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Lorenzo Iuliano,1 Giovanni Fogliato,1 Francesca Gorgoni,2 Eleonora Corbelli,1 Francesco Bandello,1 Marco Codenotti11Ospedale San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy; 2Ospedali Riuniti di Ancona, Università Politecnica Delle Marche, Ancona, ItalyAbstract: This review aims to give to the reader an overview selectively oriented on safety and efficacy of surgery, providing concise and direct answers about crucial questions of trainees and experts. Surgery for idiopathic epiretinal membrane (ERM) is a safe and effective procedure that can achieve long-term stable postoperative visual and anatomical improvement, with an overall low recurrence and complication rate. Young patients, with a short onset of symptoms and with better initial visual acuity achieve higher levels of visual outcome. The preoperative degree of metamorphopsia is the prognostic factor for their postoperative degree. Successful results may be obtained in eyes with specific optical coherence tomography criteria, such as thin ganglion cell layers, thin internal plexiform layer, longer photoreceptors outer segment, regular ellipsoid zone and cone outer segment tips line, and without ectopic inner foveal layer. Internal limiting membrane peeling demonstrates positive anatomical and functional outcomes, but final positions about its safety remain controversial.Keywords: idiopathic epiretinal membrane, outcome, safety, efficacy, prognostic factor

PurposeTo evaluate the effects of intravitreal autologous plasmin enzyme (APE) in patients with focal vitreomacular traction (VMT).MethodsAPE was obtained by incubation of patient-derived purified plasminogen with streptokinase, and intravitreally injected 5-12 days later. Twenty-four hours after injection, in case of incomplete VMT release, a pars plana vitrectomy was performed. The hyaloid internal limiting membrane adherence and removal of the posterior hyaloid were intraoperatively evaluated.ResultsThirteen patients were recruited. During preparation of APE, five patients had spontaneous release of VMT. Eight patients received APE injection (2 IU). In five patients, spontaneous resolution of VMT occurred before APE administration. Twenty-four hours after injection, persistence of VMT was detected in all the eight treated patients. Best-corrected visual acuity was 0.51±0.37 LogMAR at baseline, improving to 0.23±0.14 LogMAR at 6 months (P=0.002). Foveal thickness was 464±180 μm at baseline, reducing to 246±59 μm at 6 months (P<0.001). Hyaloid was intraoperatively judged 'partially detached' in seven cases and 'totally detached' in one case. Hyaloid peeling was evaluated 'easy' in six eyes and 'very easy' in two eyes.ConclusionsIn the current study, there was a large percentage of spontaneous resolution of VMT before an APE administration. A single intravitreal APE injection seems insufficient to induce a complete posterior vitreous detachment in these patients. [ABSTRACT FROM AUTHOR]

Introduction/Background: Detection of peripheral retinal lesions is crucial in patients at risk of developing rhegmatogenous retinal detachment. We investigated the capability of California ultra-widefield (200°) retinography (Optos, Dunfermline, UK) to detect peripheral lesions, in comparison with indirect fundus biomicroscopy. Methods: Prospective study of 40 consecutive eyes with peripheral retinal lesions referred to our Vitreoretinal Service, at IRCCS Ospedale San Raffaele in Milan, from September to November 2015. Each patient underwent indirect biomicroscopy by two independent retinal specialists (observers 1 and 2), and ultra- widefield retinography evaluated by two other retinal specialists (readers 3 and 4). For each eye number, type and localization of lesions were reported. A comparison of collected data was performed between observers (1 vs. 2) and between readers (3 vs. 4) and between observers and readers (1 & 2 vs. 3 & 4). Results: Forty eyes of twenty patients were analyzed. Observer 1 reported a total of 126 lesions in 40 eyes (mean 3.15): 53 givres, 26 white without pressure (WWPs), 20 lattice degenerations (LDs), 14 retinal holes (RHs) and 13 retinal tears (RTs). Observer 2 reported 118 lesions (mean 2.95): 50 givres, 23 WWPs, 19 LDs, 13 RHs and 13 RTs. Reader 3 reported 115 lesions (mean 2.87): 51 givres, 20 WWPs, 18 LDs, 13 RHs and 13 RTs. Reader 4 reported 114 lesions (mean 2.85): 50 givres, 20 WWPs, 18 LDs, 13 RHs and 13 RTs. No type and localization differences were reported among specialists. About the number of lesions, the comparison between indirect fundus biomicroscopy observers (1 vs. 2) and between ultra- widefield retinography readers (3 vs. 4) revealed good accordance. No significant difference was reported between observers (1 & 2) vs. readers (3 & 4) (P > 0.05). Conclusions: Our results suggest good reproducibility of both the techniques and non-inferiority of California ultra-widefield (200°) retinography compared with traditional fundus examination in detecting peripheral retinal lesions. Acknowledgements: None. [ABSTRACT FROM AUTHOR]

