Publications by authors named "Jean Pierre Hubschman"

107 Publications

Clinical update on metamorphopsia: epidemiology, diagnosis and imaging.

Curr Eye Res 2021 Apr 7. Epub 2021 Apr 7.

NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom.

Purpose: To discuss the pathophysiology of metamorphopsia, its characterisation using retinal imaging and methods of assessment of patient symptoms and visual function.

Methods: A literature search of electronic databases was performedResults: Metamorphopsia has commonly been associated with vitreomacular interface disorders (such as epiretinal membrane) and has also regularly been noted in diseases of the retina and choroid, particularly age-related macular degeneration and central serous chorioretinopathy. Developments in optical coherence tomography retinal imaging have enabled improved imaging of the foveal microstructure and have led to the localisation of the pathophysiology of metamorphopsia within the retinal layers of the macula. Alteration of alignment of inner and outer retinal layers at various retinal loci has been identified using multimodal imaging in patients with metamorphopsia in a range of conditions. Although the Amsler Grid assessment of metamorphopsia is a useful clinical indicator, new emerging methods of metamorphopsia assessment with psychophysical tests such as M-CHARTS and preferential hyperacuity perimetry, have been developed.

Conclusions: It appears that there is a complex relationship between visual acuity and metamorphopsia symptoms that vary between retinal conditions. Although metamorphopsia has traditionally been challenging to measure in the clinic, advances in technology promise more robust, easy-to-use tests. It is possible that home assessment of metamorphopsia, particularly in conditions such as age-related macular degeneration, may help to guide the need for further clinic evaluation and consideration of treatment.
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http://dx.doi.org/10.1080/02713683.2021.1912779DOI Listing
April 2021

Robotic posterior capsule polishing by optical coherence tomography image guidance.

Int J Med Robot 2021 Feb 27:e2248. Epub 2021 Feb 27.

Mechanical and Aerospace Engineering Department, University of California, Los Angeles, Los Angeles, California, USA.

Background: In cataract surgery, polishing of the posterior capsule (PC) can lead to improved surgical outcomes but is currently avoided due to its high-risk nature. This work developed a robotic system capable of performing PC polishing on ex vivo pig eyes using optical coherence tomography (OCT) guidance.

Methods: The lenses of five ex vivo pig eyes were extracted and a thin layer of glue deposited onto the PC. Transpupillary OCT scans of the anterior segment were used to generate a PC-polishing trajectory. During polishing, OCT B-scans tracked the tool tip and were displayed to the operator.

Results: Complete removal of the glue was accomplished in all five trials with no PC rupture reported.

Conclusions: The feasibility of using a robotic system guided by OCT to perform PC polishing on a biological model was demonstrated. Contributions include modelling of the PC anatomy, intraoperative OCT visualization, and automated tool-tip motion with scheduled aspiration pressures.
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http://dx.doi.org/10.1002/rcs.2248DOI Listing
February 2021

Macular edema after rhegmatogenous retinal detachment repair: risk factors, OCT analysis, and treatment responses.

Int J Retina Vitreous 2021 Jan 25;7(1). Epub 2021 Jan 25.

Retina Division, Stein Eye Institute, University of California Los Angeles, 100 Stein Plaza, Los Angeles, CA, 90095-7002, USA.

Purpose: To investigate risk factors, imaging characteristics, and treatment responses of cystoid macular edema (CME) after rhegmatogenous retinal detachment (RRD) repair.

Methods: Consecutive, retrospective case-control series of patients who underwent pars plana vitrectomy (PPV) and/or scleral buckling (SB) for RRD, with at least six months of follow-up. Clinical and surgical parameters of patients with and without CME (nCME), based on spectral-domain optical coherence tomography (OCT), were compared.

Results: Of 99 eyes enrolled, 25 had CME while 74 had nCME. Patients with CME underwent greater numbers of surgeries (P < 0.0001). After adjusting for number of surgeries, macula-off RRD (P = 0.06), proliferative vitreoretinopathy (PVR) (P = 0.09), surgical approach (PPV and/or SB, P = 0.21), and tamponade type (P = 0.10) were not statistically significant, although they all achieved significance on univariate analysis (P = 0.001 or less). Intraoperative retinectomy (P = 0.009) and postoperative pseudophakia or aphakia (P = 0.008) were more frequent in the CME group, even after adjustment. Characteristics of cCME on OCT included diffuse distribution, confluent cysts, and absence of subretinal fluid or intraretinal hyperreflective foci. Macular thickness improved significantly with intravitreal triamcinolone (P = 0.016), but not with anti-vascular endothelial growth factor agents (P = 0.828) or dexamethasone implant (P = 0.125). After adjusting for number of surgeries and macular detachment, final visual acuities remained significantly lower in the CME vs nCME group (P = 0.012).

Conclusion: Risk factors of CME include complex retinal detachment repairs requiring multiple surgeries, and pseudophakic or aphakic lens status. Although this cCME was associated with poor therapeutic response, corticosteroids were the most effective studied treatments.
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http://dx.doi.org/10.1186/s40942-020-00254-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831177PMC
January 2021

Spontaneous Conversion of Lamellar Macular Holes to Full-Thickness Macular Holes: Clinical Features and Surgical Outcomes.

Ophthalmol Retina 2021 Jan 5. Epub 2021 Jan 5.

Department of Ophthalmology, Palo Alto Medical Foundation, Palo Alto, California. Electronic address:

Purpose: To describe the clinical features and surgical outcomes of patients experiencing a spontaneous conversion of a lamellar macular hole (LMH) to a full-thickness macular hole (FTMH).

Design: Retrospective, multicenter, observational case series.

Participants: Patients with LMH who experienced a spontaneous conversion to FTMH and underwent FTMH surgery.

Methods: Clinical charts and OCT features of 20 eyes of 20 patients were reviewed.

Main Outcome Measures: OCT features and surgical outcomes of FTMH derived from LMH.

