Off the Cuff: The Importance of Stable Tears

This prospective interventional case series of 13 BRVO and 10 CRVO patients with persistent macular edema (>250μm) after at least five anti-VEGF injections evaluated the safety and efficacy of repeated intravitreal dexamethasone implant (Ozurdex) injections administered on an as-needed protocol for retinal vein occlusion patients with macular edema with poor or no response to anti- VEGF injections. Exclusion criteria included: baseline visual acuity worse than 1.5 logMAR, previous intravitreal implant, history of vitreoretinal surgery, manifest glaucoma or ocular hypertension, epiretinal membrane, retinal neovascularization, massive retinal or macular ischemia, vitreous hemorrhage or severe lens opacity, previous laser photocoagulation treatment.

Each patient received an initial intraocular dexamethasone implant, and the procedure was repeated at six months as needed. Patients were followed up at months two, four, six, eight, 10 and 12 with spectral-domain OCT and best-corrected visual acuity measurements. Exclusion criteria included: baseline visual acuity worse than 1.5 logMAR, previous intravitreal implant, history of vitreoretinal surgery, manifest glaucoma or ocular hypertension, epiretinal membrane, retinal neovascularization, retinal or macular ischemia, vitreous hemorrhage or severe lens opacity, previous laser photocoagulation treatment. Patients on topical or systemic corticosteroid therapy (during the last three months), and known steroid responders as well as diabetic patients were also excluded.

In the BRVO group, the mean CRT and BCVA significantly improved from 482.92 ±139.99μm (0.55 ±0.12 logMAR) at baseline, to 369.31 ±119.72 μm (0.43 ±0.18  logMAR) at six months. At 12 months CRT was 295.82 ± 135.48 μm and BCVA 0.29 ± 0.17  logMAR. Minimum CRT values were achieved at 3.45 months after the first injection, and 2.46 months after the second injection (197.00 ± 84.27 and 180.00 ± 76.89 μm respectively). Best BCVA values were achieved at a mean of 4 ± 0.853 months after the first injection, and four months after the second injection (0.219 ± 0.129 and 0.222 ± 0.078 logMAR respectively). In the CRVO group, neither the mean CRT nor BCVA improved significantly at six months: from 669.70 ± 203.20 μm (0.80 ± 0.231 logMAR) at baseline, to 586.20 ± 237.63 μm (0.740 ± 0.268 logMAR) at six months. At 12 months CRT was significantly improved: 549.90 ± 191.26 μm, but BCVA lacked significant improvement: 0.690 ± 0.285  logMAR. Minimum CRT values were achieved at a mean of two months after the first injection, and also two months after the second injection (261.60 ± 121.31 and 280.00 ± 177.43 μm respectively). Best BCVA values were achieved at a mean of two months after the first injection, and two months after the second injection and were 0.390 ± 0.173 and 0.385 ± 0.233 logMAR respectively. Cataract progression was a rare event (2/23 eyes), while transient steroid-induced ocular hypertension (5/23 eyes) was managed successfully with IOP-lowering medication.

Researchers wrote that dexamethasone implants should be considered as an effective and safe alternative in patients with BRVO and CRVO who have failed anti-VEGF therapy. They added that shortening the re-injection interval especially for CRVO cases should be considered.

Implantable collamer lenses (ICL) are phakic (natural lens remains in place) lenses that were first developed in the 1990s for correction of high myopia. The effectiveness and safety of ICLs are making them an increasingly popular option for vision correction in the myopic patient, competing with traditional options like glasses, contacts and procedures such as laser-assisted in situ keratomileusis. Although generally safe, due to the position of the phakic ICL in the eye, pupillary block remains a rare but vision-threatening complication of ICL implantation. Pupillary block caused by phakic ICL is a serious complication that requires urgent recognition and intervention and is poorly described in emergency medicine literature. Authors described a case of pupillary block five years after ICL implantation that was refractory to standard medical therapy, highlighting the importance of early diagnosis and referral for more definitive therapy.

A PubMed engine search was carried out using the terms "macular hole," "optical coherence tomography" and "optical coherence tomography angiography” to summarize the spectrum of optical coherence tomography (OCT) and OCT angiography (OCTA) features after full-thickness macular hole (MH) repair surgery. All reports published in English up to October 2018, irrespective of their publication status, were included. Tomographic signs analyzed were divided according to the involved portion of the retina in "inner retinal layers" and "external retinal layers." Despite predominantly involving the inner retinal layers, cystoid macular edema (CME) has been treated as a separate entity. A report on vessel density (VD) changes and the foveal avascular zone (FAZ) area modifications were included.

Different clinical findings could be observed on OCT of patients who underwent MH repair surgery. There was general consent that retinal thinning involving primarily the retinal nerve fiber layer and the ganglion cell layer took place after surgery. In the postoperative period, the outermost retinal layers got progressively restored. Persistent defects in the ellipsoid zone or in the external limiting membrane correlated with worse postoperative visual outcome. Researchers wrote that OCTA has globally demonstrated that eyes after MH closure show a reduction in macular and paramacular VD and smaller FAZ areas, compared with control or fellow eyes.

They wrote that clinicians should be aware of the most common tomographic findings to properly manage each condition. In addition, they added that significant advantages for the postoperative application of OCT and OCTA included non-invasiveness, rapid and simple execution, repeatability and precise measurements.