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Objective To investigate optical coherence tomography (OCT)-based biomarkers of visual acuity (VA) in eyes with idiopathic epiretinal membranes (ERM) undergoing surgical intervention. Purpose To assess surgical outcomes of pars plana vitrectomy (PPV) and membrane peel (MP) surgery in eyes with idiopathic ERM and identify potential imaging-based biomarkers of vision outcomes. Methods Retrospective, consecutive case series of eyes with idiopathic ERM that underwent PPV and MP surgery between 1/1/2017 and 1/1/2019. A previously described ERM grading scale was utilized for OCT analysis. The primary outcome was VA at post-operative month 6 and final follow-up. A secondary outcome was the association of OCT structural features, including ectopic inner foveal layers (EIFL), inner microcystoid changes, and ellipsoid zone (EZ) disruption, with VA outcomes. Results A total of 322 eyes with idiopathic ERM were included. Mean (± SD) follow-up was 506.6 ± 324.6 days after MP surgery. VA improved from logMAR 0.49 ± 0.27 (Snellen 20/61) pre-MP to 0.41 ± 0.30 (Snellen 20/51, p Conclusions VA improvement was noted after surgery in eyes with idiopathic ERM across all stages. Pre-operative stage 4 characteristics were associated with worse VA at 6 months. Post-operative inner microcystoid changes and EZ disruption at month 3 were additional OCT biomarkers associated with worse 6 month and final VA outcomes.

Background/aimsTo compare risk factors for poor visual outcomes in patients undergoing primary rhegmatogenous retinal detachment (RRD) repair and to develop a scoring system.MethodsAnalysis of the Primary Retinal detachment Outcomes (PRO) study, a multicentre interventional cohort of consecutive primary RRD surgeries performed in 2015. The main outcome measure was a poor visual outcome (Snellen VA ≤20/200).ResultsA total of 1178 cases were included. The mean preoperative and postoperative logMARs were 1.1±1.1 (20/250) and 0.5±0.7 (20/63), respectively. Multivariable logistic regression identified preoperative risk factors predictive of poor visual outcomes (≤20/200), including proliferative vitreoretinopathy (PVR) (OR 1.26; 95% CI 1.13 to 1.40), history of antivascular endothelial growth factor (VEGF) injections (1.38; 1.11 to 1.71), >1-week vision loss (1.17; 1.08 to 1.27), ocular comorbidities (1.18; 1.00 to 1.38), poor presenting VA (1.06 per initial logMAR unit; 1.02 to 1.10) and age >70 (1.13; 1.04 to 1.23). The data were split into training (75%) and validation (25%) and a scoring system was developed and validated. The risk for poor visual outcomes was 8% with a total score of 0, 17% with 1, 29% with 2, 47% with 3, and 71% with 4 or higher.ConclusionsIndependent risk factors were compared for poor visual outcomes after RRD surgery, which included PVR, anti-VEGF injections, vision loss >1 week, ocular comorbidities, presenting VA and older age. The PRO score was developed to provide a scoring system that may be useful in clinical practice.

