Chronic Cystoid Macular Edema Research Articles

0.18 MG FLUOCINOLONE ACETONIDE INSERT FOR THE TREATMENT OF CHRONIC POSTOPERATIVE PSEUDOPHAKIC CYSTOID MACULAR EDEMA.

To report the outcomes of the 0.18 mg fluocinolone acetonide insert (FAi) in the treatment of chronic (>6 months) postoperative cystoid macular edema after cataract surgery. This was a retrospective consecutive case series of eyes with chronic postoperative cystoid macular edema treated with the FAi. Visual acuity, intraocular pressure, optical coherence tomography metrics, and supplemental therapies were extracted from the charts before and at 3, 6, 12, 18, and 21 months after FAi placement, when available. Nineteen eyes of 13 patients with chronic postoperative cystoid macular edema after cataract surgery underwent FAi placement with an average follow-up of 15.4 months. Ten eyes (52.6%) had a ≥2-line gain in visual acuity. Sixteen eyes (84.2%) had a ≥20% reduction in optical coherence tomography central subfield thickness. Eight eyes (42.1%) had complete resolution of CME. Improvements in central subfield thickness and visual acuity were sustained throughout individual follow-up. Compared with 18 eyes (94.7%) requiring local corticosteroid supplementation before FAi, only six eyes (31.6%) required supplementation after FAi. Similarly, of the 12 eyes (63.2%) that were on corticosteroid drops before FAi, only 3 (15.8%) required drops after FAi. Eyes with chronic postoperative cystoid macular edema after cataract surgery treated with the FAi had improved and sustained visual acuity and optical coherence tomography metrics, along with a reduction in supplemental treatment burden.

Injectable Fluocinolone Implant for the Management of Chronic Postsurgical Cystoid Macular Edema in Vitrectomized Eyes.

Long-acting injectable steroids are changing the treatment paradigm for patients with chronic intraocular inflammation and cystoid macular edema (CME). We report the use of the fluocinolone implant (FAI) 0.18 mg in patients with chronic postsurgical CME following pars plana vitrectomy (PPV). This is a retrospective case series of 24 vitrectomized eyes which received FAI for the management postsurgical CME. Clinical outcomes and requirement for rescue therapy were studied. Median length of follow-up was 19.3 months (range 8.3-23.2 months). There was an improvement in median central subfield thickness from 412 μm (range 167-806 μm) to 311 μm (range 157-686 μm) following FAI (p < 0.001). The injection burden decreased significantly following study treatment (p < 0.001); however, there was no significant change in visual acuity (p = 0.334). Eighteen eyes had control of CME that did not require additional intravitreal therapy. Four eyes had initially controlled but recurrent CME requiring intravitreal steroid therapy at median of 7.8 months (range 7.6-15.4 months). One eye never attained sufficient inflammatory control despite rescue therapy. FAI can be an effective treatment in vitrectomized patients with chronic postsurgical CME and can help decrease the overall injection burden.

Sustained-release Low-dose Fluocinolone Acetonide Intravitreal Implant for Chronic Postoperative Cystoid Macular Edema: Two Case Reports.

To describe two cases of patients diagnosed with chronic postoperative cystoid macular edema associated with non-infectious posterior uveitis who had limited treatment response to previous corticosteroid modalities and then received a single intravitreal fluocinolone 0.18 mg implant. Series of two case reports. Compared to baseline, both patients experienced resolution of their disease symptoms, >3 lines of visual acuity improvement, and macular edema reduction of 56.2 and 38.4% and 15 and 6 months respectively, following the fluocinolone implant. No steroid-related adverse events including any intraocular pressure measurement >25 mm Hg were observed. A single intravitreal fluocinolone 0.18mg implant can effectively and safely treat vision loss and increased central macular thickness due to chronic postoperative cystoid macular edema associated with non-infectious posterior uveitis.

Posterior sub-Tenon triamcinolone injection in the treatment of postoperative cystoid macular edema secondary to pars plana vitrectomy.