Results: The mean baseline visual acuity (VA) was 0.21 ± 0.19 logarithm of the minimum angle of resolution (logMAR) (20/32 Snellen equivalent [SE]). Epiretinal proliferation was noted in 18 eyes (90%), and 14 eyes (75%) had an epiretinal membrane. At the diagnosis of FTMH, the mean VA decreased to 0.61 ± 0.50 logMAR (20/81 SE) (P = 0.001). The mean FTMH diameter was 224.4 ± 194.8 μm, with 15 (75%) small (≤250 μm), 2 (10%) medium (>250-≤400 μm), and 3 (15%) large (>400 μm) FTMHs. Eighteen (90%) FTMHs were sealed after 1 surgery, and 2 (10%) required an additional procedure. At the last follow-up, the mean VA was increased to 0.29 ± 0.23 logMAR (20/38 SE) (P = 0.003), but did not significantly differ from the baseline VA (P = 0.071).

Conclusions: Patients with LMH may develop an FTMH with no evidence of vitreomacular traction. A tangential traction from an epiretinal membrane may contribute to its genesis, but a progressive loss of retinal tissue and an inherent weakness of the foveal architecture in LMH eyes could be sufficient. Most FTMHs derived from LMH had a small diameter, showed epiretinal proliferation, showed limited retinal hydration, and were associated with relatively poor surgical outcomes compared with idiopathic FTMH.
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http://dx.doi.org/10.1016/j.oret.2020.12.023DOI Listing
January 2021

Traumatic Retinal Detachment in Patients with Self-Injurious Behavior: An International Multicenter Study.

Ophthalmol Retina 2020 Nov 22. Epub 2020 Nov 22.

Asociacion para Evitar la Ceguera en México, Mexico City, Mexico.

Purpose: To describe the clinical characteristics, surgical outcomes, and management recommendations in patients with traumatic rhegmatogenous retinal detachment (RRD) resulting from self-injurious behavior (SIB).

Design: International, multicenter, retrospective, interventional case series.

Participants: Patients with SIB from 23 centers with RRD in at least 1 eye.

Methods: Clinical histories, preoperative assessment, surgical details, postoperative management, behavioral intervention, and follow-up examination findings were reviewed.

Main Outcome Measures: The rate of single-surgery anatomic success (SSAS) was the primary outcome. Other outcomes included new RRD in formerly attached eyes, final retinal reattachment, and final visual acuity.

Results: One hundred seven eyes with RRDs were included from 78 patients. Fifty-four percent of patients had bilateral RRD or phthisis bulbi in the fellow eye at final follow-up. The most common systemic diagnoses were autism spectrum disorder (35.9%) and trisomy 21 (21.8%) and the most common behavior was face hitting (74.4%). The average follow-up time was 3.3 ± 2.8 years, and surgical outcomes for operable eyes were restricted to patients with at least 3 months of follow-up (81 eyes). Primary initial surgeries were vitrectomy alone (33.3%), primary scleral buckle (SB; 26.9%), and vitrectomy with SB (39.7%), and 5 prophylactic SBs were placed. Twenty-three eyes (21.5%) with RRDs were inoperable. The SSAS was 23.1% without tamponade (37.2% if including silicone oil), and final reattachment was attained in 80% (36.3% without silicone oil tamponade). Funnel-configured RRD (P = 0.006) and the presence of grade C proliferative vitreoretinopathy (P = 0.002) correlated with re-detachment. The use of an SB predicted the final attachment rate during the initial surgery (P = 0.005) or at any surgery (P = 0.008. These associations held if restricting to 64 patients with ≥12 months followup. Anatomic reattachment correlated with better visual acuity (P < 0.001).

Conclusions: RRD resulting from SIB poses therapeutic challenges because of limited patient cooperation, bilateral involvement, chronicity, and ongoing trauma in vulnerable and neglected patients. The surgical success rates were some of the lowest in the modern retinal detachment literature. The use of an SB may result in better outcomes, and visual function can be restored in some patients.
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http://dx.doi.org/10.1016/j.oret.2020.11.012DOI Listing
November 2020

Idiopathic Vitritis after Boston Type 1 Keratoprosthesis Implantation: Incidence, Risk Factors and Outcomes in a Multicentric Cohort.

Ocul Immunol Inflamm 2020 Oct 15:1-7. Epub 2020 Oct 15.

Stein Eye Institute, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California, USA.

Purpose: To determine incidence, risks factors for, and outcomes of idiopathic vitritis (IV) after Boston type 1 keratoprosthesis (KPro) implantation.

Methods: Retrospective, consecutive case series. Risk factors were analyzed between IV group and No IV group.

Results: IV occurred in 32/350 procedures (9.1%), for an average incidence of 0.02 cases per procedure-year. Presumed infectious keratitis was the only risk factor identified (HR = 7.65) Corneal necrosis and retinal detachment occurred significantly more frequently in IV group (all < .05). By last follow-up, the cumulative proportion of eyes that maintained a visual acuity >20/200 was significantly lower in IV group ( = .01), as was the KPro retention rate (HR = 0.26).

Conclusions: IV is associated with infectious keratitis, indicating that the vitritis may not be a sterile process. The increased incidence of subsequent complications leads to significantly decreased visual acuity and KPro retention in affected eyes.
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http://dx.doi.org/10.1080/09273948.2020.1826541DOI Listing
October 2020

Comparison of vitreoretinal disorders in fellow eyes of lamellar macular holes versus epiretinal membrane foveoschisis.

Graefes Arch Clin Exp Ophthalmol 2020 Dec 3;258(12):2611-2619. Epub 2020 Oct 3.

Retina Division, Stein Eye Institute, University of California Los Angeles, 100 Stein Plaza, Los Angeles, CA, USA.

Purpose: To evaluate and compare the rate and characteristics of vitreoretinal disorders in fellow eyes of lamellar macular holes (LMH) versus epiretinal membrane foveoschisis (ERMF).

Methods: Included patients in this retrospective study were divided into two groups based on spectral-domain optical coherence tomography (SD-OCT) features of their primary eye: LMH (group A) and ERMF (group B).