Topical povidone-iodine (PI) is widely used as an ocular surface antiseptic for intravitreal injections (IVIs). Although PI is generally well tolerated, it can be associated with significant ocular irritation. Aqueous chlorhexidine (AqCHX) has been described as a possibly better tolerated antimicrobial for ophthalmic procedures. We compared patient pain scores, ocular surface characteristics, and antimicrobial efficacy between PI 5% and AqCHX 0.1% during IVIs.Prospective single-center, randomized clinical trial.Patients receiving same-day bilateral intravitreal anti-vascular endothelial growth factor (VEGF) injections.Each patient had 1 eye randomized to PI or AqCHX, and the second eye received the other agent. Both eyes received topical proparacaine 0.5%.After IVIs, participants rated their pain (Wong-Baker, scale 0-10) for each eye 1 minute after PI or AqCHX instillation and 1 day after the procedure. Each eye was assessed using a standardized quantitative grading system of corneal epitheliopathy (ocular staining score). Microbial swab cultures of the conjunctiva both before instillation of topical antisepsis and 10 minutes after IVIs were given.A total of 100 eyes of 50 patients were included. The mean patient age was 68 years (range, 39-92), and 30 of 50 (60%) were male. Compared with AqCHX, eyes receiving PI had a greater mean pain score immediately after injection (1.44 vs. 0.44, P0.001) but not on postprocedure day 1 (1.04 vs. 0.48, P = 0.06). Eyes that received PI had a higher ocular staining score indicating worse corneal epitheliopathy (4.22 vs. 3.10, P0.001). There was no difference in rates of positive microbial cultures between groups. There was no difference in rates of adverse events between groups (P = 0.99), and no cases of endophthalmitis occurred.Povidone-iodine demonstrated greater ocular surface discomfort and corneal epitheliopathy compared with AqCHX during same-day bilateral IVIs. The 2 agents otherwise demonstrated no difference in positive microbial cultures or adverse events. Aqueous chlorhexidine may be a better tolerated alternative to PI for antimicrobial prophylaxis during IVIs for some patients.

Purpose: This work assesses the clinical characteristics and outcomes of various treatment methods in managing rhegmatogenous retinal detachments secondary to retinal dialysis. Methods: In this retrospective, consecutive case series, patients presenting to a tertiary referral vitreoretinal service from 2015 to 2020 were chosen. The primary outcome measure was the single-surgery anatomic success (SSAS) rate in the first 90 days after surgery and overall SSAS rate until the last visit. Results: Eighty-six eyes of 84 patients were included. Mean (SD) age was 30 (14.8) years (range, 7-71 years). Fifty-nine (70%) patients were men and 55 eyes (64%) had a history of trauma. Dialysis occurred in the inferotemporal quadrant in 50 eyes (58%) of the entire cohort and 25 of 55 eyes (45%) with prior trauma. Fifty-one eyes (59.3%) were managed by scleral buckle (SB), 25 eyes (29.2%) with laser retinopexy, and 10 eyes (11.6%) with pars plana vitrectomy (PPV). The SSAS rate in the first 90 days after surgery was 94.1% (81 of 86 eyes), including 90.1% of eyes with SB, 100% of eyes with laser retinopexy, and 100% of eyes with PPV ( P = .07). The overall SSAS rate, however, was 89.5% (77 of 86) eyes, including 90.1% of eyes with SB, 84% of eyes with laser retinopexy, and 100% of eyes with PPV ( P = .4). Final attachment rate was 100% in the entire cohort. Conclusions: With careful consideration of underlying pathology, all 3 treatment modalities can provide high rates of anatomic and functional success.

BACKGROUND AND OBJECTIVE: Data regarding hemorrhagic complications of direct oral anticoagulants (DOACs) and vitreoretinal surgery are limited. PATIENTS AND METHODS: Multicenter analysis of longitudinal, aggregated electronic health records of patients undergoing pars plana vitrectomy (PPV) with no prior history of ocular hemorrhage. Retrospective analysis of patients undergoing PPV between January 1, 2013, and December 31, 2019. The main outcomes were development of postoperative hemorrhagic complications within 1 month following vitreoretinal surgery. RESULTS: A total of 58,131 eyes underwent PPV, with 2,956 (5.1%) on anticoagulant medication prior to surgery. Eight hundred twenty-eight eyes (1.4%) developed a postoperative hemorrhage. Of eyes with anticoagulation use, 50 of 2,956 (1.29%) developed a hemorrhage, whereas 778 of 55,175 (1.41%) of the eyes with no prior anticoagulation use developed a postoperative hemorrhage ( P = .2107). CONCLUSION: Use of DOACs prior to vitreoretinal surgery does not appear to be associated with increased rates of postoperative intraocular hemorrhage. [ Ophthalmic Surg Lasers Imaging Retina . 2021;52:374–379.]