To evaluate the efficacy and safety of posterior sub-Tenon triamcinolone (PSTA) in chronic postoperative cystoid macular edema (PCME) after pars plana vitrectomy (PPV). Consecutive 22 patients who developed chronic PCME after PPV and underwent PSTA treatment were included in this retrospective study. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were measured pre injection and post injection at one month, three months, six months, and at last visit. The patients were divided into three groups according to the injection response status: complete, partial, and resistant. The mean follow-up period was 26.4 ± 16.2 months after PSTA. According to pre-injection values, there was a significant improvement in the values of BCVA and CMT at the first, third, and sixth months and at the last examination (P < 0.05). In the final examination, PCME recovered completely in 12 patients, partially in 8 patients, and resistance was observed in 2 patients. Posterior sub-Tenon triamcinolone seems to be effective in chronic PCME following PPV.

Non-steroidal anti-inflammatory agents for treating cystoid macular edema following cataract surgery.

Non-steroidal anti-inflammatory agents for treating cystoid macular edema following cataract surgery.

Intermediate-term outcomes of combined phacoemulsification and Aurolab aqueous drainage implant in eyes with refractory glaucoma and coexistent cataract.

To investigate the efficacy and safety of non-valved Aurolab aqueous drainage implant (AADI) surgery combined with phacoemulsification in eyes with refractory glaucoma and coexistent cataract. Included patients of 18years or older who underwent combined AADI-Phacoemulsification from June 2015 to January 2017 with at least 12months of consecutive follow-up. The best-corrected visual acuity, intraocular pressure (IOP), and the number of IOP-lowering medications were recorded at baseline, 2weeks, 1, 3, 6, 12, 18, and 24months. Cumulative probability of success was defined as IOP < 18mmHg or 30% reduction from the baseline at two consecutive postoperative visits after 3-months. Loss of light perception or reoperation for uncontrolled glaucoma or a complication was considered failure apart from IOP criteria. Seventeen eyes of 17 patients with a mean follow-up of 22.6 ± 4.0months were included. Baseline IOP and ocular hypotensive drugs reduced significantly from 27.9 ± 7.6mmHg to 14.0 ± 3.0mmHg (p < 0.001) and 3.24 ± 0.7 to 1.33 ± 1.1 (p = 0.001), respectively, at 24months. Cumulative probability of qualified success was 71.4% (95% Confidence Interval [CI] 40.6-88.2%) at 3months and was maintained from 6months onwards at 64.3% (95% CI 34.3-83.3%), up to 2years. Intravitreal steroid was injected in one eye (5.9%) of chronic cystoid macular edema, and tube repositioning was done in another for focal corneal decompensation. Combined AADI-Phacoemulsification surgery is a safe and effective option in providing favorable visual and IOP outcomes at an affordable cost in eyes with refractory glaucoma and coexistent cataract.

Management of Irvine-Gass syndrome with a scleral intraocular lens

Pseudophakic cystoid macular edema is a common complication when placing an intraocular lens (IOL) in the sulcus (8%). The vitrectomy with implantation of a new scleral-fixated IOL with self-blocking plugs permits to resolve the chronic pseudophakic cystoid macular edema resulting from the implantation of a 3-piece acrylic IOL placed in the sulcus. This new type of IOL seems to have multiple potential advantages compared with glued IOL or iris-claw IOL in the management of Irvine-Gass syndrome secondary to the placement of IOL in the sulcus.

Sulcus implantation of single-piece foldable acrylic intraocular lens after posterior capsule tear during phacoemulsification: Visual outcome and complications