Results: Ninety-four patients were enrolled: 59 (62.8%) in group A and 35 (37.2%) in group B. Fellow eyes in group A had a higher rate of retinal detachment (8/59 [13.6%] vs. 0/35 [0%], P = 0.024), and full-thickness macular hole (FTMH) (11/59 [18.6%] vs. 2/35 [5.7%], P = 0.079), compared with fellow eyes in group B. In group A, 4/59 patients (6.8%) showed a bilateral LMH while none from group B had a LMH in their fellow eye (0/35 [0%]), P = 0.293. Additionally, epiretinal proliferation was noted in 30/59 (50.8%) fellow eyes in group A versus 3/35 (8.6%) fellow eyes in group B, P < 0.001. Longitudinal data were available for 80/94 patients. Over a mean follow-up of 37.4 ± 29.9 months, 1/48 (2.1%) fellow eyes from group A developed a FTMH and 2/48 (4.2%) developed a LMH, while no FTMH or LMH occurred in fellow eyes of group B.

Conclusions: Fellow eyes of LMH showed a high rate of macular and peripheral vitreoretinal disorders. In addition, epiretinal proliferation was detected in a higher number of fellow eyes of LMH versus ERMF. These findings suggest a bilateral process in eyes of patients with LMH.
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http://dx.doi.org/10.1007/s00417-020-04950-yDOI Listing
December 2020

SPONTANEOUS LAMELLAR MACULAR HOLES CLOSURE.

Retin Cases Brief Rep 2020 Sep 7. Epub 2020 Sep 7.

Retina Division, Stein Eye Institute, University of California Los Angeles, Los Angeles, California.

Purpose: To report two cases of spontaneous closure of lamellar macular holes with epiretinal proliferation (ERP).

Methods: Observational cases report.

Results: Two patients affected with lamellar macular hole showed progressive and spontaneous closure of the hole associated with ERP development. At presentation, both patients presented with irregular foveal contour, and foveal cavitation with apparent loss of retinal tissue. In both cases, ERP, also called "lamellar hole-associated epiretinal proliferation", was present and increased in size over time. This proliferation progressively developed across the hole with apparent restoration of the foveal contour and preservation of visual acuity.

Conclusion: This report describes two cases of lamellar macular hole in which ERP increased over time, resulting in lamellar macular hole closure. Such observations may suggest a spontaneous healing process driven by glial cell proliferation.
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http://dx.doi.org/10.1097/ICB.0000000000001029DOI Listing
September 2020

Time dependent degradation of vitreous gel under enzymatic reaction: Polymeric network role in fluid properties.

J Biomech 2020 08 5;109:109921. Epub 2020 Jul 5.

Department of Bioengineering, University of California, Los Angeles, United States; Department of Mechanical and Aerospace Engineering, University of California, Los Angeles, United States.

The viscoelastic behavior of vitreous gel is due to the presence of biopolymers in its structure. Fluid properties of the vitreous is mainly the result of interactions between the characteristics of collagen type II and Hyaluronic Acid networks. Having a better understanding of the structure of each component and their changes during aging and various diseases such as diabetes can lead to better monitoring and treatment options. We study the effects of collagenase type II on 44 samples of porcine vitreous using an in situ rheological experiment in comparison with 18 eyes in a control group injected with Phosphate Buffered Saline Solution. We analyze the behavior of each component over time in both groups. We focus on the changes of viscosity and elasticity of the collagen network within the vitreous. The results of the analysis in this study show that the changes in the fluid properties of the vitreous after collagenase injection is driven by the structural alterations of the collagen network. Creep compliance values of the collagen network are significantly higher in the first group compared to the control group one hour and twenty-four hours after the injection. In contrast, creep compliance of the HA network shows no statistically significant change one hour after the injection in both groups. The results of the reported analysis of individual components in this study support the previous findings on the alterations within the vitreous structure in its entirety.
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http://dx.doi.org/10.1016/j.jbiomech.2020.109921DOI Listing
August 2020

Identification of epiretinal proliferation in various retinal diseases and vitreoretinal interface disorders.

Int J Retina Vitreous 2020 10;6:31. Epub 2020 Jul 10.

Retina Division, Stein Eye Institute, University of California Los Angeles, 100 Stein Plaza, Los Angeles, CA 90095 USA.

Background: To describe the presence of epiretinal proliferation in eyes with various retinal and vitreoretinal interface conditions.

Methods: Consecutive patients seen at the Stein Eye Institute, by one retina specialist, from December 2018 to March 2019, and demonstrating epiretinal proliferation on optical coherence tomography (OCT) were enrolled in this cross-sectional study. Included patients were divided into two groups: vitreoretinal interface pathologies group or retinal diseases group. Presence of epiretinal proliferation and its localization within the 9 macular sectors, as defined by the Early Treatment Diabetic Retinopathy Study (ETDRS), were assessed on OCT.

Results: 77 eyes from 69 patients demonstrated epiretinal proliferation on OCT. The most frequently involved ETDRS sector was the 1-mm central subfield, followed by inner temporal and inner nasal sectors. Localization of epiretinal proliferation correlated with the presence of any retinal abnormalities in the same quadrant (r = 0.962; P < 0.0001). 31 eyes (40.3%) demonstrated symptomatic vitreoretinal interface pathologies including lamellar macular hole, full-thickness macular hole, epiretinal membrane and history of macular peeling. 46 eyes (59.7%) manifested various retinal diseases, including age-related macular degeneration, diabetic retinopathy, refractory macular edema, vein occlusion and high myopia.

Conclusions: Epiretinal proliferation was noted in several retinal conditions and not limited only to full-thickness and lamellar macular holes. Different mechanisms affecting retinal homeostasis might trigger Müller cells dysregulation, potentially leading to abnormal retinal remodeling.
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http://dx.doi.org/10.1186/s40942-020-00233-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7350739PMC
July 2020

Relationship Between Nerve Fiber Layer Hemorrhages and Outcomes in Central Retinal Vein Occlusion.

Invest Ophthalmol Vis Sci 2020 05;61(5):54

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Purpose: To evaluate the depth and pattern of retinal hemorrhage in acute central retinal vein occlusion (CRVO) and to correlate these with visual and anatomic outcomes.

Methods: Retinal hemorrhages were evaluated with color fundus photography and fluorescein angiography at baseline and follow-up. Snellen visual acuity (VA), central foveal thickness (CFT), extent of retinal ischemia, and development of neovascularization were analyzed.