PURPOSE To describe characteristics and outcomes of primary rhegmatogenous retinal detachment in older adults (age ≥ 80). METHODS Consecutive patients with rhegmatogenous retinal detachment undergoing pars plana vitrectomy (PPV), scleral buckling (SB), or PPV/SB in the Primary Retinal Detachment Outcomes Study were evaluated. Outcome measures included single surgery anatomic success and visual acuity. RESULTS Of 2,144 patients included, 125 (6%) were 80 years or older. Compared with younger patients (age 40-79), older adults were more likely to be pseudophakic (P < 0.001), have macula-off detachments (P < 0.001), and have preoperative proliferative vitreoretinopathy (P = 0.02). In older adults, initial surgery was PPV in 73%, PPV/SB in 27%, and primary SB in 0%. Single surgery anatomic success was 78% in older adults compared with 84% in younger patients (P = 0.03). In older adults, single surgery anatomic success was 74% for PPV and 91% for PPV/SB (P = 0.03). The final mean logMAR was lower for older adults (0.79 [20/125] vs. 0.40 [20/40], [P < 0.001]). In older adults, the final mean logMAR for eyes that underwent PPV was 0.88 (20/160) compared with 0.50 (20/63) for PPV/SB (P = 0.03). CONCLUSION Octogenarians and nonagenarians presented with relatively complex pseudophakic rhegmatogenous retinal detachments. Single surgery anatomic success and visual outcomes were worse compared with younger patients, and PPV/SB had better outcomes compared with PPV alone.

Introduction Rhegmatogenous retinal detachments with inferior retinal breaks are believed to have a higher risk of recurrent rhegmatogenous retinal detachment. This study compared anatomic and visual outcomes between primary pars plana vitrectomy (PPV) and combination PPV with scleral buckle (PPV/SB) for rhegmatogenous retinal detachments with inferior retinal breaks. Methods This is an analysis of the Primary Retinal Detachment Outcomes study, a multi-institutional cohort study of consecutive primary rhegmatogenous retinal detachment surgeries from January 1, 2015, through December 31, 2015. The primary outcome was single-surgery success rate. Only eyes with inferior retinal breaks (one break in the detached retina between five and seven o'clock) were included. Results There were 238 eyes that met the inclusion criteria, 95 (40%) of which underwent primary PPV and 163 (60%) that underwent combined PPV/SB. The single-surgery success rate was 76.8% for PPV and 87.4% for PPV/SB (P = 0.0355). This remained significant on multivariate analysis (P = 0.01). Subgroup analysis showed that a superior single-surgery success rate of PPV/SB was especially noted in phakic eyes (85.2% vs. 68.6%; P = 0.0464). Conclusion Retinal detachment with inferior retinal breaks had a higher single-surgery success rate if treated with PPV/SB compared with PPV alone, particularly in phakic eyes.

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 compare 2 mg intravitreal triamcinolone (IVT) versus 40 mg posterior sub-Tenon triamcinolone acetonide (STT) for the treatment of eyes with pseudophakic cystoid macular edema.A retrospective, single-center review of eyes receiving 2 mg IVT between 3/1/2012-3/1/2017 and 40 mg STT between 1/1/2015-3/1/2017. Visual acuity (VA) and central macular thickness (CMT) were recorded at baseline, 1-, 3-, and 6-month follow-up visits.Forty-five eyes were included in the IVT group and 50 eyes in the STT group. Change in VA from baseline to 1, 3, and 6 months was not significantly different between IVT and STT (6 months: 2.3 lines vs. 2.4 lines,2 mg IVT and 40 mg STT both achieved significant improvement in vision and CMT with no significant difference between interventions at 3- and 6-month follow-up.