Purpose: To assess the rate of occurrence and the risk factors of postsurgical macular edema (PSME) in eyes with idiopathic epiretinal membrane (iERM) or full-thickness macular hole (FTMH)., Methods: Retrospective longitudinal analysis of all subjects scheduled for vitrectomy with or without combined cataract surgery over a 6-month period. Electronic medical charts and imaging data were analyzed preoperatively and at 1, 3 and 6 months after surgery., Results: From 101 patients diagnosed with iERM or FTMH, 71 patients were eligible for the study. Forty-nine eyes with iERM (69.0%) and 22 eyes with FTMH (31.0%) underwent vitrectomy either isolated (31.0%) or combined with cataract extraction (69.0%). The overall rate of PSME was 26.7%, without differences between the two groups (P = 0.9479). Combined cataract extraction did not affect the overall occurrence of PSME rate in both groups (P = 0.9255 in FTMH and P = 0.8658 in iERM). If grouped by stage, eyes with stage 4 iERM though disclosed an increased rate of PSME (57.1%) compared to lower (1 to 3) stages (14.3%, P = 0.0021), particularly when combined with cataract surgery (71.4% vs. 15.4% in stages ≤ 3, P = 0.0021). The PSME odds ratio for a stage 4 iERM is 8 (95% CI: 1.933-33.1; P = 0.0041) compared to stages 3 and below., Conclusions: PSME remains a clinically relevant and frequent event after surgery for iERM and FTMH. Patients with stage 4 iERM have an 8-fold higher likelihood of developing PSME in a 6-month postsurgical period compared to iERM in 1-3 stages, especially when combined with cataract extraction., (© 2021. The Author(s).)

Introduction: To investigate choroidal thickness changes related to the clinical activity of inflammatory choroidal neovascularization in punctate inner choroidopathy/multifocal choroiditis as compared to myopic choroidal neovascularization., Materials and Methods: Consecutive inflammatory choroidal neovascularization secondary to punctate inner choroidopathy/multifocal choroiditis, and myopic choroidal neovascularization were retrospectively reviewed. By means of enhanced-depth imaging optical coherence tomography, choroidal thickness was assessed at the same location before choroidal neovascularization development, at choroidal neovascularization onset (baseline), and after treatment., Results: Eleven eyes with inflammatory choroidal neovascularization and 11 eyes with myopic choroidal neovascularization were analyzed. Choroidal thickness beneath inflammatory choroidal neovascularization significantly increased at baseline and decreased after therapy ("Sponge sign"), reaching preclinical values. In particular, mean choroidal thickness under inflammatory choroidal neovascularization was 145 ± 85 µm at the preclinical stage, increased to 210 ± 103 µm at baseline (p = 0.006), and decreased to 136 ± 87 µm after treatment (p = 0.017). Conversely, no significant choroidal thickness changes were disclosed in myopic choroidal neovascularization eyes, under any location., Conclusion: Optical coherence tomography-based choroidal thickness evaluation may represent an additional useful tool to monitor inflammatory choroidal neovascularization activity. Moreover, choroidal thickness under choroidal neovascularizations could be used to discriminate the origin of choroidal neovascular membrane, either inflammatory or myopic, in doubtful cases and guide the therapeutic management.