Background: Posterior capsule tear (PCT) during phacoemulsification affects the type, site, and timing of intraocular lens (IOL) implantation. Aim: The aim was to evaluate the visual outcomes and complications following sulcus implantation of single-piece foldable acrylic IOL after PCT during phacoemulsification. Setting and Design: The retrospective observational study was conducted at a tertiary care center in eastern India. Methods: Records of patients between July 2017 and March 2020 were reviewed. Thirty-six eyes of 36 patients, in whom PCT had occurred during phacoemulsification, were included. Statistical Analysis Used: Microsoft Excel 2007 and SPSS 108 software were used. Preoperative and postoperative visual acuity was compared using paired t-tests. Postoperative visual outcomes and complications were assessed in percentage. Results: Postoperative visual acuity was ≥6/12 in 22 (61.11%) patients on day 1 and 30 (83.33%) patients on day 30, with a statistically significant improvement compared to preoperative vision (P < 0.05). On the first postoperative day, corneal edema was seen in 8 (22.22%) patients, increased anterior chamber reaction in 5 (13.89%) patients, and raised IOP in 4 (11.11%) patients. After 3 months, 2 (5.56%) patients needed antiglaucoma medications for IOP control, 1 (2.78%) had iridocyclitis, and 1 (2.78%) had chronic cystoid macular edema. The mean follow-up duration was 17.44 ± 12.15 months (range: 3–46 months). Conclusion: To conclude, sulcus implantation of posterior chamber IOL during phacoemulsification surgery complicated with PCT may be considered if the adequate lens is not available, and sufficient capsular support exists. Our study revealed a good final visual acuity with minimal complications, though more research to ascertain our results is warranted.

Intravitreal fluocinolone acetonide 0.19 mg (Iluvien®) for the treatment of uveitic macular edema: 2-year follow-up of 20 patients

To evaluate intravitreal 0.19mg fluocinolone acetonide implant (FAi) (Iluvien®) for the treatment of chronic non-infectious uveitis with associated cystoid macular edema (CME). A retrospective review of medical reports from a single Danish tertiary centre including 20 patients (20 eyes), treated with 0.19mg FAi for non-infectious uveitic CME. The primary endpoints were change in best corrected visual acuity (BCVA) and central retinal thickness (CRT). The secondary endpoints were recurrence rate, change in systemic treatment, and intraocular pressure (IOP). Mean follow-up of the 20 eyes was 2.3 ± 1.1years. BCVA improved at 6 (p = 0.13), 12 (p = 0.05), 18 (p = 0.03), and 24months and CRT decreased at 6 (p = 0.004), 12 (p = 0.006), 18, and 24months after 0.19mg FAi. Within 18months after implantation, four of 14 patients (28.6%) relapsed. Three of five patients discontinued systemic corticosteroids within 4months and one patient continued with reduced dose. Five of 10 patients receiving disease-modifying antirheumatic drugs (DMARDs) at time of implantation discontinued within 1year. No patients started new systemic treatment. Eight eyes were treated with topical IOP-lowering medication at the time of implantation, of these two later underwent trabeculectomy. There were no complications associated with previous glaucoma surgery. This long-term follow-up study showed that intravitreal treatment with 0.19mg FAi should be considered in the treatment of chronic non-infectious uveitic CME in selected patients. This treatment is safe even in selected glaucoma patients and may offer reduction or cessation of local or systemic anti-inflammatory treatment.

P34 The value of combined ophthalmology and rheumatology review- an unmet need

Case report - IntroductionRheumatic diseases manifest in different specialties including ophthalmology. Presentation with eye symptoms may be a sight-threatening emergency such as GCA. Other inflammatory symptoms such as uveitis present to the Eye Casualty frequently, which need prompt rheumatologist input for a holistic management.Case report - Case descriptionWe present an interesting case with multiple learning points for both rheumatologists as well as ophthalmologists.We present a case of a 73-year-old Caucasian lady who initially presented to the Eye Department. She was diagnosed as having bilateral uveitis by the ophthalmologist with an interest in uveitis. She had various investigations which showed positive HLA-B27 status, ENA, ANA, serum ACE level were normal; however, she was found to have raised immunoglobulins and plasma viscosity. She was treated with steroid eye drops and intravitreal dexamethasone implant in both eyes. She is a steroid responder and unfortunately developed glaucoma which needed two surgical procedures. She developed chronic cystoid macular oedema in Left eye.She did not have any symptoms of psoriasis or gut symptoms suggestive of inflammatory bowel disease. She did report symptoms of inflammatory bowel disease. She had an MRI of axial spine as per AS protocol, which confirmed inflammatory spondyloarthropathy. She was diagnosed to have non-radiographic spondyloarthropathy which is managed by simple anti-inflammatories. Her BASDAI is less than 3 and does not qualify for biologic treatment for her axial spondyloarthropathy. Her main symptoms were ocular, which is very active and she is not able to escalate to biologic therapy.Case report - DiscussionThis is a patient presenting with late-onset inflammatory back pain without any articular or extra-articular activity. Her main manifestation is spectrum of spondyloarthropathy with uveitis; however, we could not escalate her to biologics. She has been on topical, intraocular and oral steroids which has led on to complications. The combined clinic between rheumatologists and ophthalmologists is key in managing such patients.Case report - Key learning pointsRecurrent uveitis in HLA-B27 patients needs to be reviewed in ophthalmology combined services with rheumatologists to establish the diagnosis of SpADelay of diagnosis of SpA can be reduced by establishing combined uveitis/SpA services within the NHS widely

