months for at least 1 year after final tamponade removal. Follow-up was considered closed at 1 year after final tamponade removal., Results: Preoperative best-corrected visual acuity (BCVA), expressed as LogMar, was 2.8 ± 0.77 for group 1 and 2.1 ± 0.94 for group 2. At the last visit, the BCVA was 1.41 ± 0.96 and 1.48 ± 0.77 for groups 1 and 2 respectively. Retinal reattachment was achieved with one operation in 13 eyes of group 1 (76.5%) and 18 of group 2 (81.8%) (P = 0.69). The average number of surgery needed to achieve retinal attachment by patients of group 1 and 2 was respectively 1.36 ± 0.63 and 1.46 ± 0.59 (P = 0.77). Five patients of group 1 and four of group 2 developed a chronic glaucoma (P = 0.238)., Conclusions: PPV with ILM peeling and long-term tamponade was demonstrated to be a good surgical option to treat RD due to MMH; SO and HSO seemed to be equally effective, although the success rates remained far from an ideal 100%.