Purpose: To describe the use of silicone oil (SO) in combination with subretinal recombinant tissue plasminogen activator (rtPA) to achieve dislocation of large subretinal hemorrhage secondary to exudative age-related macular degeneration (AMD)., Methods: A single-eye 81-year-old woman, known for exudative AMD, presented for a profound vision loss in her left eye since 7 days due to a massive subretinal hemorrhage. She promptly underwent standard three-port pars plana vitrectomy with subretinal injection of rtPA and SO tamponade., Results: The surgical technique showed favorable anatomical and functional outcomes, achieving a substantial peripheral displacement of blood and visual improvement., Conclusion: This report favorably supports the use of SO in adjunction to subretinal rtPA in selected cases of subretinal hemorrhage secondary to wet AMD.

Purpose: To characterize the imaging features of blind patients with end-stage inherited retinal degeneration (IRD) and to assess possible morpho-functional correlations., Methods: In this observational cross-sectional study, we reviewed the clinical data and multimodal imaging of 40 eyes of 21 blind (light perception or less) institutional patients affected by end-stage IRD screened for Alpha AMS (Retina Implant AG, Reutlingen, Germany) retinal prosthesis eligibility. Analysis was carried out using spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography and fundus autofluorescence., Results: Among patients with IRD-related low vision, the extrapolated prevalence of the blind was roughly 10%, median age 60.4 years with a disease duration of 40.4 years, showing epiretinal membranes (80%), hyperreflective intraretinal nodules (90%) and the absence of the ellipsoid zone (77.5%) on SD-OCT examination. Cystoid macular oedema was present in 52.5% of eyes, the majority of which being of the microcystoid subtype (42.5%), while 37.5% of eyes also lacked outer and inner retinal layer segmentation. Disease duration was found to be predictive of disrupted retinal layers (P = 0.029) and microcystoid macular oedema (P = 0.035), which was also more frequent in eyes without light perception (P = 0.013)., Conclusions: Eyes without vision due to end-stage IRD have a typical imaging pattern, predominantly characterized by epiretinal membranes, hyperreflective intraretinal nodules and the absence of the ellipsoid zone. Furthermore, microcystoid macular oedema and retinal layer disruption may be considered as signs of longstanding disease.

Background and Objective: To systematically compare the intermodality and inter-rater agreement for indirect ophthalmoscopy and ultra-widefield (UWF) imaging in detecting peripheral retinal lesions predisposing to retinal rhegmatogenous detachment., Patients and Methods: In this prospective, observational, cross-sectional study, patients with a previous diagnosis of peripheral retinal lesions were enrolled. UWF pseudocolor imaging and dilated fundus examination were obtained., Results: Thirty-seven eyes (20 patients, 12 females) were enrolled. The level of inter-rater agreement was excellent in both the ophthalmoscopy-based and UWF-based assessment. The overall agreement in the UWF-based assessment was found to be Kappa = 0.874 (P < .0001). The UWF-based evaluation was demonstrated to have a sensitivity of 89.2% in detecting peripheral retinal lesions. In the sectorial analysis, the UWF-based reading had a lower sensitivity in the inferior sector., Conclusion: The identification of peripheral retinal lesions with UWF imaging allowed for an accurate and reproducible assessment. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:544-549.]., (Copyright 2019, SLACK Incorporated.)

