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Purpose To evaluate the effect of physician face mask use on rates and outcomes of post-injection endophthalmitis. Design Retrospective, comparative cohort study Methods . Setting Single-center Study Population Eyes receiving intravitreal anti-vascular endothelial growth factor injections from 7/1/2013 to 9/1/2019. Intervention Cases were divided into “face mask group” if face masks were worn by the physician during intravitreal injections or “no talking group” if no face mask was worn but a no talking policy was observed during intravitreal injections. Main Outcome Measures Rate of endophthalmitis, visual acuity, and microbial spectrum. Results Of 483,622 intravitreal injections administered, 168 out of 453,460 (0.0371%) cases of endophthalmitis occurred in the “no talking” group, and 9 out of 30,162 (0.0298%) cases occurred in the face mask group (odds ratio, 0.81; 95%CI, 0.41–1.57; p=0.527). Sixteen cases of oral flora-associated endophthalmitis were found in the “no talking” group (1 in 28,341 injections) compared to none in the face mask group (p=0.302). Mean logMAR visual acuity at presentation in cases that developed culture-positive endophthalmitis was significantly worse in the “no talking” group compared to the face mask group (17.1 lines lost from baseline acuity vs 13.4 lines lost; p=0.031), though no difference was observed at six months following treatment (p=0.479). Conclusion Physician face mask use did not influence the risk of post-injection endophthalmitis compared to a no talking policy. However, no cases of oral flora-associated endophthalmitis occurred in the face mask group. Future studies are warranted to assess the role of face mask use to reduce endophthalmitis risk, particularly due to oral flora., Highlights • Physician face mask use may not reduce the rate of post-injection endophthalmitis compared to a “no talking” policy • No cases of oral flora endophthalmitis were identified with physician face mask use • Visual outcomes following endophthalmitis were similar with physician face mask use compared to a “no talking” policy

To investigate factors associated with good visual acuity (VA) following repair of rhegmatogenous retinal detachments (RD) with proliferative vitreoretinopathy (PVR) undergoing retinectomy.Interventional, retrospective, case-control study.This single-institution study evaluated patients who underwent retinectomy during repair of RD with PVR from January 1, 2015 to December 31, 2019. A good VA cohort was identified based on a final VA ≥20/70. A 2:1 age-matched and gender-matched poor VA cohort with VA20/70 was subsequently identified. Metrics compared between the two cohorts included time from primary and recurrent RD diagnosis to surgery, lens status, initial RD size, macula involvement, PVR grade, and size of retinectomy.A total of 5355 eyes were diagnosed with primary RD during the study period, of which 345 had PVR and underwent retinectomy. The good VA cohort included 62 eyes with a mean final logMAR VA of 0.32 [Snellen 20/42], while the poor VA cohort included 119 eyes with a mean final logMAR VA of 1.54 [Snellen 20/693; P.0001]. On multivariate analysis, smaller initial RD size (P = .0090), fewer surgeries (P = .0002), shorter time between recurrent RD diagnosis and subsequent surgeries (P = .0006), better preoperative VA (P = .0276), and pseudophakia at final visit (P = .0049) remained significant predictors of good vision.Eyes undergoing retinectomy during repair of RD with PVR can achieve good VA outcomes. The primary modifiable factor associated with better VA was shorter delay between redetachment diagnosis and surgery, particularly in the absence of silicone oil tamponade.

To identify geographic and socioeconomic variables predictive of residential proximity to neovascular age-related macular degeneration (nAMD) clinical trial locations.Retrospective, cross-sectional study.Census tract-level data from public datasets and trial-level data from ClinicalTrials.gov were analyzed. We calculated the driving distance (60 miles) and time (60 minutes) from the population-weighted US census tract centroid to the nearest clinical trial site.We identified 42 trials studying nAMD across 829 unique clinical trial sites in the United States. In a multivariable model, driving distance60 miles had a significant association with rural location (adjusted odds ratio [aOR] 5.54; 95% confidence interval [CI] 3.86-7.96, P.0001) and with Midwest (aOR 2.30; 95% CI 1.21-4.38, P = .01) and South (aOR 2.43; 95% CI 1.21-4.91, P = .01) as compared to the Northeast region, and with some college or an associate's degree, as compared to a bachelor's degree (aOR 1.02; 95% CI 1.01-1.04, P = .0007, and aOR 1.05; 95% CI 1.00-1.10, P = .04, respectively). Lower odds of traveling60 miles to the nearest nAMD trial site were associated with census tracts with a higher percentage of blacks (aOR 0.98; 95% CI 0.97-0.99, P.0001), Hispanics (aOR 0.97; 95% CI 0.95-0.99, P = .002), and Asians (aOR 0.90; 95% CI 0.88-0.93, P.0001), as compared to whites, and with a lower percentage of the population200% of the federal poverty level. Similar predictors were found in time traveled60 minutes.There are geographic access disparities of clinical trial sites for nAMD in the United States.