To compare rates of ocular hypertension (OHT) in eyes receiving 40 mg sub-Tenon triamcinolone (STT), 0.7 mg dexamethasone implant (DEX), and 2 mg intravitreal triamcinolone (IVT).This study is a single-centre, retrospective case series. All patients receiving STT and DEX between 4/1/2014 and 3/1/2017 and IVT between 3/1/2012 and 3/1/2017 with a minimum of 3 months' follow-up were included. OHT was defined as an intraocular pressure (IOP)24 mm Hg. Patients receiving any other form of topical, oral, or intravitreal steroid were excluded.113 eyes from 104 patients in the STT group, 122 eyes from 109 patients in the DEX group, and 109 eyes from 103 patients in the IVT group were included. The mean number of injections for each eye was 1.7 in the STT group, 2.6 for the DEX group, and 2.8 for the IVT group (p0.001). Twenty eyes (17.7%) developed OHT in the STT group, 19 eyes (15.6%) developed OHT in the DEX group, and 14 eyes (12.8%) developed OHT in the IVT group (p = 0.60). IOP was controlled in all eyes with observation, topical IOP-lowering medication, or surgical intervention. The rate of incisional glaucoma surgery was 1.7% in the STT group, 1.6% in the DEX group, and 0% in the IVT group (p = 0.55).The rate of OHT was similar across treatment groups. The proportion of OHT in patients with a history of glaucoma was no different from that in patients without a history of glaucoma. All cases were successfully managed with observation, medical treatment, or incisional surgery.

Purpose This study evaluates outcomes of comparable pseudophakic rhegmatogenous retinal detachment (RRD) treated with pars plana vitrectomy (PPV) or PPV with scleral buckle (PPV-SB). Design Multicenter, retrospective, interventional cohort study. Participants Data were gathered from patients from multiple retina practices in the United States with RRD in 2015. Methods A large detailed database was generated. Pseudophakic patients with RRD managed with PPV or PPV-SB were analyzed for anatomic and visual outcomes. Eyes with proliferative vitreoretinopathy, giant retinal tears, previous invasive glaucoma surgery, and ≤90 days of follow-up were excluded from outcomes analysis. Single surgery anatomic success (SSAS) was defined as retinal attachment without ongoing tamponade and with no other RRD surgery within 90 days. Main Outcome Measures Single surgery anatomic success and final Snellen visual acuity (VA). Results A total of 1158 of 2620 eyes (44%) with primary RRD were pseudophakic. A total of 1018 eyes had greater than 90 days of follow-up. Eyes with proliferative vitreoretinopathy, previous glaucoma surgery, and giant retinal tears were excluded, leaving 893 pseudophakic eyes eligible for outcome analysis. A total of 461 (52%) were right eyes. A total of 606 patients (67%) were male, with a mean age of 65±11 years. Pars plana vitrectomy and PPV-SB as the first procedure were performed on 684 eyes (77%) and 209 eyes (23%), respectively. The mean follow-up was 388±161 days, and overall SSAS was achieved in 770 eyes (86%). Single surgery anatomic success was 84% (577/684) for PPV and 92% (193/209) for PPV-SB. The difference in SSAS between types of treatment was significant (P = 0.009). In eyes with macula-on RRD, SSAS was 88% in eyes treated with PPV and 100% in eyes treated with PPV-SB (P = 0.0088). In eyes with macula-off RRD, SSAS was 81% in eyes treated with PPV and 89% in eyes treated with PPV-SB (P = 0.029). Single surgery anatomic success was greater for PPV-SB than PPV for inferior (96% vs. 82%) and superior (90% vs. 82%) detachments. Mean final VA was similar for PPV (20/47) and PPV-SB (20/46; P = 0.805). Conclusions In pseudophakic RRDs, SSAS was better in patients treated with PPV-SB compared with PPV alone, whereas visual outcomes were similar for both groups.

