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Our case emphasizes the approach of a single-dose of intraoperative methotrexate (MTX) – applied directly into silicone oil – to arrest the anomalous progression of proliferative vitreoretinopathy (PVR). A 78-year-old male presented with severe vision loss secondary to a pseudophakic macula-off rhegmatogenous retinal detachment oculus sinister (OS). He was initially treated with primary pars plana vitrectomy and intraocular gas; however, the patient developed recurrent macula-off retinal detachment complicated by proliferative vitreoretinopathy OS. Subsequent management involved vitrectomy with membrane removal, silicone oil tamponade, and adjuvant intravitreal MTX. The patient had an uneventful postoperative recovery with a dramatic vision improvement after silicone oil removal OS. Here, we highlight the use of silicone oil tamponade with single-dose adjuvant MTX for the management of complex retinal detachment associated with proliferative vitreoretinopathy.

This report describes a unique case of chronic unilateral anterior uveitis associated with macular edema while on oral dabrafenib treatment for chronic recurrent pilocytic astrocytoma. After gradual taper of prednisolone acetate OS, the patient developed recurrent mild low-grade anterior uveitis and macular edema OS that required low dose of prednisolone acetate OS to prevent recurrences while on oral dabrafenib. When oral dabrafenib was temporarily discontinued for 3 months due to her ocular inflammation, she had no flares of her uveitis; however, her tumor increased significantly in size. The collaborative decision was made to continue her oral dabrafenib while on topical anti-inflammatory therapy for her uveitis. Clinicians should be aware of this potential unilateral sequela of uveitis secondary to dabrafenib. Further investigation should be conducted to identify factors that may place certain patients at higher risk for this complication.

Retinal tissue is prone to oxidant burden and oxidative stress secondary to the generation of reactive oxygen species from high metabolic demand. The formation of reactive oxygen species occurs primarily from the mitochondrial respiratory chain as well as several enzymatic and oxidation reactions that occur in the neurosensory retina and retinal pigment epithelium. This oxidative stress has been implicated in the pathogenesis of several retinal diseases and the role of antioxidants as a therapeutic treatment shows promise in slowing the progression of certain diseases. The aim of this narrative review is to describe the mechanisms of retinal oxidative stress and summarize the current available evidence for antioxidants as a treatment for vitreoretinal disorders.

Purpose: Acute macular neuroretinopathy (AMN) is a rare clinical entity with an uncertain etiology. We report an atypical case presenting with retinal hemorrhages (RH) and cotton-wool spots (CWS) following non-ocular trauma. Observations: A 49-year-old male presented with an acute onset of a paracentral scotoma in his left eye, immediately following a motor vehicle accident 1 day prior. Fundus findings revealed a unilateral nasal petalloid perifoveal lesion with the tip pointing toward the fovea associated with CWS and RH. Optical coherence tomography demonstrated disruption of the ellipsoid zone. Symptoms and exam findings improved at 2-week follow-up without any intervention, consistent with the natural history of the disease process. Conclusion: We report a rare case of AMN following non-ocular trauma with the unique fundus findings of CWS and RH. This presentation supports the role of ischemia in the retinal deep capillary plexus, of which trauma contributed to the pathophysiological process. Summary: AMN is a rare condition whose pathophysiological process remains speculative. We report an atypical case of AMN, which supports the role of trauma in the pathophysiology of deep retinal capillary plexus compromise.

