27-gauge PPV complication rates appear comparable to larger-gauge systems

MAR 16, 2018


This retrospective, multicenter case series examined the long-term visual outcomes of 27-gauge pars plana vitrectomy in patients with posterior segment disease.

Study design

The authors examined postoperative visual acuity and complications in 390 eyes that underwent vitrectomy with 27-gauge instrumentation. Cases involving multiple-gauge instrumentation or concurrent glaucoma or corneal surgery were excluded. Patients who underwent concurrent phacoemulsification were included in the study.


Overall logMAR visual acuity improved from 0.72 to 0.40 over an average follow-up period of 715 days (minimum follow-up of 365 days). Statistically significant visual improvements were noted in patients with epiretinal membrane, macular hole, vitreous hemorrhage, diabetic tractional detachment, retained lens material and endophthalmitis.

Transient postoperative hypotony occurred in 5.6% of eyes and was statistically associated with angled sclerotomy incisions or a history of vitrectomy.  Notable postoperative complications included ocular hypertension (10.8%), vitreous hemorrhage (7.9%), cystoid macular edema (3.6%), recurrent PVR detachment (1.5%), primary retinal detachment (0.78%) and endophthalmitis (0.26%).


The decision to use 27-gauge instrumentation was left to the surgeon’s discretion, so this study may have been biased toward less severe cases. Cases involving primary retinal detachment repair were relatively underrepresented in the dataset. The rates of postoperative vitreous hemorrhage (7.9%) and postoperative transient hypotony (5.6%) might be a little higher than expected. There was limited standardization of surgical technique between the surgeons.

Clinical significance

This series provides some support for the long-term effectiveness and safety of 27-gauge vitrectomy instrumentation by demonstrating a complication rate generally comparable to that of 23- and 25-gauge surgery. Wound construction in 27-gauge vitrectomy deserves further investigation.



Low-dose radiation for juxtapapillary choroidal melanoma shows promising outcomes and safety

MAR 14, 2018

Ocular Pathology/Oncology

This retrospective case series examined outcomes of patients undergoing iodine-125 plaque brachytherapy for juxtapapillary choroidal melanoma.

Study design

The analysis included 47 patients with juxtapapillary choroidal melanoma treated with iodine-125 notched brachytherapy at a single center. The cohort was divided into apex low-dose (≤84.35 Gy) and high-dose (>85.35 Gy) groups.

Main outcome measures were time to distant failure, local failure, death, enucleation, radiation retinopathy, optic neuropathy and best corrected visual acuity.


Low-dose iodine-125 plaque brachytherapy (67.5–81 Gy at tumor apex) provided distant failure, local failure, death and enucleation rates comparable with those observed in the high-dose group. The authors demonstrated that there are potentially superior outcomes in terms of reduced radiation retinopathy and optic neuropathy for lower dose brachytherapy.


Patients in this study were treated in 1 center and the results may not represent all institutions. The study was also limited by its retrospective nature and small sample size. Finally, the analysis was performed prior to routine fine needle aspiration biopsy for genetic profiling—thus, the authors were unable to examine the correlation between genetic mutations and patient outcomes.

Clinical significance

This was the first study to demonstrate that survival and tumor control are not compromised by low-dose brachytherapy. The low-dose group had similar 5-year tumor control rates as patients with juxtapapillary melanoma in the COMS (Collaborative Ocular Melanoma Study) trial.  A multi-institutional study would provide more insight into dose recommendations for juxtapapillary choroidal melanoma.


Atypical pituitary adenoma with orbital invasion


This study examines the clinical course of atypical pituitary adenoma with orbital invasion, a rare and aggressive condition that is often refractory to treatment.

Study design

The authors present a single case of pituitary adenoma invasion into the orbit, and review the disease course and treatment of this case combined with the 22 other cases reported to date.


Researchers describe the clinical features of a 31-year-old man who presented with biopsy-proven atypical pituitary adenoma invading the right orbit after a prior resection. The patient was treated with radiation, somatuline depot and temozolomide, but continued to experience recurrent tumor growth in the orbital cavity. Immunohistochemical staining of a biopsy specimen revealed high immunoreactivity. The patient experienced further vision loss, proptosis, ophthalmoplegia and cranial nerve palsies, consistent with an aggressive, refractory intracranial neoplasm.