Purpose To detail the methodology for a large multicenter retrospective cohort study (RCS) of primary rhegmatogenous retinal detachment (RRD) with detailed data collection and to present overall anatomic outcomes. Design This study used an RCS method. Participants All patients undergoing pars plana vitrectomy (PPV), scleral buckling (SB), and combined PPV/SB for primary RRD in 2015 from 5 large retina groups were included in the database. Methods To ensure validity of the cohort method, a large and detailed database was generated. Double data entry validation was conducted, and data audits were conducted. Anatomic and visual outcomes for all the cases in the dataset will be described but not compared, because the cases were not matched. In future studies, comparable cases of moderate-complexity RRD will be chosen naive to surgeon, surgery, and outcome for subgroup analysis. Main Outcome Measures Precision of data entry was confirmed by inter-rater reliability (IRR). Main surgical outcome for each procedure type was single-surgery anatomic success (SSAS). Results Inter-rater reliability showed significant agreement among raters (P 90 days of follow-up. Of these, 320 eyes (13.7%) underwent SB, 1200 eyes (51.4%) underwent PPV, and 815 eyes (34.9%) underwent PPV/SB. The SSAS was 84.2% for PPV, 91.2% for SB, and 90.2% for PPV/SB. Conclusions We compiled a large, accurately documented database of primary RRD cases repaired by PPV, SB, and PPV/SB from which cohort studies of moderately complex RRDs can be carried out. All 3 approaches had a high SSAS rate. Procedures chosen and their outcomes are described, but the broad case mix makes comparisons not possible until future cohort studies are completed.

Purpose Anatomically similar rhegmatogenous retinal detachments (RRDs) can be treated with scleral buckle (SB), pars plana vitrectomy (PPV), or SB combined with PPV (PPV/SB). This study compares moderately complex phakic primary RRD treated with SB, PPV, or PPV/SB to review anatomic and visual outcomes. Design Multicenter, retrospective, interventional cohort study. Participants Data were gathered on all patients from multiple retina practices in the United States with RRD in 2015 and >90 days of follow-up. The cohort of phakic patients with moderately complex RRD was analyzed. Methods A large and detailed database was generated. Eyes with findings that would bias toward PPV (vitreous hemorrhage, dense cataract, proliferative vitreoretinopathy, giant retinal tear, among others) were excluded. Age Main Outcome Measures Single surgery anatomic success (SSAS), defined as retinal attachment with no other RRD surgery within 90 days, is the main outcome measure. Final visual acuity is the secondary outcome measure. Pearson’s chi-square and analysis of variance were used to test treatment effect of surgery type on SSAS and vision. Results Single surgery anatomic success was noted in 155 of 169 SB cases (91.7%), 207 of 249 PPV cases (83.1%), and 271 of 297 PPV/SB cases (91.2%). Scleral buckle and PPV/SB were superior to PPV for SSAS (P = 0.0041). For macula-on or split cases, SB had significantly better visual outcomes than PPV or PPV/SB even after controlling for cataract (cases with minimal cataract at final follow-up or after cataract surgery) (P Conclusions For phakic moderately complex primary RRDs in this study of PPV versus SB versus PPV/SB, SB had the best visual outcomes, and PPV had the worst SSAS outcomes.

Purpose: This article compares 2-mg intravitreal triamcinolone (IVT) and 0.7-mg dexamethasone (DEX) implant for the treatment of diabetic macular edema in eyes that had a suboptimal response to antivascular endothelial growth factor therapy. Methods: A single-center, retrospective review was conducted of patients receiving either IVT between January 1, 2013, and January 1, 2018, or patients receiving DEX between October 1, 2015, and January 1, 2018. Visual acuity and central macular thickness (CMT) were recorded at visit of first injection and all subsequent visits. Results: Twenty-five eyes were included in the DEX group and 32 eyes were included in the IVT group. Change in vision from baseline was similar between DEX and IVT at 6-month follow-up (1.1 lines vs 2.3 lines, respectively; P = .24). Mean decrease in CMT from baseline was not different at 6-month follow-up (DEX: 120 µm vs IVT: 185 µm; P = .17). Conclusions: DEX and 2-mg IVT both achieved improvement in vision and CMT with no significant differences between treatment groups at 6-month follow-up.