To evaluate ocular hypertension (OHT) after Ozurdex injection to determine the incidence of OHT, therapy for OHT, and any associative factors such as diagnosis, underlying glaucoma and therapy, or sequential Ozurdex injection(s). Retrospective consecutive case series with patients receiving one or more intravitreal Ozurdex implantations at a tertiary care academic center. Ocular hypertension was defined as a single measurement of ≥30 mmHg or an increase of ≥10 mmHg from baseline. Ninety-four injections in 52 patients (59 eyes) were reviewed. Forty eyes received a single injection, and 19 eyes received multiple injections. Ocular hypertension developed in 14 patients (26.9%). Thirteen patients (25%) had preexisting glaucoma or suspicion of glaucoma, and 6 of these developed OHT. Glaucoma eye drops were initiated after 13 injections (13.8%). Invasive surgery for glaucoma was required in 3 patients (3.2%): all had glaucoma or suspicion of glaucoma (one case was related to neovascular glaucoma and unlikely related to steroid response after Ozurdex). There was no difference in relative intraocular pressure increase (i.e., difference between final follow-up or subsequent intravitreal injection vs. baseline) between single versus multiple Ozurdex injections (P = 0.883). Patients (26.9%) who received Ozurdex developed OHT. Glaucoma or glaucoma-suspicion factors were present in all patients who required invasive surgery for glaucoma. A greater proportion of patients who received multiple injections had an intraocular pressure elevation, but the relative intraocular pressure increase was not significant.

BACKGROUND AND OBJECTIVE: To assess the effect on best-corrected visual acuity (BCVA) and efficacy of the intravitreal sustained-release 0.7 mg dexamethasone implant (Ozurdex; Allergan, Irvine, CA) in patients with recalcitrant diabetic macular edema (DME). PATIENTS AND METHODS: Meta-analysis utilizing the MOOSE framework and a random effects model. Studies included adults undergoing treatment with Ozurdex for DME. The methodologic quality of each study was assessed using the MINORS and the Cochrane Collaboration Risk of Bias for randomized studies. RESULTS: A total of 3,859 patients among 15 studies were included in the final analysis. The mean difference in BCVA was a gain of four lines or 20 Early Treatment of Diabetic Retinopathy Study letters with Ozurdex at a mean follow-up period of 6 months. CONCLUSIONS: Treatment with Ozurdex is associated with significant mean improvement in visual acuity. Clinicians should have a multimodality approach to treating DME and be aware of this treatment option in those who have a suboptimal response to anti-VEGF therapy. [ Ophthalmic Surg Lasers Imaging Retina . 2017;48:160–166.]

Pars plana vitrectomy for acute infectious endophthalmitis can be challenging due to severe inflammation in the anterior chamber creating significant media opacity. We describe a surgical technique combining limbal based vitrectomy and pars plana vitrectomy to manage acute infectious endophthalmitis. Limbal based vitrectomy facilitates removal of anterior chamber fibrin and inflammatory membranes for safe and optimal posterior pars plana vitrectomy.

The nature of the vitreoretinal interface in conditions like diabetic macular edema (DME) remains incompletely understood. Furthermore, it is not clear what the role of pharmacological enzymatic vitreolysis will play in cases of vitreomacular traction (VMT) associated with macular disease like DME. We describe the spontaneous resolution of VMT in 2 patients with DME. As both surgical and pharmacologic interventions have been suggested to treat DME in the setting of VMT, we feel that a clarification of the nomenclature and reporting of these cases of natural history may be useful in more fully understanding the complex decision-making involved when determining whether to treat this subset of patients.

Macular hole (MH) is characterized by full-thickness anatomic defect at the fovea leading to loss of central vision. The majority (B85%) of MHs were once thought to be idiopathic with a smaller proportion being secondary to trauma, inflammation, or high myopia. However, recent optical coherence tomography (OCT) imaging suggests that early MHs originate from an intraretinal split of the macula that evolves into intraretinal cysts (Fig. 1). It has been hypothesized that MHs develop from tangential traction from prefoveal vitreous cortex and/or epiretinal membranes and anteroposterior traction at the vitreoretinal interface resulting in vitreomacular traction syndrome. MH was once considered an untreatable condition until 1991 when vitrectomy and intraocular gas tamponade was first introduced by Kelly and Wendel. In the original report of 52 eyes which included mostly stage 3 MHs, the authors reported a primary anatomic closure rate of 58%. Six months after surgery, the visual acuity (VA) had improved by Z2 lines in 73% of eyes with closed holes. Currently, surgical management can achieve anatomic closure rates better than 90%, depending on preoperative MH size, duration of symptoms, and surgical technique used. The primary goal of surgery is to close the MH by removal of tangential and anteroposterior vitreous traction, activation of marginal glial cells by vitrectomy and ERM peeling, and immobilization/apposition of hole edges by intraocular gas tamponade and face-down positioning. Repeat MH surgery has been associated with a significant reduction in anatomic closure rate and perhaps functional outcome, thus the primary focus of surgical technique should be to close the MH in 1 procedure.