Among the 22 additional cases of pituitary adenomas with orbital involvement reported thus far in the literature, half have been female and patient age has ranged from 8 to 85 years, with an average age of 33 years. The most common presenting symptom was headache, whereas progressive vision loss, symptomatic proptosis, diplopia, facial swelling, weight loss and vomiting were also reported. Presenting signs have included third nerve palsy, ptosis, proptosis, afferent pupillary defect, optic disk pallor, anisocoria, optic disk edema, bitemporal hemianopia and sixth nerve palsy. Before presenting with orbital invasion, 4 cases reported previous surgical interventions that included resection of pituitary adenoma. However, many other case reports did not indicate whether the patient underwent prior surgery. With respect to adenoma subtype, 6 of the 22 cases were prolactin secreting, 4 were ACTH secreting, 2 were GH secreting, 1 was TSH secreting, 4 were nonfunctional and 5 were unspecified.


This is a single case report with a review of the literature, which limits the conclusions that can be drawn.

Clinical significance

Atypical or aggressive pituitary adenomas with orbital invasion are uncommon but may result in serious ophthalmic deficits and system complications. Early diagnosis and management are key to reducing morbidity. This diagnosis should be considered in a patient with previous pituitary pathology, who presents with acute or progressive ocular dysfunction. Treatment and management depends on tumor subtype and histopathology indicative of aggressive behavior and increased risk of recurrence. Optimal management is not clearly defined, but surgical and medical intervention with or without adjuvant radiotherapy is the current practice.


Alert: Regeneron halts distribution of Eylea kits with affected syringes

MAR 12, 2018

By Keng Jin Lee

Regeneron Pharmaceuticals, Inc.


A recent spike in cases of intraocular inflammation among patients receiving aflibercept (Eylea) appear linked with specific batches of syringes, according to Regeneron Pharmaceuticals.

The increase in safety reports related to intraocular inflammation was first noted by the American Society of Retina Specialists (ASRS) in October 2017, and first reported by Bloomberg last month.

In a letter to healthcare providers dated February 28, Regeneron said they conducted an extensive review of manufacturing and distribution processes. The review did not find any association with the anti-VEGF drug itself, but an association was seen with certain batches of the syringe that were included in the following lots of final packaged EYLEA kits:


While it’s not issuing a formal recall, Regeneron has ceased distributing the affected kits out of an abundance of caution and recommends that practitioners not use the included syringes. Kits from these lots can be exchanged by calling 1-855-395-3248.

The letter also noted that Regeneron had communicated their findings and action plan to the U.S. Food and Drug Administration (FDA) and the American Society of Retina Specialists (ASRS). They plan to report their findings in greater detail at an upcoming scientific meeting.


Artificial photoreceptors restore vision to blind mice

Chinese researchers have unveiled a new class of retinal prosthesis that relies on nanotechnology to restore the light response. Unlike other subretinal prostheses, the new device—an array of gold-flecked nanowires—replaces damaged photoreceptors and interfaces directly with neurons, averting the need for additional electronic hardware.

If the findings hold up in humans, the device could potentially aid people with degenerative eye conditions such as retinitis pigmentosa or macular degeneration. The approach might also prove useful for reversing vision loss from nondegenerative conditions, such as trauma or retinal detachment.

“The authors have taken a novel approach to fixing a problem that affects the vision of tens of millions of people worldwide,” says Sunir Garg, MD, co-director of the retina research unit at Wills Eye Hospital and Editor-in-Chief of Retina Times.

One existing retinal prosthesis, the Argus II (Second Sight), relies on glasses with a built-in video camera to transmit information to an implanted chip. Another device, the Retina Implant Alpha AMS (Retina Implant AG) simulates photoreceptors from its position under the retina, but requires an external battery pack. Last year, researchers edged closer to a fully implantable prosthesis, constructed from light-sensitive polymers, but it was unclear how well that device interfaced with the retina.

The new prosthesis was tested in a mouse model of degenerative blindness, researchers reported March 9 in Nature Communications. The artificial photoreceptors respond to green, blue and near-ultraviolet light with an “impressive” spatial resolution of 50 microns, says Jennifer Lim, MD, director of the retina service at  the Eye and Ear Infirmary at the University of Illinois in Chicago.