Results: 108 eyes from 108 patients were evaluated. Mean age was 63.6 ± 16.1 years with a predilection for the right eye (73.1%). Average follow-up was 17.2 ± 19.2 months. Mean VA at baseline was 20/126 and 20/80 at final follow-up. Baseline (P = 0.005) and final VA (P = 0.02) in eyes with perivascular nerve fiber layer (NFL) hemorrhages were significantly worse than in eyes with deep hemorrhages alone. Baseline CFT was greater in the group with perivascular hemorrhages (826 ± 394 µm) compared to the group with deep hemorrhages alone (455 ± 273 µm, P < 0.001). The 10 disc areas of retinal ischemia was more common in patients with perivascular (80.0%) and peripapillary (31.3%) versus deep hemorrhages alone (16.1%, P < 0.001). Neovascularization of the iris was more common, although this differrence was not significant, in the groups with peripapillary (14.3%) and perivascular (2.0%) NFL versus deep hemorrhages alone (0.0%).

Conclusions: NFL retinal hemorrhages at baseline correlate with more severe forms of CRVO, with greater macular edema, poorer visual outcomes, and greater risk of ischemia and neovascularization. This may be related to the organization of the retinal capillary plexus. The depth and pattern of distribution of retinal hemorrhages in CRVO may provide an easily identifiable early biomarker of CRVO prognosis.
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http://dx.doi.org/10.1167/iovs.61.5.54DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405700PMC
May 2020

Hyperreflective Stress Lines and Macular Holes.

Invest Ophthalmol Vis Sci 2020 04;61(4):50

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Purpose: To determine the prevalence of a central hyperreflective line in eyes with full-thickness macular holes (FTMH) and lamellar macular holes (LMH) and to elucidate the pathoanatomic importance of this optical coherence tomography (OCT) sign.

Methods: This retrospective analysis evaluated patients with FTMH and LMH at the Stein Eye Institute. Clinical data was collected and SD-OCT volume scans were analyzed for the presence of a central vertical hyperreflective line in 3 separate cohorts: patients with SD-OCT preceding FTMH development, patients with SD-OCT after pars plana vitrectomy (PPVT) treatment for FTMH, and patients with SD-OCT of LMH.

Results: In total, 93 eyes with FTMH and 88 eyes with LMH were identified. Of the 93 FTMH eyes, SD-OCT volume scans were available before development of the FTMH in 12 eyes. Of these, 6 (50%) displayed a vertical hyperreflective line preceding the development of the FTMH. Fifty-one eyes underwent PPVT with resolution of the FTMH, and 26 displayed a hyperreflective line after resolution (51%). Of the 88 eyes with LMH, 22 displayed a hyperreflective line (25%). All hyperreflective lines were noted at the central fovea.

Conclusions: SD-OCT illustrated the presence of a central vertical hyperreflective line preceding FTMH and after resolution of FTMH after PPVT in approximately one-half of cases, and concurrent with LMH in 25% of cases. This vertical hyperreflective line may represent an early SD-OCT marker for the development of FTMH, and may be a sign of central foveal dehiscence owing to disruption of the Muller cell cone.
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http://dx.doi.org/10.1167/iovs.61.4.50DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7401923PMC
April 2020

PRIMA subretinal wireless photovoltaic microchip implantation in non-human primate and feline models.

PLoS One 2020 8;15(4):e0230713. Epub 2020 Apr 8.

Fondation Ophtalmologique A. De Rothschild, Paris, France.

Purpose: To evaluate the surgical technique for subretinal implantation of two sizes of PRIMA photovoltaic wireless microchip in two animal models, and refine these surgical procedures for human trials.

Methods: Cats and Macaca fascicularis primates with healthy retina underwent vitrectomy surgery and were implanted with subretinal wireless photovoltaic microchip at the macula/central retina. The 1.5mm PRIMA chip was initially studied in feline eyes. PRIMA implant (2mm,1.5mm sizes) arrays were studied in primates. Feasibility of subretinal chip implantation was evaluated with a newly-developed surgical technique, with surgical complications and adverse events recorded.

Results: The 1.5mm implant was placed in the central retina of 11 feline eyes, with implantation duration 43-106 days. The 1.5mm implant was correctly positioned into central macula of 11 primate eyes, with follow-up periods of minimum 6 weeks (n = 11), 2 years (n = 2), and one eye for 3 years. One primate eye underwent multi-chip 1.5mm implantation using two 1.5mm chips. The 2mm implant was delivered to 4 primate eyes. Optical coherence tomography confirmed correct surgical placement of photovoltaic arrays in the subretinal space in all 26 eyes. Intraoperative complications in primate eyes included retinal tear, macular hole, retinal detachment, and vitreous hemorrhage that resolved spontaneously. Postoperatively, there was no case of significant ocular inflammation in the 1.5mm implant group.

Conclusions: We report subretinal implantation of 1.5mm and 2mm photovoltaic arrays in the central retina of feline and central macula of primate eyes with a low rate of device-related complications. The in vivo PRIMA implantation technique has been developed and refined for use for a 2mm PRIMA implant in ongoing human trials.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0230713PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141693PMC
July 2020

Advanced robotic surgical systems in ophthalmology.

Eye (Lond) 2020 09 9;34(9):1554-1562. Epub 2020 Mar 9.

Advanced Robotic Eye Surgery (ARES) Lab, Stein Eye Institute, University of California, Los Angeles, Los Angeles, CA, USA.

In this paper, an overview of advanced robotic surgical systems in ophthalmology is provided. The systems are introduced as representative examples of the degree of human vs. robotic control during surgical procedures. The details are presented on each system and the latest advancements of each are described. Future potential applications for surgical robotics in ophthalmology are discussed in detail, with representative examples provided alongside recent progress.
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http://dx.doi.org/10.1038/s41433-020-0837-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608507PMC
September 2020

Optical coherence tomography-based consensus definition for lamellar macular hole.

Br J Ophthalmol 2020 12 27;104(12):1741-1747. Epub 2020 Feb 27.

Ophthalmology, Lariboisière Hospital, Paris, France.

Background: A consensus on an optical coherence tomography definition of lamellar macular hole (LMH) and similar conditions is needed.