Background: To investigate, using optical coherence tomography angiography (OCT-A), changes in perfusion density and in the foveal avascular zone (FAZ) in eyes with idiopathic vitreomacular traction (VMT) after ocriplasmin injection., Methods: In this pilot study, we enrolled sixteen VMT eyes treated with intravitreal ocriplasmin injection. Sixteen healthy eyes were considered as controls. Macular perfusion density in 3 plexuses [superficial capillary plexus (SCP), deep capillary plexus (DCP), choriocapillaris (CC)] was calculated at baseline and at 1 month after injection., Results: After injection, VMT anatomically resolved in 9 eyes (56.2%), whereas 7 eyes (43.8%) achieved an incomplete VMT separation. Superficial capillary plexus perfusion density was reduced significantly after injection (from 0.427 ± 0.027 to 0.413 ± 0.028; p = 0.0146), while no differences were noted in the DCP (p = 0.2717) nor in the CC (p = 0.6848). Study-eye perfusion density was statistically similar to control eyes in all three plexuses, both at baseline and at follow-up. The FAZ in the SCP area remained unchanged after injection (p = 0.168) but was significantly inferior to controls both at baseline and at 1 month (0.198 ± 0.074 vs. 0.196 ± 0.070; p = 0.007)., Conclusions: Eyes with VMT have a perfusion density comparable to healthy controls, but a smaller FAZ. After ocriplasmin injection the perfusion density in the SCP is reduced, regardless the anatomical success. Limited by the small sample size and the pilot nature of the study, we found microvascular changes after ocriplasmin injection, which may be due to retinal traction release.

Purpose : To describe clinical features and outcome in bilateral acute retinal necrosis (BARN). Methods : Observational retrospective longitudinal review of ocular findings. Results : Thirty eyes of 15 patients (age 44.1 ± 15.8). Delay of involvement between eyes was 57.2 ± 105.2 months (median 3, range 0.5-360). Herpes simplex virus (HSV)-1 was the most frequent (20 eyes, 66.6%), followed by HSV-2 (five eyes, 16.7%) and varicella zoster virus (VZV, four eyes, 13.3%). Visual acuity worsened in 7 (23%) eyes, improved in 4 (13%), and remained stable in 19 (63%). Major complications included retinal detachment (11 eyes, 36%), optic atrophy (11 eyes, 33%), proliferative vitreoretinopathy (four eyes, 13.3%), neovascular glaucoma (four eyes, 13.3%), phthisis bulbi (three eyes, 10%). Symptoms-to-referral average time was 2.7 ± 1.0 weeks (range 1-4). Conclusions : In our study BARN was associated with severe visual outcome and high rate of ocular complications. Although BARN is a rare disease, the course is aggressive, regardless prompt referral in tertiary-care uveitis centers.

Purpose: To describe vitreal, retinal, and choroidal features of eyes affected by Endogenous candida endophthalmitis (ECE) analyzed by spectral domain optical coherence tomography (SD-OCT) and to evaluate their clinical impact., Methods: Medical records and SD-OCT images from eyes diagnosed with ECE at four retina and uveitis tertiary referral centers were retrospectively evaluated. Spectral domain optical coherence tomography images were analyzed to evaluate the structural changes occurring in the vitreous, the retina, and the choroid in areas involved by ECE. Baseline and final best-corrected visual acuity were correlated with SD-OCT findings., Results: Fifteen eyes from nine patients were enrolled. Vitreous involvement (vitreous cells, posterior hyaloid thickening) was detected in 13/15 eyes. Peculiar hyper-reflective preretinal aggregates obscuring the underlying retina because of a shadowing effect ("rain-cloud" sign) were noticed in all eyes with vitreous involvement. Two patterns of retinal and choroidal findings were identified: the first (six eyes) confined within the inner retinal layers (Intraretinal Pattern), the second (nine eyes) involving both retina (full thickness) and choriocapillaris (Chorioretinal Pattern). None of the eyes showed both patterns. None of the eyes, regardless the pattern, showed choroidal thickening. Baseline best-corrected visual acuity was not associated with OCT pattern (P = 0.09). On the contrary, final best-corrected visual acuity was significantly higher in patients showing Intraretinal Pattern (∼20/25, 0.06 ± 0.08 LogMAR) than in subjects with Chorioretinal Pattern (∼20/50, 0.44 ± 0.30 LogMAR) (P = 0.01)., Conclusion: Endogenous candida endophthalmitis showed peculiar features on SD-OCT. Two distinct patterns of chorioretinal involvement influencing the final best-corrected visual acuity were identified. Spectral domain optical coherence tomography could be useful in the diagnosis, management, and outcome prediction in ECE.