Purpose To investigate bacterial dispersion with patient face mask use during simulated intravitreal injections. Design Prospective cross-sectional study MethodsSetting Single-center Study Population Fifteen healthy subjects were recruited Intervention Each participant was instructed not to speak for 2-minutes, simulating a “no-talking” policy, while in an ophthalmic examination chair with an blood agar plate secured to the forehead and wearing various face masks (no mask, loose fitting surgical mask, tight-fitting surgical mask without tape, tight-fitting surgical mask with adhesive tape securing the superior portion of the mask, N95 mask, and cloth mask). Each scenario was then repeated while reading a 2-minute script, simulating a talking patient. Main Outcome Measures Number of colony-forming units (CFU) and microbial species. Results During the “no-talking” scenario, subjects wearing a tight-fitting surgical mask with tape developed fewer CFUs compared to subjects wearing the same mask without tape (difference, 0.93CFU; 95%CI, 0.32–1.55; P=.003). During the speech scenarios, subjects wearing a tight-fitting surgical mask with tape had significantly fewer CFUs compared to subjects without a face mask (difference, 1.07CFU; P=.001), subjects with a loose face mask (difference, 0.67; P=.034), and subjects with a tight face mask without tape (difference, 1.13; P.99) and “speech” (P=.831) scenarios. No oral flora was isolated in “no-talking” scenarios, but was isolated in 8/75 (11%) cultures in speech scenarios (P=.02). Conclusion Addition of tape to the superior portion of a patient’s face mask reduced bacterial dispersion during simulated intravitreal injections, and had no difference in bacterial dispersion compared to wearing N95 masks., Highlights • Patient face mask use may alter bacterial dispersion around the eye during intravitreal injections. • There was significantly more bacterial dispersion when wearing a tight-fitting face mask without tape compared to wearing a tight-fitting mask with tape. • There was no difference in bacterial dispersion between tight-fitting surgical masks with tape and N95 masks. • Taping the superior portion of a patient’s face mask may limit bacterial dispersion when performing intravitreal injections.

Purpose To evaluate the incidence of unexpected management changes on the first day after pars plana vitrectomy (PPV) for retinal detachment repair. Design Retrospective cohort study. Methods The medical and billing records of a large academic private practice were electronically queried for all cases of PPV for retinal detachment performed between January 1, 2017, and December 31, 2017. All cases of PPV for rhegmatogenous or tractional retinal detachment with completed postoperative day 1 (POD1) and postoperative week 1 (POW1) visits were included. The preoperative consultation, operative report, and POD1 and POW1 (postoperative days 5-14) visits were reviewed. Main outcome measures were incidence of unexpected management changes (change in or extended positioning, additional procedure, change in drop regimen, or shortened interval follow-up) at the POD1 visit after uncomplicated PPV for retinal detachment. Results Overall, 418 surgeries from 364 eyes and 355 patients were included. Eleven cases (2.6%) had an intraocular pressure (IOP) over 30 mm Hg at POD1. IOP-lowering drops were prescribed for 30 cases (7.2%). Silicone oil tamponade was positively associated with high IOP at POD1 (relative risk = 3.23, 95% confidence interval 0.96-10.84, P = 0.06). No additional management changes were made besides treating elevated IOP. Conclusions Management changes on POD1 after vitrectomy for retinal detachment repair are relatively uncommon and were solely IOP related in this patient group. There may be flexibility regarding the type of POD1 encounter necessary, including an IOP check with an ophthalmic technician or non–retinal eye care provider. Larger, prospective studies are needed to better determine the most efficient follow-up routine.