CYSTOID MACULAR EDEMA AFTER FOUR-POINT SCLERAL FIXATION OF INTRAOCULAR LENS.

To assess the incidence of cystoid macular edema (CME) associated with 4-point Gore-Tex suture intraocular lens (IOL) scleral fixation, before and after institution of routine intravitreal triamcinolone acetonide prophylaxis and long-term topical nonsteroidal anti-inflammatory drug usage. Consecutive patients were included after IOL implantation with concurrent pars plana vitrectomy for spontaneous IOL dislocation due to pseudoexfoliation syndrome. We compared short-term prophylactic nonsteroidal anti-inflammatory drugs only (Group A) to prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs (Group B). Twenty-six eyes of 26 patients with pseudoexfoliation syndrome and spontaneous IOL dislocation were studied. Mean logMAR visual acuity improved from 1.27 ± 0.80 (20/375 Snellen equivalent) preoperatively to 0.46 ± 0.39 (Snellen 20/43) postoperatively (P < 0.001). Visual outcomes were similar for Groups A and B. In Group A, 10/16 eyes had CME, 4/16 had chronic CME longer than 6 months, and 1 longer than 12 months. In Group B, 1/10 had CME (which was both chronic and refractory). In eyes with pseudoexfoliation syndrome and spontaneous IOL dislocation, 4-point Gore-Tex suture IOL ab externo fixation yielded good visual outcomes, although CME was observed more than reported elsewhere. Prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs seem to reduce the risk of postoperative CME.

Intravitreal Fluocinolone 0.19mg Implant in the Management of Chronic Non-Infectious Uveitis: 12-Month Outcomes from a Single Tertiary Centre

ABSTRACT Aim To present efficacy and safety of 0.19 mg fluocinolone acetonide insert (FAi) to treat chronic noninfectious uveitis (NIU) in a single referral center. Methods A retrospective observational clinical study of 11 eyes with NIU complicated by chronic cystoid macular edema (CMO). Results The main indication for treatment was chronic CMO in all 11 eyes. The mean central retinal thickness (CRT) at baseline was 435 μm ± 176, improving to 296 μm ± 67 at 12 months. Raised intraocular pressure (IOP) was the commonest adverse event. An IOP >21 mmHg was observed in three eyes, and >30 mmHg in one eye, managed with topical therapy. The mean best corrected visual acuity (BCVA) was stable at 12 months. There were no observed recurrences of uveitis. Two eyes received adjunctive treatment for worsening CRT. Conclusions Our results suggest FAi is an effective maintenance treatment for NIU with favorable functional and anatomical outcomes.

Surgery for idiopathic epiretinal membrane.

