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Purpose: To report the long-term outcome of pars plana vitrectomy (PPV) for management of retained posterior segment intraocular foreign body (IOFB) secondary to gunshot injury., Methods: This is a retrospective interventional case series including consecutive patients who had PPV for retained posterior segment IOFB secondary to gunshot injury. Main outcome measures were final best-corrected visual acuity (BCVA), long-term globe survival and detection of complications. Spearman correlation analyzed relationships between numerical data. Kruskal-Wallis test compared differences in initial BCVA and final BCVA across variables. Categorical variables were tested using Chi square or Fisher's exact test. P value is significant at 0.05., Results: The study included 103 eyes of 103 patients. Mean baseline BCVA was 0.01 decimal unit (2 logMAR). Mean duration from primary repair to PPV was 3 weeks. Mean duration of post-operative follow-up was 60 months. Mean final BCVA was 0.04 decimal unit (1.3 logMAR), p 0.001. Post-operatively, BCVA improved in 58.2% of patients. Nineteen patients (18%) gained ≥2 lines of vision, and 15 patients (14.5%) achieved final BCVA of 0.4 decimal unit (logMAR 0.4). All complications were related to the original injury. These included macular scar (19%), macular pucker (6%), recurrent retinal detachment (4%), subretinal fibrosis (3%), consecutive optic atrophy (3%), and PVR (3%). Phthisis bulbi or sympathetic ophthalmia did not develop in any case., Conclusion: PPV for removal of IOFB caused by gunshot injury yielded long-term favorable functional outcome with excellent globe survival. Poor initial BCVA, location of IOFB in the posterior pole, associated lens injury and retinal detachment are significant adverse prognostic factors for final BCVA but not for globe survival., Competing Interests: The authors report no conflicts of interest in this work., (© 2021 Ghoraba et al.)

Purpose: To assess the efficacy of pars plana vitrectomy (PPV) and silicone oil tamponade for management of myopic retinal detachment associated with macular hole (MRDMH) and to assess the anatomical and functional outcomes of this technique and its long-term validity after silicone oil removal., Methods: Retrospective interventional non-comparative case series including consecutive patients who had PPV and silicone oil tamponade for MRDMH. All patients had an axial length ≥26 mm. Main outcome measures were retinal re-attachment and macular hole closure after silicone oil removal, improvement of best-corrected visual acuity (BCVA), and complications secondary to surgery. Chi square/Fisher's exact test was used to analyze categorical variables, while One-way ANOVA/Kruskal-Wallis test was used to compare variables across the closure type and complications. Correlations between numerical variables were tested using Spearman correlation. Kaplan-Meier method was used to estimate the event-free survival. P value is significant at 0.05., Results: The study included 26 eyes of 26 patients. Retinal re-attachment rate after primary and secondary surgeries was 88.4% and 100%, respectively. W-type macular hole closure occurred in 58% of eyes. Vision improved in 58% of eyes. Mean final BCVA was 0.05 decimal units, p = 0.004. Cataract and glaucoma developed in 42% and 15% of eyes, respectively. Initial BCVA, axial length and duration of silicone oil tamponade did not correlate significantly with either the type of macular hole closure or the final BCVA., Conclusion: PPV and silicone oil tamponade technique promotes successful anatomical and functional outcome in MRDMH. Long-term success is maintained after silicone oil removal. High incidence of silicone oil-induced complications mandate its removal from eyes with successful retinal re-attachment., Competing Interests: The authors report no conflicts of interest in this work., (© 2021 Ghoraba et al.)