Purpose: To investigate, using the Dynamic Vessel Analyzer (DVA), the retinal vascular changes that may occur after vitrectomy for idiopathic epiretinal membrane (ERM)., Methods: Twenty-six eyes of 13 patients affected by unilateral idiopathic ERM were prospectively analyzed. 13 fellow eyes were used as control. The static (central retinal artery and vein equivalents) and dynamic (after flicker light stimulus) DVA analysis was performed at baseline (1 day before surgery) and 6 months after vitrectomy., Results: The static DVA analysis did not highlight any significant change between investigational eyes and controls at baseline and 6 months after surgery. The DVA dynamic analysis showed similar arterial flicker response between cases and controls at baseline (p = 0.3396), but disclosed a significant reduction of the arterial flicker response after surgery in the study eyes compared to fellow eyes (p = 0.0024). No significant changes were appreciated in the venous flicker response after surgery between cases and controls, both at baseline (p = 0.3450) and at the follow-up examination (p = 0.4214)., Conclusions: The physiological flicker-induced vasoconstriction is reduced after vitrectomy in arteries. The oxygen saturation change occurring after vitrectomy might have a role in the vascular tone modification.

Purpose: To evaluate the dynamic and static retinal vascular functionality in young females using combined hormonal contraceptive (CHC)., Methods: Thirty-eight consecutive young female subjects were enrolled in this study between January 2015 and December 2015. Subjects were divided in two groups: CHC group, defined as CHC use for ≥6 months, and control group, defined as no current and prior CHC use. Participants underwent a dynamic and static retinal vessel analysis using the Dynamic Vessel Analyzer (DVA, Imedos, Jena, Germany)., Results: Seventeen subjects continuously took CHC for 54.6 ± 29.3 months, while 21 subjects belonged to control group. No difference was found between the CHC and control groups for age (p = 0.1), smoking status (p = 0.6), and systolic (p = 0.3) and diastolic (p = 0.1) blood pressure. With regard to dynamic analysis, women taking CHC exhibited a marked significant vasoconstriction following flicker stimulation in comparison with control group (-2.43 ± 2.5 vs 0.63 ± 2.1, respectively; p = 0.0002). No significant difference was observed between groups for mean arterial (p = 0.2) and venous dilatations (p = 0.3), arteriovenous ratio (p = 0.09), central retinal artery equivalent (p = 0.4), and central retinal venous equivalent (p = 0.5)., Conclusions: CHC may affect vessel reactivity to flicker light by increasing arteries constriction. This may reflect systemic changes in vascular functionality in subjects using CHC. Moreover, CHC should be considered as a confounding bias in studies involving DVA.

Purpose: To analyze the course of eyes with vitreomacular traction (VMT), and to find by optical coherence tomography (OCT) possible correlations between vitreomacular interface area changes and the chance of spontaneous VMT resolution., Methods: Retrospective analysis of all consecutive patients presenting with VMT over a 24-month period. We introduced a novel OCT evaluation model to assess the vitreomacular interface area. Central foveal thickness (CFT) and best-corrected visual acuity (BCVA) were also analyzed throughout follow-up., Results: Twenty-six eyes of 18 symptomatic patients were followed for 12.9 ± 4.8 months. Eyes were subdivided into groups according to their clinical course. Six eyes (23%) had a spontaneous resolution of the VMT (group A), and the interface area before its occurrence (39565 ± 26409 μm(2)) was smaller than at study entry (99434 ± 38819 μm(2); p = 0.03). The interface area did not significantly change throughout follow-up in the group that underwent surgery (group B, 11 eyes) and in the group that remained overall stable (group C, 9 eyes). At baseline, the interface area was smaller in group A compared to groups with non-resolved VMT (mean values of group B and C together) (785095 ± 920721 μm(2); p = 0.002). CFT and BCVA did not significantly change in any of the studied groups. Vitreomacular interface area of 101002 μm(2) was identified as the threshold value separating the spontaneous VMT resolution group from the group with non-resolved VMT (p < 0.001)., Conclusions: The more the vitreomacular interface area reduced over time, the higher was the chance of spontaneous VMT resolution. An area below 101002 μm(2) was the threshold value indicating a higher chance of spontaneous release of VMT.