Epiretinal membrane is an abnormal sheet of avascular fibrocellular tissue that develops on the inner surface of the retina. Epiretinal membrane can cause impairment of sight as a consequence of progressive distortion of retinal architecture. To determine the effects of surgery compared to no intervention for epiretinal membrane. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, EmbaseOvid, ISRCTN registry, US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). There were no restrictions to language or year of publication. The databases were last searched on 20 May 2020. We included randomised controlled trials (RCTs) assessing surgical removal of idiopathic epiretinal membrane compared to placebo, no treatment or shamtreatment. Paired or within-person studies were included, as well as those where both eyes of a single participant were treated. We used standard methods expected by Cochrane, and assessed certainty using the GRADE system. We considered the following five outcome measures: mean change in best corrected visual acuity (BCVA) in the study eye between baseline (before randomisation), 6 months and 12 months later; proportion of people with a gain of 0.3 logMAR or more of visual acuity in the study eye as measured by a logMAR chart at a starting distance of 4 m at 6 months and 12 months after randomisation; proportion of people with a loss of 0.3 logMAR or moreof visual acuity in the study eye as measured by a logMAR chart at a starting distance of 4 m at 6 months and 12 months after randomisation; mean quality of life score at 6 months and 12 months following surgery, measured using a validated questionnaire; and any harm identified during follow-up. We included one study in the review. This was a RCT including 53 eyes of 53 participants with mild symptomatic epiretinal membraneand BCVA of 65 or more Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Participants were randomly allocated to immediate surgery or to watchful waiting with deferred surgery if indicated by evidence of disease progression. The study was limited by imprecision owing to the small number of participants and was at some risk of bias owing to inconsistencies in the time points for outcome assessment and in the management of lens opacity. At 12 months, the visual acuity in the immediate surgery group was higher by a mean of 2.1 (95% confidence interval (CI) -2.0 to 6.2 ETDRS letters; 53 participants; low-certainty evidence) than the watchful waiting/deferred surgery group. The evidence of the effect of immediate surgery on gains of 0.3 logMAR or more of visual acuity is very uncertain (risk ratio (RR) 0.55, 95% CI 0.06 to 4.93; 53 participants; very low-certainty evidence). At 12 months, no participant in either group sustained a loss of 0.3 logMAR or more of visual acuity(53 participants; low-certainty evidence). The included study did not measure quality of life. At 12 months, no serious adverse event was identified in any participant. One participant developed chronic minimal cystoid macular oedema following immediate surgery (53 participants; low-certainty evidence). We found no RCT that directly investigated the effect of surgery compared to no intervention. For severe disabling epiretinal membrane, the lack of a RCT comparing surgery to no intervention may reflect evidence from non-randomised studies in favour of surgery; a RCT may be considered unnecessary and ethically unacceptable because a superior effect of surgery is widely accepted. For mild symptomatic epiretinal membrane, however, the value of surgery is uncertain. Low-certainty evidence from this review suggests that watchful waiting or deferred surgery may offer outcomes as favourable as immediate surgery. However, this finding needs to be confirmed in further RCTs with appropriate statistical power, masking of treatment allocation, consistent management of cataract, and measurement of outcomes including patient-reported quality of life over a more extended time frame.

Stellate nonhereditary idiopathic foveomacular retinoschisis treated as cystoid macular edema

Stellate nonhereditary idiopathic foveomacular retinoschisis (SNIFR) is a rare eye disease, hitherto unreported in Indians. We report a case of SNIFR in an Indian female wrongly treated as cystoid macular edema (CME). Differentiation between chronic CME and foveoschisis is paramount while dealing with rare diseases like SNIFR.

Efficacy of Topical Nepafenac 0.3% in the Management of Postoperative Cystoid Macular Edema.

PurposeTo assess the effect of twice-daily nepafenac ophthalmic suspension 0.3% on postoperative cystoid-macular-edema (CME).Patients and MethodsIn this prospective, clinic-based, non-randomized case-series, 21 patients (21 eyes) were enrolled with either acute or chronic postoperative CME after cataract extraction. Patients were treated with twice-daily nepafenac 0.3% drops, and followed for at least a 4-month period. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT)-derived central retinal thickness (CRT) were measured.ResultsFrom 21 patients, eight presented with acute postoperative CME and 13 with chronic CME. Mean follow-up was 4.82±1.24 months. No adverse events were reported during the study. Baseline BCVA was 0.49±0.36 logMAR and improved to 0.36±0.42 logMAR at the last follow-up visit (P<0.005). CRT decreased from 450.40±90.74 μm at baseline to 354.60±81.49 μm (P<0.05), following treatment.ConclusionOur outcomes strongly suggest that administrating nepafenac 0.3% drops on a twice-daily regimen could be a promising alternative for the management of postoperative CME. Additional studies are necessary to further validate our results.