Methods: The panel reviewed relevant peer-reviewed literature to reach an accord on LMH definition and to differentiate LMH from other similar conditions.

Results: The panel reached a consensus on the definition of three clinical entities: LMH, epiretinal membrane (ERM) foveoschisis and macular pseudohole (MPH). LMH definition is based on three mandatory criteria and three optional anatomical features. The three mandatory criteria are the presence of irregular foveal contour, the presence of a foveal cavity with undermined edges and the apparent loss of foveal tissue. Optional anatomical features include the presence of epiretinal proliferation, the presence of a central foveal bump and the disruption of the ellipsoid zone. ERM foveoschisis definition is based on two mandatory criteria: the presence of ERM and the presence of schisis at the level of Henle's fibre layer. Three optional anatomical features can also be present: the presence of microcystoid spaces in the inner nuclear layer (INL), an increase of retinal thickness and the presence of retinal wrinkling. MPH definition is based on three mandatory criteria and two optional anatomical features. Mandatory criteria include the presence of a foveal sparing ERM, the presence of a steepened foveal profile and an increased central retinal thickness. Optional anatomical features are the presence of microcystoid spaces in the INL and a normal retinal thickness.

Conclusions: The use of the proposed definitions may provide uniform language for clinicians and future research.
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http://dx.doi.org/10.1136/bjophthalmol-2019-315432DOI Listing
December 2020

Distinctive Mechanisms and Patterns of Exudative Versus Tractional Intraretinal Cystoid Spaces as Seen With Multimodal Imaging.

Am J Ophthalmol 2020 04 17;212:43-56. Epub 2019 Dec 17.

Humanitas University, Eye Unit, Humanitas-Gavazzeni Hospital, Bergamo, Italy.

Purpose: To determine clear-cut distinctions between tractional and exudative intraretinal cystoid spaces subtypes.

Design: Retrospective, multicenter, observational case series.

Methods: A cohort of patients diagnosed with intraretinal cystoid spaces and imaged with optical coherence tomography (OCT), fluorescein angiography (FA), blue fundus autofluorescence (BFAF), en face OCT, and OCT angiography (OCT-A) was included in the study. All images were qualitatively and quantitatively evaluated.

Results: In this study were included 72 eyes of 69 patients. Exudative intraretinal cystoid spaces (36/72 eyes, 50%) displayed a "petaloid" morphology as seen with en face OCT, FA, and BFAF. Tractional intraretinal cystoid spaces (24/72 eyes, 33.3%), displayed a radial "spoke-wheel" en face OCT pattern. There was no leakage with FA and BFAF did not reveal specific patterns. Eyes with full-thickness macular hole (FTMH, 12/72 eyes, 16.7%) displayed a "sunflower" en face OCT appearance. FTMH showed OCT, OCT-A, and BFAF features of both exudative and tractional cystoid spaces, but without any FA leakage. Inner nuclear layer (INL) thickness was significantly lower in tractional cystoid spaces (P < .001). There were a greater number of INL cystoid spaces in both the exudative and FTMH subgroups (P = .001). The surface area of INL cystoid spaces was significantly lower in the tractional subgroup (P < .001). There was a significant reduction of the microvascular density in eyes with exudative vs tractional (P = .002) and FTMH (P < .001) subgroups.

Conclusions: Exudative and tractional intraretinal cystoid spaces displayed characteristic multimodal imaging features and they may represent 2 different pathologic conditions with equally different clinical implications.
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http://dx.doi.org/10.1016/j.ajo.2019.12.010DOI Listing
April 2020

Semiautomated optical coherence tomography-guided robotic surgery for porcine lens removal.

J Cataract Refract Surg 2019 11;45(11):1665-1669

Stein Eye Institute, University of California, Los Angeles, USA.

Purpose: To evaluate semiautomated surgical lens extraction procedures using the optical coherence tomography (OCT)-integrated Intraocular Robotic Interventional Surgical System.

Setting: Stein Eye Institute and Department of Mechanical and Aerospace Engineering, University of California, Los Angeles, USA.

Design: Experimental study.

Methods: Semiautomated lens extraction was performed on postmortem pig eyes using a robotic platform integrated with an OCT imaging system. Lens extraction was performed using a series of automated steps including robot-to-eye alignment, irrigation/aspiration (I/A) handpiece insertion, anatomic modeling, surgical path planning, and I/A handpiece navigation. Intraoperative surgical supervision and human intervention were enabled by real-time OCT image feedback to the surgeon via a graphical user interface. Manual preparation of the pig-eye models, including the corneal incision and capsulorhexis, was performed by a trained cataract surgeon before the semiautomated lens extraction procedures. A scoring system was used to assess surgical complications in a postoperative evaluation.

Results: Complete lens extraction was achieved in 25 of 30 eyes. In the remaining 5 eyes, small lens pieces (≤1.0 mm) were detected near the lens equator, where transpupillary OCT could not image. No posterior capsule rupture or corneal leakage occurred. The mean surgical duration was 277 seconds ± 42 (SD). Based on a 3-point scale (0 = no damage), damage to the iris was 0.33 ± 0.20, damage to the cornea was 1.47 ± 0.20 (due to tissue dehydration), and stress at the incision was 0.97 ± 0.11.

Conclusions: No posterior capsule rupture was reported. Complete lens removal was achieved in 25 trials without significant surgical complications. Refinements to the procedures are required before fully automated lens extraction can be realized.
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http://dx.doi.org/10.1016/j.jcrs.2019.06.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6941892PMC
November 2019

EFFECT OF LASER PHOTOCOAGULATION ON MACULAR EDEMA ASSOCIATED WITH MACULAR HOLES.

Retin Cases Brief Rep 2019 Sep 10. Epub 2019 Sep 10.

Division of Retina, Stein Eye Institute, University of California Los Angeles Geffen School of Medicine, Los Angeles, CA.

Purpose: To report the outcomes of laser therapy to barricade eccentric full-thickness macular hole with associated cystoid macular edema.

Methods: We report two patients who developed an eccentric full-thickness macular hole with persistent cystoid macular edema after pars plan vitrectomy with and without internal limiting membrane peel for epiretinal membrane and the results of argon laser therapy.