PURPOSE To evaluate practice patterns for bilateral same-day intravitreal anti-vascular endothelial growth factor (VEGF) injections and determine the rate of unilateral and bilateral postinjection endophthalmitis after bilateral same-day intravitreal anti-VEGF injections. DESIGN Retrospective cohort study. METHODS The records of a large academic private practice were electronically queried for all office visits, during which bilateral intravitreal anti-VEGF injections were performed between April 1, 2012 and August 21, 2017 for patients with a diagnosis of neovascular age-related macular degeneration, diabetic macular edema, or retinal vein occlusion. Demographic information and indication for injection were recorded for each patient and office visit. Charts of patients with endophthalmitis were reviewed, and information was collected on presentation examination, culture data, and visual outcomes. RESULTS During the study period, 101 932 bilateral same-day intravitreal anti-VEGF injections were performed over 50 966 office visits for 5890 patients. The mean (standard deviation) age of patients in this cohort was 74.2 (14.1) years and 60.6% of patients were female. The 2 most common indications for injection were neovascular age-related macular degeneration (54.3% of patients) and diabetic macular edema (35.4% of patients). Twenty-eight cases of endophthalmitis (0.027% of total injections) occurred during the study period. There were no cases of bilateral endophthalmitis, and no patients had more than 1 occurrence of endophthalmitis. CONCLUSIONS In this large cohort of patients undergoing bilateral same-day intravitreal anti-VEGF injections, there were no cases of bilateral endophthalmitis. Additionally, the overall rate of unilateral endophthalmitis was low and comparable to prior studies of unilateral injections. These results support the safety of bilateral same-day intravitreal anti-VEGF treatment.

Purpose To determine the efficacy and durability of aflibercept used in a treat-and-extend (TAE) regimen for neovascular age-related macular degeneration (NVAMD). Design Multicenter, prospective, open label, noncomparative, interventional study. Methods Forty eyes of 40 patients with treatment-naive NVAMD were managed with a TAE regimen of intravitreal aflibercept. The main endpoints were the change in mean and median best-corrected visual acuity from baseline at years 1 and 2. Other endpoints included mean number of annual injections and treatment intervals. Results Thirty-five (87.5%) and 31 patients (77.5%) completed year 1 and year 2, respectively. The mean letter gain was 7.2 ( P P = .269) letters at 1 and 2 years, respectively, from a mean baseline of 58.9 letters (20/63 Snellen equivalent). The median visual gain was 11.5 and 7.5 letters at 1 and 2 years, respectively, from a median baseline of 59.0 letters (20/63 Snellen equivalent). The mean number of injections was 8.0 and 6.5 during the first and second year, respectively. Twelve-week or longer treatment intervals were used in 35% and 38% of patients during the first- and second-year time points, respectively. Conclusion Intravitreal aflibercept TAE therapy led to significant visual improvement in eyes with NVAMD at 1 year, with some loss in the visual gains at the end of year 2 that was not related to loss of exudative control. TAE therapy with aflibercept is a rational strategy to reduce treatments and clinic evaluations over 2 years with satisfactory outcomes.

To evaluate endophthalmitis rates after penetrating keratoplasty (PK) and endothelial keratoplasty (EK) and to compare clinical outcomes.Retrospective cohort study.The medical and billing records of several large academic private practices in Philadelphia, PA were electronically queried for all surgical visits during which a PK or EK was performed between April 1, 2012 and August 31, 2018. Demographic information and transplant characteristics were recorded for each patient and office visit. An additional query was performed to identify all cases of endophthalmitis based on diagnosis and procedure billing codes. Charts of patients with endophthalmitis were individually reviewed, and information was collected on triggering factors, clinical evaluation at presentation, management, culture data, visual outcomes, and graft survival rates. The main outcome measure was incidence of presumed infectious endophthalmitis following PK or EK.During the study period, 1676 PKs and 2292 EKs for 3069 patients were performed. The mean age of patients in this transplant cohort was 66.4 (± 17.5) years and 54.6% of patients were women. Sixteen cases of endophthalmitis occurred during the study period; 12 cases of endophthalmitis occurred after PK and 4 cases occurred after EK. The rate of endophthalmitis after EK (4 of 2292; 0.2%) was significantly lower than that after PK (12 of 1676; 0.7%) (P = .01). In addition, the odds of developing endophthalmitis after PK or EK performed in conjunction with anterior vitrectomy were significantly higher than after either PK or EK alone (odds ratio 8.66; 95% confidence interval 2.98-25.18; P.001). Visual acuity outcomes were poorer after PK-related endophthalmitis than EK-associated cases (P = .01). The rate of graft failure at final follow-up was significantly higher in post-PK endophthalmitis (P = .02).In this large cohort of patients undergoing either PK or EK, rates of endophthalmitis were low for both procedures and significantly lower for EK compared with PK. Eyes with endophthalmitis after PK had poorer visual acuity outcomes and graft prognosis compared with those with endophthalmitis after EK.