Purpose: To assess the efficacy of customized slab segmentation in eliminating projection artifacts in swept-source optical coherence tomography angiography (SS-OCTA) images of Best vitelliform macular dystrophy (BVMD)., Methods: Prospective case series including different stages of BVMD. We analyzed SS-OCTA images for flow signals in the outer retina and coregistered B-scan images for distortion of the segmentation slabs defining the outer retina. We applied a customized method for slab realignment whenever BVMD lesions produced distortion of the slabs. Afterward, we checked the images to determine whether the previously noted flow signal had persisted or disappeared, described as "true flow" or "pseudoflow", respectively. Categorical variables were analyzed with X 2 or Fisher's exact tests, while quantitative variables were analyzed with independent t -test at p <0.05., Results: The study included 39 eyes of 22 patients. We detected BVMD patterns I (dome-shaped hyperreflective lesion without neurosensory retinal detachment), II (knob-like hyperreflective lesion with localized neurosensory retinal detachment), and III (heterogeneous scattered hyperreflective material) in 49%, 23%, and 28% of eyes, respectively. Pseudoflow was evident mostly in eyes with pattern II lesions, presence of flow signal within BVMD lesions, and lesions whose height represented >80% of the retinal thickness ( p <0.001)., Conclusion: Customized slab segmentation is effective in eliminating projection artifact in SS-OCTA images of BVMD., Summary: Projection artifact is a significant confounding factor in emerging SS-OCTA technology through production of pseudoflow signals that can lead to misinterpretation of images of BVMD lesions. The present study proposes a customized method for correction of segmentation errors to eliminate projection artifacts in SS-OCTA images of BVMD patients., Competing Interests: The authors report no conflicts of interest in this work., (© 2021 Moussa et al.)

Purpose: To compare different types of macular holes regarding the anatomic and functional success following pars plana vitrectomy (PPV) and internal limiting membrane (ILM) removal., Methods: A retrospective review of all patients with macular holes treated by PPV, ILM removal with gas tamponade from January 2014 to July 2017 in Magrabi Eye Hospital., Results: One hundred fifty-seven eyes of 153 patients were analyzed. The eyes were classified according to the etiology of macular hole into four groups: 79 eyes with idiopathic macular hole (IMH), 51 eyes with traumatic macular hole (TMH), 16 eyes with macular hole in diabetic patients (DMH) and 11 eyes with myopic macular hole (MMH). We classified the IMH group based on the International Vitreomacular Traction Study Classification according to size into 3 subgroups; subgroup 1: ≤250µ, subgroup 2: >250 to 400µ and subgroup 3: ≥400 µ. All types of macular hole showed statistically significant postoperative improvement in BCVA compared to the baseline except cases with MMH. Anatomic postoperative hole closure was achieved in 86.1%, 60.7%, 43.65%, an 45.46% of eyes with IMH, TMH, DMH and MMH, respectively. In eyes with IMH, closure rate in subgroup 1 was significantly higher than in subgroups 2, and 3., Conclusion: PPV, ILM peel and C2F6 technique yielded variable anatomic and functional outcomes in different types of macular holes. Anatomic results were most favorable in IMH and least favorable in MMH. The smaller the diameter of the hole the better the results. The underlying pathogenetic mechanisms that lead to different types of macular holes are pivotal in determining the final outcome., Competing Interests: This work was self-funded by the authors. The authors report no conflicts of interest for this work., (© 2021 Ghoraba et al.)

Objective: To describe the optical coherence tomography (OCT) findings in terms of macular hole closure and ellipsoid zone (EZ) recovery following modified internal limiting membrane (ILM) surgical technique in traumatic macular holes (TMH)., Methods: The study was a retrospective case series that recruited 16 consecutive patients with TMH. Following vitrectomy (PPV), we performed modified ILM surgical technique (IFT) in which ILM peel was stopped at the edges of the hole forming a floating ILM flap. Primary outcome measures were pattern of TMH closure and recovery of EZ. Student's T -test and Pearson's correlation coefficient were used for statistical analysis., Results: The study had 16 eyes of 16 patients. Mean baseline minimum linear diameter (MLD) was 562µ. Mean baseline best-corrected visual acuity (BCVA) was 1.4 logMAR. U-pattern closure occurred in 50% of eyes, V-pattern closure occurred in 31.2% of eyes, whereas W-pattern closure occurred in 18.7% of eyes. Mean BCVA improvement was 5 lines (p 0.02). Failure of recovery of EZ was detected in 75% of eyes. In the present series, neither pre-operative MLD nor time lapse prior to surgery were significant factors in determining the closure pattern of TMH, the grade of EZ recovery or final BCVA., Conclusion: Modified IFT is effective in promoting macular hole closure and improving visual acuity in patients with TMH. The technique does not promote recovery of EZ., Competing Interests: The authors declare no conflicts of interest regarding the publication of this article. The authors did not receive funding from any institution in support of this publication., (© 2019 Ghoraba et al.)

