Repair of progressive retinal detachment complicating degenerative retinoschisis: surgical management and outcomes in phakic eyes

Background Degenerative retinoschisis is a common condition defined by the splitting of the neurosensory retina that may rarely be associated with progressive retinal detachment (RD). Here, we aim to describe the anatomic and functional outcomes of surgical treatment of progressive symptomatic retinal detachment complicating degenerative retinoschisis (PSRDCR) using pars plana vitrectomy (PPV), scleral buckle (SB), or combined PPV/SB procedure. Methods A retrospective chart review of patients with PSRDCR between Jan 1, 2008 and Dec 31, 2019 was conducted. Data regarding demographics, surgical approach, and anatomic/functional outcomes were collected. Results Of the 4973 charts with RD repair during the study period, 36 eyes (0.7%) had retinoschisis with RD. 18 eyes met inclusion criteria (0.4%). The median age was 54 years (range 18–74) and all eyes were phakic. All eyes had outer layer breaks (OLBs) and 16 eyes (89%) had identifiable inner layer breaks. All OLBs were posterior to the equator in charts where position was recorded (16 eyes). The single surgery anatomic success (SSAS) and final anatomical success rates were 66% (12/18) and 100%, respectively. Eyes treated with PPV/SB had an SSAS rate of 75% (9/12), while PPV and SB had SSAS rates of 66% (2/3) and 33% (1/3), respectively. Conclusions PSRDCR is an exceedingly rare complication of degenerative retinoschisis associated with an SSAS rate lower than for uncomplicated rhegmatogenous RD. The majority of PSRDCR were repaired via combined PPV/SB in our study, and the rarity of this complication limits statistical support of an optimal surgical method in our and prior studies. The role of SB combined with PPV for PSRDCR requires further investigation.

Case series of clinical features in siblings with X-linked juvenile retinoschisis

X-linked juvenile retinochisis (XLRS) is a rare inherited bilateral vitreoretinal dystrophy which usually affects males early in life. We describe the clinical findings, outcome, and challenges in treatment of three siblings diagnosed with XLRS. Three siblings with ages ranging from 5 to 9 years old presented with reduced visual acuity (VA) and posterior segment showing varying degrees of vitreous veil and spoke-wheel maculopathy. Optical coherence tomography (OCT) of the macula was performed, revealing retinoschisis in all eyes. All three siblings were diagnosed with XLRS and were started on topical brinzolamide twice daily. OCT was repeated at 6 months and 18 months. At 18 months, three eyes showed stable VA and three eyes showed improved in VA. One out of the three eyes with stable VA showed improved retinoschisis while the other two eyes showed worsening retinoschisis. On the other hand, one out of the three eyes with improved VA had improved retinoschisis and the other two had worsening retinoschisis. We demonstrated that the VA of patients with retinoschisis is not directly proportional to the degree of splitting of the neurosensory retina. Retinoschisis treatment is challenging, as there is no one proven effective treatment up to date.

Combined approach to the treatment of choroidal neovascularization in patients with chronic central serous chorioretinopathy

Purpose. To evaluate the effectiveness of combined treatment of chronic central serous chorioretinopathy (CCSCRP) complicated by 1st type choroidal neovascularization (CNV), using subthreshold micropulse laser exposure (SMILV) on the retina and intravitreal administration of angiogenesis inhibitors (IAOAI). Material and methods. In the period from 2017 to 2019, 37 patients (20 men and 16 women) with monolateral chronic recurrent CCSCRP complicated with CNV 1st type, were observed at the Kaluga branch of the S. Fyodorov Eye Microsurgery Federal State Institution. The aged of patients were from 35 to 57 years. In the main group were included 22 patients (22 eyes). In the main group, the anti-VEGF drug was injected once at the initial stage of treatment. During the follow-up examination before the next injection, while the detachment of the neurosensory retina persisted, the patients were immediately transferred to the combination therapy (SMILV + IAOAI). 15 patients (15 eyes) were included in the control group, whose treatment was started with 5 loading doses of the anti-angiogenic drug with an interval of 4 weeks. Results. In the main group, the number of IAOAI varied from 5 to 8 (6.1 ± 0.8). After a single injection of an angiogenesis inhibitor, a positive result was achieved in 3 cases (14%). These patients were performed two additional IAOAI with an interval of 4 weeks, then the interval was increased to 8 weeks. 19 patients (86%) had the detachment of the neurosensory retina with a height of 135-252 µm (177±28.2 µm). SMILV followed by IAOAI was performed for these patients. During the year of observation, from 8 to 10 injections of the inhibitor (8.8 ± 0.77) were performed in the control group of the study. The positive effect after injections of the anti-VEGF drug for 5 months was achieved only in 6 cases (42%). Conclusion. The proposed combination of laser exposure followed by the administration of an angiogenesis inhibitor is effective and can be used as an alternative and safe treatment for 1st type choroidal neovascularization in patients with chronic cerebrovascular accident. Key words: choroidal neovascularization, chronic central serous chorioretinopathy, intravitreal administration of angiogenesis inhibitors, subthreshold micropulse laser exposure.