Creutzfeldt-Jakob disease is a rare degenerative disease of the brain characterized by rapid irreversible neurological decline. The Heidenhain variant describes any case of Creutzfeldt-Jakob disease in which visual symptoms predominate in the early stages. The authors report a 63-year-old female who had rapidly progressive bilateral visual field loss since 2 months prior to evaluation. Over the following 2 weeks, the patient developed rapidly progressive visual changes and eventually died. Her case has several unusual features: (1) lack of neurological deficits classically seen with Creutzfeldt-Jakob disease such as myoclonus and ataxia; (2) rapid progression of a clearly documented consecutive homonymous hemianopia over less than 2.5 months from onset of symptoms to death; (3) early symmetric temporal atrophy of the optic nerves and paracentral retinal thinning with optical coherence tomography imaging; (4) negative single-photon emission computed tomography imaging; and (5) negative magnetic resonance i...

BACKGROUND To compare the mean central macular thickness (CMT) and the mean average optic nerve retinal nerve fiber layer (RNFL) thickness in the eyes of patients with a history of optic neuritis and/or multiple sclerosis (MS) using 5 commercially available optical coherence tomography (OCT) instruments. METHODS Cross-sectional study including 46 patients (92 eyes) with a history of optic neuritis and/or MS. Both eyes were imaged on the same day with 5 OCT instruments: 1 time-domain OCT (Stratus) and 4 different Fourier-domain (spectral-domain) OCT (3D OCT-1000, Cirrus, RTVue-100, and Spectralis). RESULTS Twenty-five patients (50 eyes) were included in the final analysis after excluding patients with diabetes, glaucoma, ocular hypertension, or retinal pathology and inadequate scan quality. Randomized block analysis of variance revealed statistically significant differences across instruments (P < 0.001) for both eyes for mean CMT and mean average optic nerve RNFL. When testing for significant differences in measurements from instrument to instrument, some difference was noted between the right and left eyes. CONCLUSIONS Statistically significant differences exist among commercially available OCT instruments in measuring mean CMT and mean average RNFL thickness in patients with optic neuritis and/or MS. These findings likely result from the differences in data acquisition and segmentation algorithm software among OCT instruments. Awareness of these variations among OCT instruments will be important in using these instruments for clinical trials and management of patients with optic neuritis and/or MS.

Orbital involvement in nonendemic Burkitt lymphoma is rare. The authors report a unique case of a patient who sought treatment for extraocular muscle enlargement without a concurrent orbital mass, which subsequently led to the diagnoses of Burkitt lymphoma and acquired immune deficiency syndrome in an adult patient. The case report adhered to the principles of the Declaration of Helsinki and Health Insurance Portability and Accountability Act compliance. This single case report was institutional review board exempt, given that it does not meet the definition of human subjects' research.

Purpose To report a case of daily wear soft contact lens-associated keratitis caused by Alcaligenes xylosoxidans in a portable toilet sanitation worker. Methods A previously healthy 30-year-old man presented with bilateral decreased vision, redness, and irritation, beginning 1 week earlier. The patient had been treated with moxifloxocin for 1 week before presentation without improvement. Bacterial staining cultures were performed from corneal scrapings, contact lenses, contact lens case, and solution. Preliminary culture results and antibiotic sensitivities were generated using an automated identification system. Positive results from the contact lens, case, and solution were confirmed using polymerase chain reaction (PCR). Results The contact lenses, contact lens case, and solution cultures revealed heavy growth of A. xylosoxidans. These findings were confirmed by PCR. The organism was found to be resistant to aminoglycosides, fluoroquinolones, and cephalosporins. The patient was started on polymyxin B or trimethoprim. After 21 days of treatment, the infection completely resolved with a final spectacle-corrected visual acuity of 20/25. Conclusions To our knowledge, this is the first case report of a corneal infection caused by A. xylosoxidans, which was isolated and identified from a contact lens, case, and solution using culture and PCR technique as well the first description of ocular surface disease resolution after the treatment with topical polymyxin B or trimethoprim. A. xylosoxidans should be considered as uncommon but potential pathogen capable of infectious spread through contaminated contact lens solution.