� PURPOSE: To evaluate the outcome of pars plana vitrectomy, subretinal tissue plasminogen activator (t-PA) infusion and intraocular gas tamponade with and without postsurgical antivascular endothelial growth factor (VEGF) injection for thick submacular hemorrhage due to exudative age-related macular degeneration (AMD). � DESIGN: Retrospective, comparative, interventional case series. � METHODS: SETTING: 2 retina referral centers. The patient population included 101 eyes of 101 patients with neovascular AMD and thick submacular hemorrhage who underwent surgical displacement of the hemorrhage with or without postoperative anti-VEGF injections. Main outcome measures included degree of blood displacement, best and final postoperative visual acuity (VA), and adverse events. Snellen acuity was converted to logMAR for statistical analysis. � RESULTS: All patients were followed for a minimum of 3 months (mean, 15.3 months, range, 3-70 months). In 83 (82%) of 101 eyes, the procedure resulted in complete hemorrhage displacement from the fovea. Mean preoperative VA was 20/2255 (2.05 logMAR). The acuity significantly improved to 20/893 (1.65 logMAR) at month 1 (P < 0.001) at month 1; 20/678 (1.53 logMAR) at month 3 (P < 0.001), and 20/1150 (1.76 logMAR) at month 12 (P [ 0.002). Best postoperative visual acuity improved by at least 1 line in 83 (82%) of 101 eyes, and 19.6% of eyes gained 3 lines or more at month 3. The visual acuity of the group of eyes that received postoperative anti-VEGF injection (n [ 39) showed greater visual acuity improvement 6 months postoperatively compared to the group of eyes that did not receive postoperative anti-VEGF. Postoperative complications included vitreous hemorrhage in 2 eyes, rhegmatogenous retinal detachment in 4 eyes, and recurrent thick subretinal hemorrhage in 6 eyes. � CONCLUSIONS: Vitrectomy with subretinal t-PA injection and gas tamponade was found to be relatively effective for displacement of thick submacular hemorrhage with a significant improvement in visual acuity. There is a loss of acuity over time; the addition of postoperative anti-VEGF therapy may help maintain the visual

To evaluate the association between initial subfoveal choroidal thickness and response to anti-vascular endothelial growth factor (anti-VEGF) therapy in central retinal vein occlusion (CRVO) eyes.Retrospective cohort study.Forty-three eyes from 42 patients with treatment-naïve CRVO were included. All patients included were treated with a standard algorithm of 3 monthly anti-VEGF injections. Serial enhanced depth imaging optical coherence tomography scans were used to measure subfoveal choroidal thickness and central macular thickness (CMT). Baseline predictors (particularly choroidal thickness) for functional response (best-corrected visual acuity gain ≥2 lines) were assessed at 3 months follow-up using univariate and multivariate analyses.Forty-three eyes from 42 patients were included. Initial choroidal thickness in CRVO eyes (246 ± 102 μm) was greater than in their fellow eye (197 ± 86 μm; P = .023). In addition, mean choroidal thickness at baseline for functional responders (272.2 ± 107.3 μm) was greater than that of nonresponders (209.6 ± 85.8 μm; P = .039). A higher baseline choroidal thickness (for every 100-μm increase in choroidal thickness) was found to be a positive predictor for functional response (regression coefficient: 0.7; P = .04) on univariate analysis, whereas age (70 years old) was the only positive predictor for functional response with an odds ratio of 6.49 (95% confidence interval: 1.11-38.1; P = .03) on multivariate regression analysis.Baseline choroidal thickness and age may help predict which patients with CRVO have favorable visual outcomes following short-term anti-VEGF therapy.

Purpose To characterize anatomic and visual outcomes in patients with full-thickness macular hole (FTMH) at baseline in ocriplasmin phase 3 clinical trials, focusing on the relationship between resolution of vitreomacular adhesion and FTMH closure. Design Two multicenter, randomized, double-masked clinical trials. Methods Pharmacologic FTMH closure was one of multiple secondary endpoints. OCT scans were obtained at baseline and at all postinjection visits, and for patients with baseline FTMH, evaluated for FTMH width, vitreomacular adhesion, and epiretinal membrane. Results FTMH closure was observed in a greater proportion of ocriplasmin- vs vehicle-injected patients with baseline FTMH width ≤250 μm (58.3% vs 16.0%, P 250 to ≤400 μm (36.8% vs 5.3%, P = .009). Among FTMH patients in the ocriplasmin group, ≥2-line visual acuity gains at month 6 were achieved by a greater percentage of those who achieved hole closure at day 28 vs those who did not achieve this outcome (72.1% vs 25.4%). Conclusions Ocriplasmin demonstrated efficacy in closure of small and medium FTMH, and in FTMH without epiretinal membrane at baseline. Visual acuity gains occurred more frequently when hole closure was achieved after ocriplasmin treatment compared to when this outcome did not occur. Ocriplasmin treatment is an additional option for the management of patients with FTMH and vitreomacular adhesion.