Purpose To report the incidence and course of ocular hypertension after intravitreal injection of 2-mg triamcinolone acetonide (IVT). Methods In a retrospective, consecutive series, all patients receiving 2-mg IVT at a single institution between March 1, 2012, and March 1, 2017, with a minimum of 3-month follow-up were reviewed. Ocular hypertension was defined as an intraocular pressure (IOP) measurement over 24 mmHg at any follow-up visit after IVT. Patients receiving topical, periocular, or intravitreal corticosteroid other than 2-mg IVT were excluded. Results A total of 106 eyes in 100 patients receiving at least one injection of 2-mg IVT were included. Eyes received an average of 2.9 injections (range 1-17), and average patient follow-up was 15.1 months (range 3.0-52.5 months). A total of 14 eyes (13.2%) in 14 patients developed ocular hypertension after a median of 1.5 injections (range 1-9) with an average peak IOP of 29 mmHg (range 25-38 mmHg). Overall, a total of 11 eyes (10.4%) had an IOP elevation ≥10 mmHg above baseline at any point after first IVT. In all cases of ocular hypertension, IOP was successfully managed with observation or topical IOP-lowering medication alone; no patients required surgical intervention. Conclusion Ocular hypertension developed in 13.2% of eyes receiving intravitreal injection of 2-mg triamcinolone acetonide. Incidence of ocular hypertension after 2-mg IVT compares favorably with other intravitreally administered corticosteroids.

Purpose:This study examines treatment-based outcomes of endophthalmitis due to antivascular endothelial growth factor (anti-VEGF) intravitreal injection and its effect on subsequent management of neovascular disease.Methods:A retrospective multicenter study was conducted of 157 patients with a diagnosis of endophthalmitis following anti-VEGF intravitreal injection at 10 major ophthalmic centers.Results:The median number of injections before endophthalmitis was 10 (range, 1 to 84 injections). Initial treatment with tap and inject with or without subsequent vitrectomy trended toward smaller visual acuity changes from baseline (4 ETDRS [Early Treatment Diabetic Retinopathy Study] letter difference vs 19 ETDRS letter difference) compared with initial vitrectomy, but the difference was not statistically significant. There was no significant change in medication choice among injections after endophthalmitis. There was a statistically significant shift away from regular interval (1- to 2-month) injections and a shift toward treat-and-extend and as-needed injection algorithms.Conclusions:The visual outcomes were not significantly different between patients who initially underwent tap and injection of antibiotics and those who underwent vitrectomy. There was no significant change in medication choice before and after endophthalmitis but there was a shift toward lower-frequency injection algorithms after postintravitreal injection endophthalmitis compared with prior.