Prognostic factors affecting macular hole closure types

Purpose: In this study, we aimed to evaluate the relationship between macular hole closure types assessed by optical coherence tomography (OCT) and the preoperative prognostic factors. Materials and methods: In total, 183 patients who underwent pars plana vitrectomy and internal limiting membrane peeling for idiopathic macular hole between August 2014 and August 2019 were reviewed retrospectively. The preoperative measurements of the macular hole including minimum linear diameter (MLD), basal hole diameter (BHD) and hole height (HH) were measured on OCT images. The patients were divided into two closure types on the basis of postoperative OCT findings (type 1 closure: retinal edges were flat and there was no defect of the neurosensory retina on the fovea; type 2 closure: retinal edges were flat and there was a defect of the neurosensory retina on the fovea). The difference of prognostic factors such as age; duration of symptoms; preoperative best-corrected visual acuity (BCVA); preoperative macular hole measurements, including MLD, BHD and HH; and rate of reopening between two types were statistically analysed. Results: The mean age of patients was 66.33 ± 8.09 years (range: 48–88 years). According to OCT imaging, 117 eyes (63.9%) were classified into the type 1 closure group, and 66 eyes (36.1%) were classified into the type 2 closure group. There were no significant differences between two groups in age, duration of symptoms and preoperative BCVA ( p = 0.694, p = 0.092 and p = 0.15). MLD and BHD were significantly larger, and reopening was significantly more common in type 2 group ( p < 0.05, p = 0.04 and p < 0.005); however, there was no significant difference in HH between two groups ( p = 0.239). Conclusion: Preoperative horizontal measurements of macular hole may help to determine postoperative visual expectations and anatomical success, and predict the possibility of reopening.

Bilateral Central Serous Retinopathy in Patient with Chronic Kidney Disease on Haemodialysis: A Case Report

Central Serous Chorioretinopathy (CSCR) is the detachment of the neurosensory retina and/or Retinal Pigment Epithelium (RPE) due to accumulation of fluid in the sub retinal space, mostly confined to the macula. Hereby, presenting a rare case of a 32-year-old patient with defective vision in both eyes, she was a known case of Chronic Kidney Disease (CKD) on haemodialysis. On examination best corrected visual acuity was 6/9, on dilated fundus examination with ring reflex in both eyes, Optical Coherence Tomography (OCT) macula showed detachment of the neurosensory retina from RPE with the sub retinal fluid. This case is considered to be rare due to the unusual association noted between CSCR and End State Renal Disease (ESRD), in a female patient with no history of usage of corticosteroids or known identifiable risk factors. Hence, it is essential to screen patients with ESRD for CSCR to prevent vision threatening complications.