Purpose To analyze a single center's experiences with ocriplasmin on vitreomacular traction (VMT) and the rate of VMT release, full-thickness macular hole (full-thickness MH) closure, and best-corrected visual acuity (BCVA) changes. Design Retrospective interventional case series. Methods Single-center study of 58 eyes of 56 patients who received intravitreal ocriplasmin for VMT with or without full-thickness MH. VMT release, full-thickness MH closure, visual acuity changes, and anatomic characteristics on spectral-domain optical coherence tomography (SD OCT) were analyzed. Results VMT resolved in 29 of 58 eyes (50%) and nonsurgical closure of full-thickness MH was achieved in 4 of 15 eyes (27%). Mean logMAR BCVA among all treated eyes improved from 0.51 (20/65) at baseline to 0.36 (20/46) at final follow-up ( P = .0018) with mean follow-up of 8.7 months. When compared to eyes without VMT release, eyes with successful vitreomacular release had a better pretreatment BCVA (20/48 vs 20/89, P = .004) and final follow-up BCVA (20/31 vs 20/68, P = .0001). Improvement in BCVA was significant in eyes with VMT release ( P = .0001). Transient ellipsoid zone changes were noted in 26% of treated eyes (n = 15), of which 14 had successful VMT release. Transient subfoveal fluid accumulation was noted in all these patients with vitreomacular release. Mean time to resolution of ellipsoid zone changes was within 38 days. Conclusion In clinical practice, intravitreal injection of ocriplasmin achieved VMT release in approximately one half of treated eyes, with a 27% closure rate for full-thickness MH. Transient ellipsoid changes were evident in 26% of treated eyes, more common in eyes with successful VMT release.

To determine 3-year treatment outcomes after 1 to 3 years of ranibizumab or bevacizumab therapy using a treat-and-extend regimen in patients with neovascular age-related macular degeneration (AMD).Retrospective, interventional, consecutive case series.We treated 212 eyes from 196 patients diagnosed with treatment-naive neovascular AMD between January 2009 and March 2013; they were treated with either ranibizumab or bevacizumab for a minimum of 1 year, using a treat-and-extend regimen. The main outcome measures were change from baseline best-corrected Snellen visual acuity (BCVA), proportion of eyes losing3 BCVA lines, proportion of eyes gaining ≥ 3 BCVA lines, change from baseline central retinal thickness, and mean number of injections at 1, 2 and 3 years of follow-up.The mean follow-up period was 1.88 years (median, 2 years). At baseline, mean BCVA was 20/139; it improved to 20/79 (P0.001) after 1 year of treatment and was maintained at 20/69 and 20/64 at 2 and 3 years follow-up (P0.001), respectively. At baseline, mean central retinal thickness was 351 μm and significantly decreased to 285 μm, 275 μm and 276 μm at 1, 2 and 3 years of follow-up (P0.001), respectively. Patients received, on average, 7.6, 5.7 and 5.8 injections over years 1, 2 and 3 of treatment, respectively. At final follow-up, 94% of eyes had lost3 lines BCVA, and 34.4% of eyes had gained ≥ 3 lines BCVA.The treat-and-extend regimen is effective in achieving and maintaining visual and anatomic improvements in patients with neovascular AMD for up to 3 years of treatment.