PURPOSE To report a case of biopsy-proven corneal intraepithelial neoplasia (CIN) diagnosed and followed clinically using high-resolution anterior segment optical coherence tomography (AS-OCT) and in vivo confocal microscopy (IVCM). METHODS Observational case report. RESULTS A 57-year-old man presented with decreased vision in the right eye for 2 months before presentation. His best-corrected visual acuity was 20/70 in the affected eye, and the slit-lamp examination revealed superficial opacification of the anterior cornea originating from the temporal limbus with a "leopard-spot" pattern more centrally. The lesion was excised at his 2-month follow-up, and the histological examination revealed squamous dysplasia consistent with CIN. Visual acuity improved, and the slit-lamp examination revealed barely visible residual disease at the temporal limbus. However, AS-OCT showed a thicker and highly reflective epithelial layer near the temporal limbus, similar to initial presentation, highlighting this residual disease. IVCM demonstrated dysplastic cells consistent with residual disease. Therefore, we treated the patient with topical interferon alpha-2b (1 million IU/mL) 4 times daily in the affected eye. At 3-month follow-up, the patient's best-corrected visual acuity was 20/20 in the affected eye with persistent but improved residual disease adjacent to the temporal limbus. In the mid-periphery of the inferonasal cornea, focal areas of iatrogenic linear scarring were confirmed to be limited to the anterior stroma by AS-OCT and IVCM at 6-month follow-up. CONCLUSIONS AS-OCT and IVCM are noninvasive techniques that can be used to diagnose and aid in the management of CIN, which may present as subclinical disease through slit-lamp biomicroscopy alone.

Importance Internal limiting membrane (ILM) abrasion is an alternative surgical technique for successful full-thickness macular hole (MH) repair. Objective To study the effects of ILM abrasion as an alternative method of MH repair. Design, Setting, and Participants Retrospective consecutive case series from January 2006 to December 2008. Demographic data and preoperative, intraoperative, and postoperative examination records of all patients were reviewed for patients who underwent ILM abrasion with a diamond-dusted membrane scraper during vitrectomy for MH repair. A total of 100 eyes underwent ILM abrasion as an alternative to traditional ILM peeling. Main Outcomes and Measures Rate of MH closure and visual acuity (VA) outcomes at 3 months after surgery. Results Macular hole closure was achieved with a single surgical procedure in 94 of 100 eyes (94.0%; 95% CI, 87.4%-97.8%). Among all patients, the median preoperative VA was 20/100 (range, 20/30 to hand motions; 25th quartile, 20/60; and 75th quartile, 20/160), and the median postoperative VA at 3 months after surgery was 20/60 (range, 20/20 to hand motions; 25th quartile, 20/40; and 75th quartile, 20/100). Among all patients with stage 2 MHs, 30 of 38 patients (78.9%) had at least 2 lines of VA gain: 15 of 23 (65.2%) were phakic, and 15 of 15 (100%) were pseudophakic. Four of 38 patients (10.5%) with stage 2 MHs had at least 2 lines of VA loss, and all were phakic. Among all patients with stage 3 or 4 MHs, 42 of 62 (67.7%) had at least 2 lines of VA gain, of which 30 of 38 (78.9%) were phakic and 22 of 24 (91.7%) were pseudophakic. Six of 62 patients (9.7%) with stage 3 or 4 MHs had at least 2 lines of VA loss: 4 were phakic, and 2 were pseudophakic. In total, 35.0% (95% CI, 25.7%-44.3%) of patients achieved 20/40 vision or better, and 52.0% (95% CI, 42.2%-61.8%) of patients achieved 20/50 vision or better. Conclusions and Relevance Abrasion of the ILM with a diamond-dusted membrane scraper at the time of vitrectomy achieves high rates of MH closure. This technique avoids complete removal of the retinal ILM basement membrane and subjacent tissues and appears to provide MH closure rates similar to those of traditional ILM peeling.