“This is precisely what is lacking in current approaches: replacing defunct photoreceptors with artificial ones that can use the electrical wiring inherent in the retina,” says Dr. Lim, who is leading the UIC surgical team in a phase 4 trial of the Argus II. “These scientists have succeeded in engineering a nanoparticle photoreceptor that appears to be able to relay signals to the ganglion cells in blind mice, which then have cortical responses to light.”


a) Location of implant; b) side-by-side comparison showing location of the implanted nanowire (NW) array.

Both Drs. Garg and Lim agree that more work is needed to determine if the device will work in humans, and whether it can replace photoreceptors damaged by either degenerative diseases or trauma.  

“However, I believe it is an elegant method and engineering triumph that hopefully will be able to truly replace the defective photoreceptors in patients blind from photoreceptor disease,” Dr. Lim says.


Current criteria for diagnosing ocular sarcoidosis appear insufficient


This multicenter retrospective study explored clinical features that distinguish ocular sarcoidosis from other forms of uveitis. The authors also estimated the sensitivity and specificity of the International Workshop on Ocular Sarcoidosis (IWOS) guidelines for characterizing uveitis patients suspected of having sarcoidosis.

Study design

Medical records from 884 uveitis patients from 19 centers in 12 countries were included in the final analysis. Of these, 167 had sarcoidosis that was confirmed from a positive biopsy or from evidence of bilateral hilar lymphadenopathy (BHL) on chest radiograph or CT scan.


Among sarcoidosis cases, the most common clinical findings were bilateral disease (86%), snowballs or string of pearls (50%), mutton-fat keratic precipitates, iris nodules or both (46%) and chorioretinal peripheral lesions (37%). As expected, chest x-ray, angiotensin converting enzyme (ACE) levels and lysozyme levels were neither sensitive nor specific.

The authors compared their findings to the IWOS diagnostic criteria and found that 97 of 167 (37%) patients suspected of having sarcoidosis did not meet the IWOS criteria.


Although this study was retrospective, the authors attempted to overcome this limitation with a large uveitis control group. The study was also inadequately powered to evaluate differences between populations.

Clinical significance

This study reminds us not to rely on chest x-ray and lysozyme and ACE levels to rule out sarcoidosis. Even CT of the chest is not always positive in biopsy-proven sarcoidosis.

It is important to note that the IWOS criteria were strongly influenced by features described in East Asian patients, so it is unsurprising that the IWOS was somewhat lacking in this study with a diverse cohort. The findings here remind us that the diagnosing ocular sarcoidosis depends on a cluster of findings. Despite some drawbacks, the IWOS guidelines do recognize the need to assess a variety of clinical signs and laboratory findings. Diagnostic criteria are notoriously difficult to devise, and are often designed for consistency in reporting research than necessarily applying to the patient in your chair. With no definitive diagnostic test for ocular sarcoidosis, we await more advanced techniques, such as latent class analysis or machine learning, which may lead to a more generalizable classification system.


SightLife Surgical acquires Kamra inlay

MAR 09, 2018

By Keng Jin Lee

SightLife Surgical

Cataract/Anterior Segment, Refractive Mgmt/Intervention

AcuFocus will sell the Kamra technology to Seattle-based SightLife Surgical, according to a press release on the company’s website.

Approved by the FDA in April 2015, the Kamra inlay is the first device for surgical correction of presbyopia. The ultra-thin, opaque, donut-shaped implant creates a small-aperture effect that provides an extended depth of focus in presbyopic patients who have not had cataract surgery

Dr. Minoru Tomita, who has performed more than 6,000 Kamra procedures in Japan, discusses the advantages of the inlay in this interview from AAO 2016.

“The Kamra inlay is a minimally invasive solution for a greatly underserved and growing segment of the population,” said Richard L. Lindstrom, MD, a surgeon at Minnesota Eye Consultants and board member for both AcuFocus and SightLife Surgical. “I’m excited about the progress achieved today and the strong corneal focus of the SightLife Surgical team moving forward. I believe the KAMRA inlay will have a bright future and will be an increasingly utilized solution for presbyopia correction.”

AcuFocus president and chief operating officer Al Waterhouse said the acquisition would allow the company to focus on bringing their IC-8 small aperture IOL to U.S. markets. The IC-8 is designed to treat presbyopic patients with cataracts, and has already received the European CE Mark approval.

The terms of the acquisition were not disclosed. The deal is expected to close at the end of this month.