We report a case of Terson syndrome, providing the first intrasurgical imaging of subinternal limiting membrane blood diffusion in Terson syndrome. We highlight some remarkable in vivo anatomical findings that may give a contribution to the debate about its pathogenesis. Here we hypothesize that the subretinal space might be unlikely to be a primary source of intraocular hemorrhage, and we support the two generally accepted theories about blood diffusion from the retinal vasculature or from the perivascular spaces.

Purpose: We describe the worldwide epidemiology of uveitis through a systematic literature review.
, Methods: Data obtained from the most relevant studies published until November 2012 were reported.
, Results: Results of our research were structured in sections about the epidemiology of uveitis by anatomical location of inflammation (anterior, intermediate, posterior, and panuveitis), type of inflammation (infectious and noninfectious), and by age (children and elderly). Difficulties encountered analyzing the different epidemiologic studies were discussed in a dedicated section.
, Conclusions: Limited information is available regarding the epidemiology of uveitis. Worldwide epidemiologic studies may help the clinician in the management of patients with inflammatory ocular diseases, enabling the comparison of different uveitis entities.

Unlabelled: PURPOSE. To report a case of scleral dislocation mimicking glaucoma progression., Methods: Interventional case report., Results: A 71-year-old man was referred for glaucoma surgery in his right eye because of perimetry defect progression and uncontrolled intraocular pressure despite maximal medical therapy. A scleral buckling procedure in his right eye was previously performed for rhegmatogenous retinal detachment. At the time of presentation, a visible protruded sponge buckle element was noted at ocular inspection, without any sign of infection. The buckle element was posteriorly in contact with the optic nerve and anteriorly protruding under intact conjunctiva. We eventually managed for its removal via upper eyelid orbitotomy. Visual field lesions were unchanged on every follow-up visit., Conclusions: This case report describes severe permanent optic nerve damage due to previous misdiagnosis of a rare complication of scleral buckling surgery. Our surgical solution appears to be a safe and successful approach for this ocular disorder, also able to stabilize visual function and interrupt disease progression.

Purpose: To investigate the relationship between type of intraocular tamponade and unintentional retinal displacement after vitrectomy for rhegmatogenous retinal detachment., Methods: Twenty-three eyes of 23 consecutive patients affected by rhegmatogenous retinal detachment underwent 3-port pars plana vitrectomy with gas (C3F8) or silicone oil (polydimethylsiloxane) tamponade. Ophthalmologic examination and fundus autofluorescence were performed before surgery (baseline) and at the 7-day, 1-month, and 3-month postoperative visits. Macula sparing rhegmatogenous retinal detachment underwent fixation test (with microperimetry) at baseline and at the 7-day and 1-month follow-up examinations., Results: Fundus autofluorescence revealed postoperative retinal displacement in 12 of the 23 eyes (52.2%). Occurrence of retinal displacement was higher in eyes with gas tamponade (10 of 14 eyes; 71.4%) compared with eyes with silicone oil (2 of 9 eyes; 22.2%) (P = 0.036). Retina shifted downward in all eyes with C3F8 and upward in all eyes with polydimethylsiloxane. Baseline and follow-up macular fixation was tested in 10 macula-on cases. In all cases, a shift of mean fixation point was present at the 7-day postoperative examination, with a partial return toward the baseline mean fixation point at the 1-month follow-up examination., Conclusion: In eyes with rhegmatogenous retinal detachment treated with vitrectomy and gas or silicone oil tamponade, retinal displacement may occur despite successful reattachment. Type of intraocular tamponade seems to influence the occurrence of retinal dislocation and its direction.

The vitreous is involved in multiple diseases when an incomplete posterior vitreous detachment (PVD) occurs. An incomplete PVD can lead to several pathological conditions. Such visually threatening conditions are traditionally of exclusive surgical interest. In contrast, pharmacological vitreolysis is the effort to reduce or eliminate the pathogenetic role of the vitreous solely by means of drug delivery. Here we aim to review and summarize the evidence available to date about this challenging new approach., (© 2013 S. Karger AG, Basel.)