To evaluate the short-term functional and anatomic outcomes of patients with persistent diabetic macular edema (DME) who were converted from bevacizumab and/or ranibizumab to aflibercept.Retrospective, interventional, noncomparative, consecutive case series.Only eyes treated with at least 4 consecutive injections of ranibizumab/bevacizumab spaced 4-6 weeks apart prior to conversion and with at least 2 aflibercept injections afterward were considered for inclusion. Pertinent patient demographic, examination, and treatment data were extracted from clinical charts and tabulated for analysis.Fifty eyes of 37 patients were included. Eyes received a mean of 13.7 bevacizumab/ranibizumab injections prior to conversion, followed by 4.1 aflibercept injections over 4.6 months of subsequent follow-up. The mean logMAR visual acuity at the pre-switch visit was 0.60 ± 0.43 (Snellen equivalent, 20/80). This improved to 0.55 ± 0.48 (Snellen equivalent, 20/70) by the second visit after conversion, corresponding to a mean logMAR change of -0.05 ± 0.22 (P = .12). The average central macular thickness from the pre-switch spectral-domain optical coherence tomography scan was 459.2 ± 139.2 μm. This significantly improved to 348.7 ± 107.8 μm by the second visit following conversion, reflecting a mean decrease of 112 ± 141 μm (P .0001). The mean intraocular pressure (IOP) recorded at the pre-switch visit was 15.1 ± 3.3 mm Hg. At the second follow-up after converting to aflibercept, the IOP averaged 14.9 ± 3.2 mm Hg, with a mean decrease of 0.2 ± 3.0 mm Hg (P = .63).Conversion to aflibercept for persistent DME resulted in significant anatomic improvements. While trends towards improved visual acuity and reduction in IOP were observed, these were not statistically significant.

Purpose To examine the usefulness of 23-gauge pars plana vitrectomy (PPV) in removing retained lens fragments and to determine which cases require 20-gauge ultrasonic fragmentation. Design Retrospective comparative case series. Methods Twenty eyes in 20 consecutive patients who had 23-gauge PPV for retained lens fragments after complicated cataract surgery at Wills Eye Institute were retrospectively reviewed. Retained lens fragments were graded based on percentage of total nuclear size. Every surgical case started with 23-gauge PPV, but 1 sclerotomy was enlarged to facilitate 20-gauge ultrasonic fragmentation if all lens material could not be adequately removed. Results Twelve patients (60%) were successfully managed with 23-gauge PPV alone while 8 patients (40%) required 20-gauge ultrasonic fragmentation. The 23-gauge cases had a lower percentage of retained lens fragments (median 10%, range 0% to 75%) compared to the 20-gauge cases (median 90%, range 10% to 100%). Conclusion 23-Gauge PPV is a feasible approach in the surgical management of select cases of retained lens fragments.

To provide prompt visual rehabilitation and to reduce the need for repeated operations, we performed vitrectomy with silicone oil tamponade in 16 consecutive eyes with retinal detachments related to cytomegalovirus retinitis and acute retinal necrosis in 13 patients with acquired immunodeficiency syndrome. In all 16 eyes (100%), retinas were reattached with one operation. Preservation of ambulatory vision was achieved in six of eight eyes (75%; mean follow-up, 14.6 weeks). No patient with hand motion visual acuity or worse preoperatively recovered ambulatory vision. Visual acuity recovery was limited by optic nerve disease in five eyes (31%). Silicone oil-related side effects did not adversely affect visual outcome in any eye. Six patients (46%) have since died (mean, 4.4 months postoperatively). These data indicated that successful surgical repair of these detachments can be consistently achieved with this approach. The prognosis for ambulatory vision is strongly related to preoperative visual acuity.

To report the initial experience and safety profile of 23-gauge pars plana vitrectomy (PPV) in eyes undergoing vitreoretinal surgery.Retrospective, multicenter, consecutive, interventional case series.The inclusion criteria for this study included eyes that underwent primary, 23-gauge PPV for various indications including, but not limited to, epiretinal membrane, nonclearing vitreous hemorrhage, idiopathic macular hole, and rhegmatogenous retinal detachment (RD), and postoperative follow-up of at least 12 weeks. Exclusion criteria included history of prior vitrectomy, glaucoma filtration surgery, or administration of gas at expansile concentrations. Main outcome measures included best-corrected Snellen visual acuity (VA), intraocular pressure (IOP), intraoperative complications, and postoperative complications.Ninety-two patients met the inclusion criteria. The overall VA improved from 20/238 (range, 20/25 to hand motions [HM]) preoperatively to 20/82 (range, 20/20 to HM) postoperatively (P.001). Each surgical indication experienced a statistically significant VA improvement. Intraoperative complications included retinal tears observed in two eyes (2.2%). Sclerotomy sutures were required intraoperatively in two eyes (2.2%). Postoperative complications included postoperative day 1 hypotony in six eyes (6.5%), a retinal tear in one eye (1.1%), and a recurrent RD in one eye (1.1%). No cases of endophthalmitis were observed.Intraoperative and postoperative complications were rare in this series of 23-gauge vitrectomy. Postoperative day 1 hypotony was the most common complication observed. All cases of postoperative hypotony resolved at postoperative week 1 without intervention. Retinal tear or detachment was an uncommon complication in the intraoperative and postoperative settings. Postoperative endophthalmitis was not noted in this case series.