Importance The effects of position on retinal and choroidal structure are absent from the literature yet may provide insights into disease states such as age-related macular degeneration (AMD). Objective To evaluate the effect of postural change on retinal and choroidal structures in healthy volunteers and patients with non-neovascular AMD. Design, Setting, and Participants Prospective observational case series at an academic tertiary care retina service from September 2013 to April 2014 involving 4 unaffected volunteers (8 eyes) and 7 patients (8 eyes) with intermediate AMD. Healthy volunteers selected for the study had no evidence of ocular disease. Patients with AMD were required to have at least 10 intermediate-sized drusen. Exposures Spectral-domain optical coherence tomography with enhanced depth imaging in upright (sitting) and supine positions. Stable imaging was achieved using a rotating adjustable mechanical arm that we constructed to allow the optical coherence tomography transducer to rotate 90°. The Iowa Reference Algorithms were used to quantify choroid and choriocapillaris thicknesses. Main Outcomes and Measures Changes in sitting and supine position central macular thickness (in micrometers), total macular volume (in cubic millimeters), choroidal thickness (in micrometers), and choriocapillaris-equivalent thickness (CCET, in micrometers). Results Choriocapillaris-equivalent thickness was thinner in healthy participants (9.89 μm; range, 7.15-12.5 μm) compared with patients with intermediate AMD (16.73 μm; range, 10.31-27.38 μm) ( P = .02); there was no difference in overall choroidal thickness between the 2 groups ( P = .38). There was a 15% CCET reduction among healthy participants when transitioning from a sitting (9.89 μm) to supine (8.4 μm; range, 6.92-10.7 μm) position ( P = .02) vs a CCET reduction of 11.1% from sitting (16.73 μm) to supine (14.88 μm; range, 8.76-20.8 μm) positioning ( P = .10) in patients with intermediate AMD. Conclusions and Relevance Intermediate AMD appears to be associated with an increase in CCET and with a lack of positional responses that are observed in the CCET of normal eyes. Our results suggest that although outer portions of the choroid do not appear to be responsive to modest positional or hydrostatic pressure, the choriocapillaris capacity is, and this is measurable in vivo. Whether this physiologic deviation that occurs in AMD is related to atrophy, inflammation, or changes in autoregulatory factors or growth factors remains to be determined.

To compare Cirrus Fourier-domain optical coherence tomography (OCT) with Stratus time-domain OCT for imaging retinal diseases and quantifying retinal thickness (RT) of all nine OCT zones, central macular thickness, and average macular thickness in eyes with and without macular edema.Prospective comparison between two OCT systems.RT measurements were performed in 120 eyes of 60 patients suspected of having increased retina thickness using both Stratus and Cirrus OCT on the same day. Twenty-one eyes had both 512 x 128 and 200 x 200 Cirrus cube scans done.Data from 101 eyes (53 patients) were analyzed; 46 eyes (45.5%) had macular edema on clinical examination (Group 1), whereas 55 eyes (54.4%) had no clinical evidence of macular edema (Group 2). There was modest correlation between all thickness measurements in 909 zones and each group (range of Pearson correlation, 0.51 to 0.89) and average value was significantly greater when measured with Cirrus OCT for all eyes (mean difference, 43.2 microm; P.0001). There were few measurement differences between different resolution Cirrus cube scans.Cirrus OCT measures RT approximately 43 microm greater than Stratus OCT, which is likely attributable to Cirrus OCT detection of the outer band of the retinal pigment epithelium vs Stratus OCT detection of the inner/outer segment photoreceptor junction. All zones showed a wide degree of variability in correlation. Both Cirrus cube scans provide similar data. Future studies comparing these systems might consider utilizing average macular thickness values, which reflect macular volume and may provide more consistent measurements.