Artifact-Free Evaluation of Choriocapillaris Perfusion in Central Serous Chorioretinopathy

In this study, using optical coherence tomography angiography (OCTA) we evaluated choriocapillaris perfusion in eyes with central serous chorioretinopathy (CSC) after excluding all possible artifacts caused by alterations of neurosensory retina or retinal pigment epithelium (RPE). We have included 22 unilateral acute CSC patients (18 males and four females, 41.8 ± 5.7 years) and 18 healthy subjects (13 males and five females, 40.9 ± 9.7 years). The number of flow voids per 1 mm2 of scan area and percentage of flow signal area was calculated based on choriocapillaris slab of 3 × 3 mm2 OCTA scans after excluding all possible artifacts caused by alterations of neurosensory retina or RPE. The percentage of flow signal area after the exclusion of neurosensory retina and RPE alterations in the eyes of healthy individuals was higher than in CSC eyes (p = 0.006) and fellow unaffected eyes of CSC patients (p = 0.02). The number of flow voids larger than 25,000 µm2 in eyes of healthy individuals was lower than in the CSC eyes (p = 0.0006). There were no statistically significant differences in study parameters between CSC eyes and fellow eyes of CSC patients (p > 0.05). The general decrease of choriocapillaris perfusion in both eyes of CSC patients exists independently of the presence of acute disease or asymptomatic structural RPE changes.

Imaging Features of a Retinal Detachment and Secondary Epiretinal Membrane Following Inadvertent Globe Penetration From Peribulbar Anesthesia

Purpose: We present imaging features of retinal detachment (RD) and secondary epiretinal membrane in a case of an inadvertent globe penetration following preoperative peribulbar anesthesia. Methods: A 60-year-old woman was referred for a localized RD and epiretinal membrane following uneventful cataract surgery. Widefield fundus photography and optical coherence tomography were used to assess and record the pathology. The current literature was reviewed. Results: Full-thickness breaks were noted in the neurosensory retina extending into the scleral wall. Vertical tracks were noted in the inferotemporal quadrant of the eye. The patient underwent trans pars plana vitrectomy, membrane peel, and gas. Her 1-month postoperative visual acuity was 20/30. Conclusions: Globe penetration with RD is a rare but potentially sight-threatening complication of peribulbar anesthesia. Diagnosis can be challenging because of the infrequency of occurrence and delays in presentation. A high index of suspicion is key alongside consideration of other likely differentials.

Focal Choroidal Excavation in a Case of Choroidal Osteoma Associated with Choroidal Neovascularization

Purpose: To report a case of choroidal osteoma associated with reactivation of choroidal neovascularization (CNV) and development of focal choroidal excavation (FCE). Case Report: A 34-year-old woman with choroidal osteoma complicated by CNV in the right eye for two years presented with deterioration of visual acuity in her right eye. A small retinal hemorrhage accompanied by subretinal fluid (SRF) was seen in the macular area of the right eye. Optical coherence tomography (OCT) showed that the inner retina was intact, and the outer retinal layers had outward displacement. SRF and a wedge-shaped choroidal depression were also seen. This choroidal excavation was not present on previous OCT images. The integrity of the inner retinal layers was maintained, and an optically clear space was present between the neurosensory retina and the retinal pigment epithelium. Conclusion: Choroidal osteoma can be complicated by CNV and FCE could occur as a consequence. Again, FCE can lead to CNV development. This cascade can deteriorate vision and sometime lead to permanent visual loss.

Unilateral multiple serous retinal detachments secondary to non-Hodgkin’s lymphoma responsive to systemic steroids

Purpose: To describe a case of unilateral multiple bullous neurosensory retina detachments (NRDs) secondary to non-Hodgkin’s aggressive large B-cell lymphoma treated with chemotherapy and high doses of systemic steroids. Methods: A case report based on patient observation, clinical records, and retinal imaging during 2 years of follow-up. Results: A 26-year-old Hispanic man presented at our clinic with sudden unilateral visual loss and multiple NRDs in the left eye with increased choroidal thickness, 1 week after oral steroid treatment due to low back pain and fever. In the following days, a non-Hodgkin’s aggressive large B-cell lymphoma was diagnosed. The patient underwent three cycles of chemotherapy (CHT) with protocol R-CHOP21 (including oral prednisone) with complete resolution of NRD. During 2 years of follow-up, no recurrence of NRD occurred, despite the need to continue CHT with oral steroids for a year due to lymphoma relapse. Conclusion: Neurosensory retina detachments may be an initial manifestation of large B-cell lymphoma as a consequence of a pro-inflammatory state involving the chorioretinal structures, thus adding steroid treatment could be useful for its resolution.