Purpose To evaluate the safety and efficacy of the Port Delivery System with ranibizumab (PDS) for neovascular age-related macular degeneration (nAMD) treatment. Design Phase 2, multicenter, randomized, active treatment–controlled clinical trial. Participants Patients diagnosed with nAMD within 9 months who had received 2 or more prior anti–vascular endothelial growth factor intravitreal injections and were responsive to treatment. Methods Patients were randomized 3:3:3:2 to receive the PDS filled with ranibizumab 10 mg/ml, 40 mg/ml, 100 mg/ml, or monthly intravitreal ranibizumab 0.5-mg injections. Main Outcome Measures Time to first implant refill assessed when the last enrolled patient completed the month 9 visit (primary efficacy end point), improvement in best-corrected visual acuity (BCVA) and central foveal thickness (CFT), and safety. Results The primary analysis population was 220 patients, with 58, 62, 59, and 41 patients in the PDS 10-mg/ml, PDS 40-mg/ml, PDS 100-mg/ml, and monthly intravitreal ranibizumab 0.5-mg arms, respectively. Median time to first implant refill was 8.7, 13.0, and 15.0 months in the PDS 10-mg/ml, PDS 40-mg/ml, and PDS 100-mg/ml arms, respectively. At month 9, the adjusted mean BCVA change from baseline was ‒3.2 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, ‒0.5 ETDRS letters, +5.0 ETDRS letters, and +3.9 ETDRS letters in the PDS 10-mg/ml, PDS 40-mg/ml, PDS 100-mg/ml, and monthly intravitreal ranibizumab 0.5-mg arms, respectively. At month 9, the adjusted mean CFT change from baseline was similar in the PDS 100-mg/ml and monthly intravitreal ranibizumab 0.5-mg arms. The optimized PDS implant insertion and refill procedures were generally well tolerated. After surgical procedure optimization, postoperative vitreous hemorrhage rate was 4.5% (7/157; 1 event classified as serious). There was no evidence of implant clogging. Conclusions In the phase 2 Ladder trial, the PDS was generally well tolerated and demonstrated a dose response across multiple end points in patients with nAMD. The PDS 100-mg/ml arm showed visual and anatomic outcomes comparable with monthly intravitreal ranibizumab 0.5-mg injections but with a reduced total number of ranibizumab treatments. The PDS has the potential to reduce treatment burden in nAMD while maintaining vision.

Purpose: The purpose of this article is to provide a data-driven set of best practices to consider in the management of diabetic macular edema (DME). Methods: The current discussion and recommendations represent the authors’ interpretations of data from selected references based on perceived relevance and study design. Results: DME is a common cause of visual impairment globally. The underlying progressive retinal microvascular damage is associated with upregulation of VEGF and a multitude of other inflammatory pathways. Three clinically relevant subcategories of DME can be identified: central-involved DME (CIDME) with preserved visual acuity, CIDME with associated visual loss, and non-CIDME. Management approaches may include observation, laser photocoagulation, intravitreal pharmacotherapy with anti-VEGF agents or corticosteroids, or a combination of these, and may vary depending on the specific type of DME and associated severity of diabetic retinopathy. Additional factors to consider in the management of patients with DME include the appropriate use of imaging and recognition of the chronic nature of the underlying disease process in many eyes. Conclusions: DME management is complex. Intravitreal pharmacotherapies are the current cornerstone of treatment for CIDME and appear poised to remain so for the foreseeable future.

Recent reports of retinal vasculitis (some cases were also occlusive) after brolucizumab injection has ignited a poorly understood immunogenicity alert in the form of intraocular inflammation and r...

Full-thickness macular hole (FTMH) formation following rhegmatogenous retinal detachment (RRD) repair may limit post-operative visual acuity and often requires a return to the operating room, but little is known about this phenomenon. This study included all patients with a FTMH that developed after RRD repair from January 1, 2015–July 31, 2020. The main outcome was the rate of FTMH formation following RRD repair as well as characteristics of FTMH following RRD repair that spontaneously close. There were 470 eyes with a diagnosis of both a FTMH and a RRD during the study period. Of these, 27 (0.28%) developed a FTMH following RRD repair. The median time to FTMH diagnosis was 91 days (25th, 75th quartiles 40, 204 days). The mean minimum hole diameter was 514.5 ± 303.6 microns. There were 4 FTMHs (14.8%) that spontaneously closed without surgical intervention. The spontaneous closure was noted from 4 to 12 weeks after the initial diagnosis of the FTMH. These holes were smaller than the holes that did not close spontaneously (mean minimum diameter 161.8 ± 85.2 vs 588.7 ± 279.3 microns, p = 0.0058). Of the 27 post-operative FTMHs, there were 23 eyes (85%) that underwent surgical intervention with pars plana vitrectomy and internal limiting membrane peeling. Nineteen eyes (83%) closed with one surgery, 20 eyes (87%) ultimately closed, while 3 eyes (11.1%) did not close. FTMH is relatively uncommon to occur following RRD repair with a prevalence of 0.28% in our series with 87% of these holes achieving closure following surgery or spontaneously. Approximately 15% of FTMHs following RRD repair closed spontaneously and these holes were significantly smaller.