Purpose To present the microbiologic spectrum and susceptibilities of isolates in posttraumatic endophthalmitis, and to provide a review of the literature. Design Retrospective consecutive case series. Methods A review of 1182 consecutive open globe injuries was performed, identifying 10 patients with culture-proven endophthalmitis. Results Thirteen organisms were isolated from 10 eyes with posttraumatic endophthalmitis. Isolated organisms included Streptococcus species (46.2%), coagulase-negative Staphylococcus (23.1%), and Bacillus cereus (15.4%). All organisms tested were susceptible to vancomycin and tobramycin. The most commonly isolated organisms from an aggregate posttraumatic endophthalmitis pool of 372 cases obtained by literature-based meta-analysis were coagulase-negative Staphylococcus (21.5%) and Bacillus cereus (18.5%). Conclusion We report a high prevalence of gram-positive pathogens and a notable prevalence of Bacillus cereus in posttraumatic endophthalmitis. Susceptibility results suggest that posttraumatic endophthalmitis isolates are generally susceptible to vancomycin and tobramycin.

Purpose To determine the incidence of subsequent retinal tears (SRT) in patients who were previously treated for acute posterior vitreous detachment (PVD)-related retinal tears. Design Retrospective chart review. Methods A retrospective chart review of 155 eyes of 137 consecutive patients treated for acute PVD-related retinal tears was performed. Results During a median follow-up of 13 months (range 3 to 157 months) after treatment, SRT developed in 19 (12.2%) of 155 treated eyes. Most of the SRT occurred during the first 6 months (12 of 19 eyes) after initial treatment. Subsequent vetinal tears developed within the first 12 months in 15 of 19 treated eyes, however only six of 15 of these eyes were symptomatic. Of those patients who developed SRT after 12 months, all had new visual symptoms. Conclusion Patients who present with acute PVD-related retinal tears are at a low but significant risk for developing SRT. A significant number of patients treated for PVD-associated retinal tears present within 1 year with SRT without symptoms.

To determine the association between baseline subfoveal choroidal thickness and short-term response to intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy in diabetic macular edema (DME).Retrospective, consecutive case series.Fifty-three eyes from 42 patients diagnosed with treatment-naïve DME were treated with 3 monthly intravitreal injections of ranibizumab or bevacizumab. Serial enhanced depth imaging optical coherence tomography scans were used to measure subfoveal choroidal thickness and central macular thickness (CMT). Anatomic response (CMT decrease ≥ 50 μm) and functional response (best-corrected visual acuity gain ≥ 1 line) were assessed at 3 months follow-up using univariate and multivariate analyses.After 3 monthly anti-VEGF treatments, subfoveal choroidal thickness decreased significantly (225 μm at baseline, 201 μm at 3 months, P.0001). The anatomic responder group (32 eyes) had a greater baseline choroidal thickness (243 ± 15 μm) than the nonresponder group (21 eyes, 198 ± 13 μm, P = .03). Similarly, the functional responder group (28 eyes) tended to have a greater baseline subfoveal choroidal thickness (239 ± 12 μm) than the nonresponder group (25 eyes, 211 ± 16 μm, P = .08). Multivariate analyses revealed that a greater baseline subfoveal choroidal thickness was associated with a better anatomic (odds ratio = 1.12 for every 10 μm increase, P = .03) and functional response (odds ratio = 8.45 for200 μm vs ≤ 200 μm, P = .008).Baseline subfoveal choroidal thickness may help predict which patients with DME will respond more favorably in the short term to intravitreal anti-VEGF pharmacotherapy. In this study, eyes with a thicker baseline subfoveal choroidal thickness had better short-term anatomic and functional responses.

Purpose To compare the rate of intraoperative sclerotomy-related retinal breaks (SRRB) between 20- and 25-gauge vitrectomy systems for the correction of macular pucker (MP) and macular hole (MH). Design Retrospective interventional case series. Methods Single institution review of 347 consecutive eyes of 333 patients between August 2003 and May 2005 receiving pars plana vitrectomy (PPV) for MP or MH repair. Eyes were excluded if they had any form of proliferative retinopathy, or if there was an intraoperative conversion of any sclerotomy from 25- to 20- gauge. Results Fourteen (6.4%) of 219 eyes in the 20-gauge group had SRRB vs 4 (3.1%) of 128 eyes in the 25-gauge group (Fisher exact test, P value = .22). Conclusions There was a trend for slightly lower rates of intraoperative sclerotomy-related retinal breaks, single or multiple, with 25-gauge PPV compared with 20-gauge PPV, but the differences were not statistically significant.