Results: Barricade argon laser therapy was applied concentric to the full-thickness macular hole. Associated cystoid macular edema was noted to resolve within 1 to 3 months of therapy in both cases.

Conclusion: Barricade laser therapy surrounding a macular hole can lead to resolution of associated cystoid macular edema. Pathogenic mechanisms to explain this favorable outcome are discussed.
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http://dx.doi.org/10.1097/ICB.0000000000000901DOI Listing
September 2019

DETECTION OF NEUROSENSORY RETINAL DETACHMENT COMPLICATING DEGENERATIVE RETINOSCHISIS BY ULTRA-WIDEFIELD FUNDUS AUTOFLUORESCENCE IMAGING.

Retina 2020 May;40(5):819-824

Retina Division, Stein Eye Institute, University of California Los Angeles, Los Angeles, California.

Purpose: To determine whether neurosensory retinal detachment complicating degenerative retinoschisis (RS) can be reliably detected with ultra-widefield fundus autofluorescence evaluation.

Methods: Consecutive patients diagnosed with RS who had ultra-widefield fundus autofluorescence imaging were included in this retrospective case series. According to the fundus autofluorescence patterns, we divided the eyes into two groups: 1) eyes with RS and a hyperautofluorescent leading edge and 2) eyes with RS and without hyperautofluorescence. Peripheral spectral domain optical coherence tomography images at the level of RS were obtained.

Results: Thirty-eight eyes that met eligibility criteria were identified. Review of ultra-widefield fundus autofluorescence demonstrated 21/39 (55%) eyes with distinctive hyperautofluorescence over the area of RS (Group A) and 17/38 (45%) eyes without any form of hyperautofluorescence (Group B). Spectral domain optical coherence tomography images confirmed the presence of full-thickness neurosensory retina separation from the underlying retinal pigment epithelium in the areas of hyperautofluorescence in 10/10 eyes (100%) from Group A. None (0/11; 0%) of the eyes from Group B showed full-thickness neurosensory retina separation on the spectral domain optical coherence tomography imaging of the retina-RS interface.

Conclusion: Hyperautofluorescent findings suggest the presence of a neurosensory retinal detachment. Retinal detachment associated with RS can be reliably detected on ultra-widefield fundus autofluorescence and may be a useful diagnostic imaging modality.
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http://dx.doi.org/10.1097/IAE.0000000000002488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7176347PMC
May 2020

The role of Müller cells in tractional macular disorders: an optical coherence tomography study and physical model of mechanical force transmission.

Br J Ophthalmol 2020 04 20;104(4):466-472. Epub 2019 Jul 20.

Eye Unit, Humanitas University, Humanitas-Gavazzeni Hospital, Bergamo, Italy.

Background: To explore the role of foveal and parafoveal Müller cells in the morphology and pathophysiology of tractional macular disorders with a mathematical model of mechanical force transmission.

Methods: In this retrospective observational study, spectral-domain optical coherence tomography images of tractional lamellar macular holes and patients with myopic foveoschisis were reviewed and analysed with a mathematical model of force transmission. Parafoveal Müller cells were modelled as a structure composed of three rigid rods, named R1, R2 and R3. The angle formed between the rods was referred to as θ . R1, R2 and R3 lengths as well as the variation of the angle θ were measured and correlated with best corrected visual acuity (BCVA).

Results: In tractional lamellar macular holes, there was a significant reduction of the angle θ towards the foveal centre (p<0.001). By contrast, there were no significant differences in θ in myopic foveoschisis (p=0.570). R2 segments were more vertical in myopic foveoschisis. There was a significant association between lower θ angles at 200 µm temporal and nasal to the fovea and lower BCVA (p<0.001 and p=0.005, respectively). The stiffness of parafoveal Müller cells was predicted to be function of the angle θ , and it grew very rapidly as the θ decreased.

Conclusion: Parafoveal Müller cells in the Henle fibre layer may guarantee structural stability of the parafovea by increasing retinal compliance and resistance to mechanical stress. Small values of the angle θ were related to worse BCVA possibly due to damage to Müller cell processes and photoreceptor's axons.
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http://dx.doi.org/10.1136/bjophthalmol-2019-314245DOI Listing
April 2020

The Effect of Haptic Feedback on Efficiency and Safety During Preretinal Membrane Peeling Simulation.

Transl Vis Sci Technol 2019 3;8(4). Epub 2019 Jul 3.

University of California Los Angeles Stein Eye Institute, Los Angeles, CA, USA.

Purpose: We determine whether haptic feedback improves surgical performance and outcome during simulated a preretinal membrane peeling procedure.

Methods: A haptic-enabled virtual reality preretinal membrane peeling simulator was developed using a surgical cockpit with two multifinger haptic devices. Six subjects (three trained retina surgeons and three nonsurgeons) performed the preretinal membrane peeling surgical procedure using two modes of operation: visual and haptic feedback, and visual feedback only.

Results: Task completion time, tool tip path trajectory, tool-retina collision force, and retinal damage were all reduced with haptic feedback used and compared to modes where haptic feedback was disabled.

Conclusions: Haptic feedback improves efficiency and safety during preretinal membrane peeling simulation.

Translational Relevance: These findings highlight the potential benefit of haptic feedback for improving performance and safety of vitreoretinal surgery.
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http://dx.doi.org/10.1167/tvst.8.4.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6613593PMC
July 2019

LAMELLAR MACULAR HOLES IN THE PRESENCE OF AGE-RELATED MACULAR DEGENERATION.

Retina 2020 Jun;40(6):1079-1086

Retina Division, Stein Eye Institute, University of California Los Angeles, Los Angeles, California; and.

Purpose: To investigate whether age-related macular degeneration (AMD) has an influence on the prevalence and anatomical characteristics of lamellar macular holes (LMHs).

Methods: Clinical records and spectral-domain optical coherence tomography images of 756 eyes of 423 consecutive patients diagnosed with AMD were reviewed and analyzed. Spectral-domain optical coherence tomography was used to identify degenerative or tractional LMH subtypes and assess their morphology. The clinical and optical coherence tomography findings of AMD eyes with LMH were compared with those of a control group of eyes with LMH without AMD from a previously published report.