Purpose: The purpose of this study was to evaluate the safety of high-dose intravitreal triamcinolone acetonide (IVTA) as affordable low-cost alternative to anti-vascular endothelial growth factor (anti-vascular endothelial growth factor [anti-VEGF] agents) in lower-middle-income countries., Patients and Methods: This was a retrospective interventional non-comparative case series. The study recruited patients who received 20 mg IVTA for treating various retinal and optic nerve diseases over the past 5 years. Main outcome measure was assessment of complications secondary to high-dose IVTA. The crosstabs procedure was used to display the interaction between the variables tested. The ANOVA test was used to analyze the differences among group means., Results: The study included 207 eyes of 168 patients. The main indication for high-dose IVTA were diabetic macular edema 64%, and macular edema secondary to retinal vein occlusion 19%. The mean follow-up period post-injection was 22 months. Mean number of injections was 1.3. Cataract developed in 54% of eyes. Glaucoma developed in 18.5% of eyes. Glaucoma surgery for intractable glaucoma attributed to high-dose IVTA was needed in 1% of eyes. Endophthalmitis and retinal detachment developed in one patient each., Conclusion: High-dose IVTA is a safe and cost-effective alternative to anti-VEGF agents. Cataract formation and intraocular pressure rise do not pose major adverse effects when weighed against the risk of vision loss due to inability to afford anti-VEGF treatment., Competing Interests: Disclosure The manuscript discusses the use of high-dose IVTA as alternative to anti-VEGF agents. Currently, high-dose IVTA is used as an off-label ocular therapeutic agent that is not approved by the US Food and Drug Administration. The authors report no conflicts of interest in this work.

Purpose: The aim of this study was to assess the efficacy of swept-source optical coherence tomography angiography (SS-OCTA) in delineating the morphology of choroidal neovascular membrane (CNV)., Patients and Methods: This was a retrospective observational case series reviewing clinical data and fundus fluorescein angiography (FFA), swept-source optical coherence tomography (SS-OCT), and SS-OCTA images of patients with CNV and comparing the findings. The swept-source technology enables deeper penetration and superior axial resolution. The incorporated blood flow detection algorithm, optical coherence tomography angiography ratio analysis (OCTARA), enables visualization of CNV in vivo without the need for dye injection., Results: The study included 136 eyes of 105 patients. Active lesions on SS-OCTA images showed increased capillary density, extensive arborization, vascular anastomosis and looping, and peri-lesional hollow. Inactive lesions showed decreased capillary density, presence of large linear vessels, and presence of feeder vessels supplying the CNV. We detected positive correlation between SS-OCTA, FFA, and SS-OCT images in 97% of eyes. In the remaining 3%, SS-OCTA confirmed the absence of CNV, whereas FFA and SS-OCT either were inconclusive in the diagnosis of CNV or yielded false-positive results., Conclusion: SS-OCT and SS-OCTA represent a reproducible risk-free analog for FFA in imaging CNV. SS-OCTA is particularly versatile in cases where FFA and SS-OCT are inconclusive., Competing Interests: Disclosure None of the authors have proprietary interest in any material used in this study. The authors report no other conflicts of interest in this work.

Purpose: We aimed to assess corneal biomechanics using the ocular response analyzer in patients with normal-tension glaucoma (NTG), and to evaluate the relationship between corneal biomechanics and visual field loss., Methods: This was a prospective observational case series including patients with bilateral asymmetric NTG. For all patients, corneal hysteresis (CH), corneal resistance factor (CRF), CH - CRF difference, and central corneal thickness values were matched against the mean deviation (MD) of the visual field and the cup/disc ratio. For paired-eye comparison in each patient, both eyes were categorized into a better-eyes group and a worse-eyes group according to lower and higher corneal-compensated intraocular pressure readings, respectively. Statistical analysis was carried out with the independent-samples Student's t-test, and the level of statistical significance was set at 0.05. Correlation was assessed using Pearson's correlation coefficient., Results: The study included 240 eyes of 120 patients. CH was inversely proportional to the MD in the visual field (P=0.01). CRF in both eyes was inversely proportional to the MD of the visual field (P=0.01). CH - CRF difference was directly proportional to the MD of the visual field (P=0.01). For paired-eye comparison, lower corneal-compensated intraocular pressure was associated with higher CH, higher CRF, smaller cup/disc ratio, and less deterioration of MD of visual field., Conclusion: CH, CRF, and CH - CRF are more powerful predictors of NTG progression than central corneal thickness.