Retinal Detachment associated with Viral Retinitis

Viral retinitis of which incidence is 0.63/1000000 per year, is necrotizing, vaso-occlusive retinopathy. In practice, 90 % of cases are acute retinal necrosis in which etiological agents are Varicella-Zoster Virus and Herpes Simplex Virus and Cytomegalovirus retinitis. 65 % of patients with viral retinitis develop a retinal detachment. Retinal detachment due to viral retinitis is almost-always rhegmatogenous and tractional and associated with proliferative vitreoretinopathy. Pars plana vitrectomy combined with silicone oil injection is the most commonly used techniques for the treatment of retinal detachment associated with viral retinitis. Optic atrophy, chronic cystoid macular edema, epiretinal membrane, proliferative vitreoretinopathy, and hypotony are the most commonly seen complications that are limiting functional improvement.

The Role of Subthreshold Micropulse Yellow Laser as an Alternative Option for the Treatment of Refractory Postoperative Cystoid Macular Edema.

Background: To evaluate the efficacy and the safety of subthreshold micropulse yellow laser (SMYL) in the treatment of chronic postoperative cystoid macular edema (PCME), which is refractory to standard therapies. Methods: A retrospective chart review of ten eyes of ten patients affected by refractory PCME who underwent SMYL was performed. Five PCME cases were subsequent to uncomplicated cataract surgery (CS), two cases to complicated CS (CCS) with posterior capsule rupture and three cases occurred after retinal detachment surgery (RD). All conditions were refractory to conventional treatments prior to SMYL interventions for at least 4 months, including nonsteroidal anti-inflammatory eyedrops, topical steroids, oral indomethacin, sub-Tenon’s triamcinolone injections and Dexamethasone intravitreal implants. All patients underwent one or more treatments with 577 nm SMYL photo-stimulation, with 7 × 7 grids with confluent spots and a 5% duty cycle covering the whole edematous retina, including the foveal center. Best corrected visual acuity (BCVA) and central macular thickness (CMT) were obtained using OCT, and evaluated before and after the treatment at 1, 2, 3 and 6-month follow-ups. Results: A complete subfoveal macular edema resolution was observed in all of the eyes, with statistically significant improvements in terms of BCVA and CMT in all of the follow-up timelines (at 6 months, p = 0.002 and p = 0.005, respectively). The mean number of laser treatments was 1.3. At the final follow-up, a complete subfoveal edema reabsorption was observed in all patients with visual acuity improvement. No complications were observed in any case. Conclusions: SMYL seems to be a safe and effective treatment for the long-term resolution of refractory PCME and may be a useful alternative to expensive and invasive therapeutic options.

Czy terapia implantem doszklistkowym deksametazonu jest lepszym wyborem niż iniekcje leków anty-VEGF w leczeniu powikłań zakrzepu naczyń żylnych siatkówki?

Retinal vein occlusion (RVO) is a retinal vein disease whose complications can lead to decreased visual acuity and even blindness. The most common cause of decreased visual acuity during RVO is a chronic cystoid macular edema. The therapy involves medications with proven efficacy from the anti-VEGF group: ranibizumab, aflibercept, off-label bevacizumab and corticosteroids: dexamethasone in the form of a prolonged-release implant, fluocinolone, and off-label triamcinolone, characterized by short half-life. Scientific reports and clinical trials confirm the efficacy of anti-VEGF drugs and corticosteroids in the treatment of RVO. Therapy should be selected individually for each patient, including accompanying diseases, both systemic and local ailments. Anti-VEGF drugs and corticosteroids improve the retinal and choroidal morphology and restore the function of the retina by improving its sensitivity; confirmed in the microperimetric examination, which translates into improved visual acuity. Anti-VEGF therapy is associated with the necessity of reinjection, especially in the case of recurrence of macular edema and decreased visual acuity, which may result in the possibility of a reduced response to the medicine being used. In this situation, it is recommended to switch to another anti-VEGF drug or to a dexamethasone treatment.