Results: Lamellar macular holes were identified in 25 eyes of 23 patients (3.3%; 25 of 756). Seventeen of 25 eyes (68%) presented with degenerative LMH and underlying late neovascular AMD. Mean best-corrected visual acuity was worse in eyes with AMD and LMH eyes than in those with AMD and no LMH (20/230 vs. 20/98; P = 0.02). The mean outer diameter was greater in the group with degenerative LMH with concomitant AMD than in the control group of degenerative LMH without AMD (1,323.9 ± 999.1 µm vs. 905.9 ± 356.8 µm, respectively; P = 0.01).

Conclusion: The incidence of degenerative LMH increased in advanced forms of AMD, whereas the presence of tractional LMH subtype may be unrelated to AMD evolution.
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http://dx.doi.org/10.1097/IAE.0000000000002532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7242169PMC
June 2020

Type III Uveal Effusion Syndrome: Unilateral Idiopathic Serous Detachment.

Ophthalmol Retina 2018 06 6;2(6):637-639. Epub 2018 Feb 6.

Hospital Oftalmologico Dr Pedro Lagleyze, Buenos Aires, Argentina.

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http://dx.doi.org/10.1016/j.oret.2017.12.007DOI Listing
June 2018

Effects of Collagenase type II on Vitreous Humor, an in-situ Rheological Study.

J Biomech Eng 2019 Apr 3. Epub 2019 Apr 3.

Department of Mechanical & Aerospace Engineering, Department of Bioengineering, University of California Los Angeles, Los Angeles, California, 90095.

The purpose of this study is to quantify the impact of enzyme activity on the vitreous humor structure over time to understand the mechanical characteristics of the vitreous humor gel. Changes in the mechanical behavior of the vitreous occur to many reasons including aging, which may lead to many vitreoretinal diseases. The degeneration of the vitreous has been studied; however, in-situ experimental procedures to validate the existing hypotheses are limited. We examined thirty-eight porcine eyes using in-situ rheological creep tests to measure the mechanical properties of the vitreous humor of the eyes prior to, 1 and 24 hours after the intravitreal injection. Eyes in one group were injected with collagenase type II solution and eyes in the control group were injected with Phosphate Buffered Saline solution with calcium and magnesium chloride. Prior to the injection, viscosity and creep compliance intercept values between both groups were not statistically different. At 1 hour and 24 hours after the injection, vitreous properties in eyes from the first group showed a statistically significant increase in the J intercept (representing the inverse of elasticity) values compared with the control group. In addition, 1 and 24 hours after the injection, vitreous viscosity was lower in eyes from the first group than in eyes from the control group. These findings are a foundation for future studies on the effectiveness of intravitreal drugs to modify the mechanical properties of the vitreous humor.
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http://dx.doi.org/10.1115/1.4043358DOI Listing
April 2019

Lamellar macular hole surgery - current concepts, future prospects.

Clin Ophthalmol 2019 8;13:143-146. Epub 2019 Jan 8.

Retina Division, Stein Eye Institute, University of California Los Angeles, Los Angeles, CA, USA.

Lamellar macular holes present distinct morphological features including tractional or non-tractional epimacular membranes, foveal tissue alterations, defects of the outer retinal layers, or a separation of the retinal layers. At present, degenerative lamellar holes are differentiated from tractional holes based on the morphological characteristics seen in OCT. The current treatment approach is based on this gross differentiation. Considering the recent developments in high-resolution imaging, this classification needs to be revisited since morphological features may present simultaneously, making it difficult to separate these entities. In addition, a revisited classification may be of value to better standardize the indication for surgical treatment.
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http://dx.doi.org/10.2147/OPTH.S188309DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329342PMC
January 2019

Bilateral Acquired Progressive Retinal Nerve Fiber Layer Myelination.

Ophthalmic Surg Lasers Imaging Retina 2018 10;49(10):e147-e150

The authors present the multimodal imaging findings of an unusual case of bilateral acquired progressive myelination of the optic disc during a 10-year follow-up period in a hyperopic adolescent patient in the absence of an underlying ocular or systemic abnormality. Myelination of the left optic disc was noted at age 7 and of the right optic disc at age 13, but no other ocular or systemic abnormalities were identified. Cross-sectional optical coherence tomography (OCT) and en face OCT angiography confirmed the presence of myelination of the retinal nerve fiber layer and excluded other etiologic possibilities including an astrocytic hamartoma. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e147-e150.].
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http://dx.doi.org/10.3928/23258160-20181002-18DOI Listing
October 2018

PARS PLANA VITRECTOMY FOR THE TREATMENT OF TRACTIONAL AND DEGENERATIVE LAMELLAR MACULAR HOLES: Functional and Anatomical Results.

Retina 2019 Nov;39(11):2090-2098

Retina Division, Stein Eye Institute, University of California Los Angeles, Los Angeles, California.

Purpose: Functional and anatomical outcomes of vitrectomy with membrane peeling were compared in tractional lamellar macular holes (LMH)/macular pseudoholes (MPH) versus degenerative LMH.

Methods: This multicenter retrospective study enrolled patients with a minimum follow-up of 6 months. The association of spectral domain optical coherence tomography parameters with preoperative and postoperative best-corrected visual acuity was analyzed.

Results: Seventy-seven (74.8%) tractional LMH/MPH and 26 (25.2%) degenerative LMH were included. Preoperative best-corrected visual acuity was better in tractional LMH/MPH (0.39 ± 0.2 logarithm of the minimal angle of resolution, 20/50 Snellen equivalent) than degenerative LMH (0.56 ± 0.2 logarithm of the minimal angle of resolution, 20/66 Snellen equivalent; P < 0.001). Premacular membranes were found in all tractional LMH/MPH, whereas LMH-associated epiretinal proliferation (LHEP) was present in all degenerative LMH. Primary anatomical success was achieved in 97/103 eyes (94.2%), with foveal restoration occurring earlier in degenerative LMH (1.6 ± 2.3 vs. 3.3 ± 3.6 months; P = 0.025). Best-corrected visual acuity improved in both tractional LMH/MPH and degenerative LMH (P < 0.001 and P = 0.012, respectively) but was better in tractional LMH/MPH (P = 0.001).