To describe metallic intraocular foreign body (IOFB) injuries and identify prognostic factors for visual outcome and globe survival.Interventional, consecutive, retrospective case series.setting: Wills Eye Hospital. study population: Ninety-six eyes of 96 patients with metallic intraocular foreign bodies. procedures: Metallic IOFB injuries between January 1991 to June 2002 were reviewed for clinical characteristics, surgical intervention, and outcome. Univariate and multivariate analyses were performed to identify prognostic variables. main outcome measures: Final visual acuity and globe survival.The average patient age was 33.0 years with a male predominance (94%). Forty percent of eyes had a presenting vision of 20/50 or better. Following IOFB removal, 40% of patients required additional interventions. Thirty-one percent of eyes had a final acuity of 20/50 or better. Eight percent of patients ultimately required enucleation or evisceration. Excellent visual outcome (defined asor =20/50) was associated with multiple variables, including normal lens at presentation and anterior segment IOFB (P.003). Factors associated with poor visual outcome (defined as20/200) included uveal prolapse and posterior segment IOFB (P.0003). Globe loss was associated with younger age, presenting light perception (LP) or no light perception (NLP) vision, BB/pellet injury, and the presence of an afferent pupillary defect (P.01).Multiple prognostic factors were identified in this large analysis of metallic IOFB injuries, which may help predict visual outcome and globe survival. Most of these variables were independent of intervention and can be identified at the time of initial presentation.

Purpose To evaluate the efficacy and safety of ranibizumab administered monthly for three months and then quarterly in patients with subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). Design Phase IIIb, multicenter, randomized, double-masked, sham injection-controlled trial in patients with predominantly or minimally classic or occult with no classic CNV lesions. Methods Patients were randomized 1:1:1 to 0.3 mg ranibizumab (n = 60), 0.5 mg ranibizumab (n = 61), or sham (n = 63) treatment groups. The primary efficacy endpoint was mean change from baseline visual acuity (VA) at month 12. Results Mean changes from baseline VA at 12 months were −16.3, −1.6, and −0.2 letters for the sham, 0.3 mg, and 0.5 mg groups, respectively ( P ≤ .0001, each ranibizumab dose vs sham). Ranibizumab arrested CNV growth and reduced leakage from CNV. However, the treatment effect declined in the ranibizumab groups during quarterly dosing (e.g., at three months the mean changes from baseline VA had been gains of 2.9 and 4.3 letters for the 0.3 mg and 0.5 mg doses, respectively). Results of subgroups analyses of mean change from baseline VA at 12 months by baseline age, VA, and lesion characteristics were consistent with the overall results. Few serious ocular or nonocular adverse events occurred in any group. Conclusions Ranibizumab administered monthly for three months and then quarterly provided significant VA benefit to patients with AMD-related subfoveal CNV and was well tolerated. The incidence of serious ocular or nonocular adverse events was low.

Purpose The vision gains reported with monthly intravitreal ranibizumab in the MARINA and ANCHOR trials led to an immediate paradigm shift in the treatment of neovascular AMD with retina physicians universally switching to the pan-VEGF blocking agents ranibizumab and bevacizumab, and patients expecting visual improvement. As these agents are primarily used on a pro re nata (PRN) dosing schedule (because neither patients nor physicians want monthly injections), the factors involved in making the treatment and retreatment decisions are very important in any attempt to maximize vision gain. Design Analysis of literature, ongoing clinical trials, and the clinical assessments that can aid clinicians in treatment and retreatment decisions. Methods Literature review and perspective. Results If a monthly injection protocol is not used, clinicians should use both functional and anatomic criteria to attempt to guide treatment and retreatment decisions. Qualitative optical coherence tomography (OCT) appears to be the most sensitive and practical assessment tool to determine anatomic response to treatment but should be used in conjunction with clinical examination. Conclusions If monthly intravitreal injections are not performed, a combination of clinical examination (looking for new hemorrhage) and qualitative OCT (to assess response to treatment and early signs of recurrent leakage) can be used to guide anti-vascular endothelial growth factor (anti-VEGF), treatments with the goal of maintaining a "normal" retinal anatomy in an attempt to maximize the benefit (visual acuity gains) to risk (number of injections required) ratio.