Surgery for idiopathic epiretinal membrane

Background Epiretinal membrane is an abnormal sheet of avascular fibrocellular tissue that develops on the inner surface of the retina. Epiretinal membrane can cause impairment of sight as a consequence of progressive distortion of retinal architecture. Objectives To determine the effects of surgery compared to no intervention for epiretinal membrane. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, ISRCTN registry, US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). There were no restrictions to language or year of publication. The databases were last searched on 20 May 2020. Selection criteria We included randomised controlled trials (RCTs) assessing surgical removal of idiopathic epiretinal membrane compared to placebo, no treatment or sham treatment. Paired or within-person studies were included, as well as those where both eyes of a single participant were treated. Data collection and analysis We used standard methods expected by Cochrane, and assessed certainty using the GRADE system. We considered the following five outcome measures: mean change in best corrected visual acuity (BCVA) in the study eye between baseline (before randomisation), 6 months and 12 months later; proportion of people with a gain of 0.3 logMAR or more of visual acuity in the study eye as measured by a logMAR chart at a starting distance of 4 m at 6 months and 12 months after randomisation; proportion of people with a loss of 0.3 logMAR or more of visual acuity in the study eye as measured by a logMAR chart at a starting distance of 4 m at 6 months and 12 months after randomisation; mean quality of life score at 6 months and 12 months following surgery, measured using a validated questionnaire; and any harm identified during follow-up. Main results We included one study in the review. This was a RCT including 53 eyes of 53 participants with mild symptomatic epiretinal membrane and BCVA of 65 or more Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Participants were randomly allocated to immediate surgery or to watchful waiting with deferred surgery if indicated by evidence of disease progression. The study was limited by imprecision owing to the small number of participants and was at some risk of bias owing to inconsistencies in the time points for outcome assessment and in the management of lens opacity. At 12 months, the visual acuity in the immediate surgery group was higher by a mean of 2.1 (95% confidence interval (CI) -2.0 to 6.2 ETDRS letters; 53 participants; low-certainty evidence) than the watchful waiting/deferred surgery group. The evidence of the effect of immediate surgery on gains of 0.3 logMAR or more of visual acuity is very uncertain (risk ratio (RR) 0.55, 95% CI 0.06 to 4.93; 53 participants; very low-certainty evidence). At 12 months, no participant in either group sustained a loss of 0.3 logMAR or more of visual acuity (53 participants; low-certainty evidence). The included study did not measure quality of life. At 12 months, no serious adverse event was identified in any participant. One participant developed chronic minimal cystoid macular oedema following immediate surgery (53 participants; low-certainty evidence). Authors' conclusions We found no RCT that directly investigated the effect of surgery compared to no intervention. For severe disabling epiretinal membrane, the lack of a RCT comparing surgery to no intervention may reflect evidence from non-randomised studies in favour of surgery; a RCT may be considered unnecessary and ethically unacceptable because a superior effect of surgery is widely accepted. For mild symptomatic epiretinal membrane, however, the value of surgery is uncertain. Low-certainty evidence from this review suggests that watchful waiting or deferred surgery may offer outcomes as favourable as immediate surgery. However, this finding needs to be confirmed in further RCTs with appropriate statistical power, masking of treatment allocation, consistent management of cataract, and measurement of outcomes including patient-reported quality of life over a more extended time frame.

Advanced Birdshot Chorioretinopathy Presenting as Chronic Cystoid Macular Edema and Vitritis Following Cataract Surgery

Purpose: The purpose of this case report is to present a case of birdshot chorioretinopathy in an elderly woman who presented with postoperative macular edema and vitritis following cataract surgery. Methods: A retrospective case report was compiled of the use of optical coherence tomography, scanning laser ophthalmoscopy, fluorescein angiography, and wide-angle fundus photography to document exam findings. Results: An 81-year old woman presented with steroid-resistant bilateral cystoid macular edema and vitritis following cataract surgery. Clinical testing, including serum HLA-A29, was suggestive of birdshot chorioretinopathy. Pars plana vitrectomy with membrane peeling was performed, and the patient was started on both steroid-sparing immunomodulatory therapy and systemic corticosteroids. Her macular edema improved and her disease progression stabilized. Conclusions: To the best of the authors’ knowledge, this is the oldest patient diagnosed with birdshot chorioretinopathy to be reported in the literature. The unusual initial presentation following cataract extraction highlights the importance of diagnostic vigilance when facing an unusual case of posterior uveitis.