Conclusion: The presence of premacular membranes and absence of LMH-associated epiretinal proliferation in all tractional LMH/MPH further distinguishes this from degenerative LMH. Best-corrected visual acuity improved in both subgroups but more so in tractional LMH/MPH. Complete anatomical restoration of foveal microanatomy was rare in degenerative LMH, reflecting significant morphological and pathophysiological differences between the two lesions.
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http://dx.doi.org/10.1097/IAE.0000000000002326DOI Listing
November 2019

Effect of Ciliary Neurotrophic Factor on Retinal Neurodegeneration in Patients with Macular Telangiectasia Type 2: A Randomized Clinical Trial.

Ophthalmology 2019 04 4;126(4):540-549. Epub 2018 Oct 4.

Department of Molecular Medicine, The Scripps Research Institute; Division of Ophthalmology, Scripps Clinic; and the Lowy Medical Research Institute, La Jolla, California.

Purpose: To test the effects of an encapsulated cell-based delivery of a neuroprotective agent, ciliary neurotrophic factor (CNTF), on progression of macular telangiectasia type 2, a neurodegenerative disease with no proven effective therapy.

Design: Randomized sham-controlled clinical trial.

Participants: Ninety-nine study eyes of 67 eligible participants were enrolled.

Methods: Single-masked randomized clinical trial of 24 months' duration conducted from May 2014 through April 2017 in 11 clinical centers of retinal specialists in the United States and Australia. Participants were randomized 1:1 to surgical implantation of intravitreal sustained delivery of human CNTF versus a sham procedure.

Main Outcome Measures: The primary outcome was the difference in the area of neurodegeneration as measured in the area of the ellipsoid zone disruption (or photoreceptor loss) measured on spectral-domain (SD) OCT images at 24 months from baseline between the treated and untreated groups. Secondary outcomes included comparison of visual function changes between treatment groups.

Results: Among the 67 participants who were randomized (mean age, 62±8.9 years; 41 women [61%]; 58 white persons [86%]), 65 (97%) completed the study. Two participants (3 study eyes) died and 3 participants (4 eyes) were found ineligible. The eyes receiving sham treatment had 31% greater progression of neurodegeneration than the CNTF-treated eyes. The difference in mean area of photoreceptor loss was 0.05±0.03 mm (P = 0.04) at 24 months. Retinal sensitivity changes, measured using microperimetry, were correlated highly with the changes in the area of photoreceptor loss (r = 0.86; P < 0.0001). The mean retinal sensitivity loss of the sham group was 45% greater than that of the treated group (decrease, 15.81±8.93 dB; P = 0.07). Reading speed deteriorated in the sham group (-13.9 words per minute) with no loss in the treated group (P = 0.02). Serious adverse ocular effects were found in 2 of 51 persons (4%) in the sham group and 2 of 48 persons (4%) in the treated group.

Conclusions: In participants with macular telangiectasia type 2, a surgical implant that released CNTF into the vitreous cavity, compared with a sham procedure, slowed the progression of retinal degeneration. Further research is needed to assess longer-term clinical outcomes and safety.
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http://dx.doi.org/10.1016/j.ophtha.2018.09.041DOI Listing
April 2019

Intraocular robotic interventional surgical system (IRISS): Semi-automated OCT-guided cataract removal.

Int J Med Robot 2018 Dec 28;14(6):e1949. Epub 2018 Aug 28.

Mechanical and Aerospace Engineering, University of California, Los Angeles, California, Los Angeles.

Background: With the development of laser-assisted platforms, the outcomes of cataract surgery have been improved by automating several procedures. The cataract-extraction step continues to be manually performed, but due to deficiencies in sensing capabilities, surgical complications such as posterior capsule rupture and incomplete cataract removal remain.

Methods: An optical coherence tomography (OCT) system is integrated into our intraocular robotic interventional surgical system (IRISS) robot. The OCT images are used for preoperative planning and intraoperative intervention in a series of automated procedures. Real-time intervention allows surgeons to evaluate the progress and override the operation.

Results: The developed system was validated by performing lens extraction on 30 postmortem pig eyes. Complete lens extraction was achieved on 25 eyes, and "almost complete" extraction was achieved on the remainder due to an inability to image small lens particles behind the iris. No capsule rupture was found.

Conclusion: The IRISS successfully demonstrated semiautomated OCT-guided lens removal with real-time supervision and intervention.
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http://dx.doi.org/10.1002/rcs.1949DOI Listing
December 2018

BRANCH RETINAL ARTERY WALL RUPTURE AND SUBSEQUENT OCCLUSION DURING PARS PLANA VITRECTOMY WITH MEMBRANE PEEL.

Retin Cases Brief Rep 2021 Mar;15(2):131-134

Stein Eye Institute, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.

Purpose: To report a case of branch retinal artery wall rupture and subsequent branch retinal artery occlusion occurring during a routine pars plana vitrectomy with epiretinal membrane and internal limiting membrane peeling.

Methods: Case report. Multimodal imaging including fluorescein angiography, spectral domain optical coherence tomography (OCT), en face OCT, and OCT angiography were performed.

Results: An 86-year-old woman presented with a symptomatic epiretinal membrane in the right eye. Pars plana vitrectomy with epiretinal membrane and internal limiting membrane peel was performed. During the peel, spontaneous preretinal and intraretinal hemorrhage emanating from an adjacent branch retinal artery developed. At postoperative Week 1, OCT showed retinal thinning and hyperreflectivity suggestive of vascular accident. At postoperative Year 1, OCT imaging revealed retinal atrophy while fluorescein angiography demonstrated the arterial occlusion, and OCT angiography illustrated reduction in retinal perfusion in the region of the branch retinal artery occlusion.

Conclusion: The authors report an unusual case of retinal arterial wall rupture and hemorrhaging during routine pars plana vitrectomy with membrane peel resulting in a branch retinal artery occlusion and subsequent retinal atrophy. Surgeons must limit stress on the underlying retina during membrane peel to avoid this surgical complication.
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http://dx.doi.org/10.1097/ICB.0000000000000764DOI Listing
March 2021