Cystoid macular edema (CME) following cataract surgery is a well-known entity. Less is known regarding the risk factors of developing CME following repair of rhegmatogenous retinal detachments (RRD...

Purpose To investigate the effect of the coronavirus disease 2019 (COVID-19) pandemic on the clinical presentation of acute, primary rhegmatogenous retinal detachment (RRD). Design Single-center, consecutive case series with historical controls. Participants Consecutive patients seeking treatment for primary RRD in a 50-day period during the COVID-19 pandemic (March 9–April 27, 2020) and the corresponding 50-day period during the previous year (March 4–April 22, 2019) in the United States. Methods The cohorts were compared to assess demographic variables and clinical presentations. Multivariate logistic regression was used to identify factors predictive of presenting macular attachment status. Main Outcome Measures The primary outcome was the proportion of patients with macula-on RRD at presentation. Secondary outcomes included visual acuity (VA), duration of symptoms before presentation, proportion seeking treatment within 1 day of symptom onset, and presence of primary proliferative vitreoretinopathy (PVR). Results Eighty-two patients were included in the 2020 cohort compared with 111 patients in the 2019 primary control cohort. Demographic factors were similar between the groups. Significantly fewer patients demonstrated macula-on RRD in the 2020 cohort (20/82 patients [24.4%]) than in the 2019 cohort (55/111 patients [49.5%]; P = 0.001). Patients in the 2020 cohort showed worse median VA at presentation (1.00 logarithm of the minimum angle of resolution [logMAR; Snellen equivalent, 20/200] in 2020 vs. 0.48 logMAR [Snellen equivalent, 20/60] in 2019; P = 0.008), fewer patients sought treatment within 1 day of symptoms (16/80 patients [19.5%] in 2020 vs. 41/106 patients [36.9%] in 2019; P = 0.005), and a greater proportion demonstrated primary PVR (11/82 patients [13.4%] in 2020 vs. 5/111 patients [4.5%] in 2019; P = 0.03). In multivariate analysis, younger age (P = 0.03) and established patient status (P = 0.02) were independent predictors of macula-on status in the 2020 cohort. Conclusions Patients with primary RRD during the 2020 COVID-19 pandemic were less likely to have macula-on disease and more likely to delay seeking treatment and to show worse vision and PVR.

To identify differences in preoperative characteristics and intraoperative approaches between surgeons with higher versus lower single surgery success rates (SSSR) for repair of rhegmatogenous retinal detachments (RRDs).This study is a sub-analysis of subjects who underwent RRD repair in the Primary Retinal Detachment Outcomes (PRO) study, a multi-institutional, retrospective comparative interventional study. The PRO study examined consecutive primary RRD surgeries from January 1, 2015 through December 31, 2015. The primary outcome was variations in surgical approach to different types of RRDs with secondary analyses of pre and intraoperative metrics for surgeons with SSSR 90% compared to those80% who performed at least 40 operations during the study period.A total of 689 surgeries were included in the analysis. The mean SSSR was 94% for the higher tier and 75% for the lower tier (p 0.0001). Surgeons with90% SSSR were more likely to have graduated fellowship more recently (p = 0.0025), use less perfluorocarbon liquid (p 0.0001), perform less 360 degree laser retinopexy (p 0.0001), and perform a higher percentage of primary buckles and combined PPV/SB (p 0.0001). For pseudophakic eyes there was no difference between PPV and PPV/SB use (p = 0.6211).Surgeons with high SSSR typically performed SB as well as combination PPV/SB for more RRDs. Similar numbers of PPV and PPV/SB were performed for pseudophakic eyes, suggesting that the difference in SSSR between the two groups may be related to a combination of preoperative and intraoperative decisions as well as differences in technique.

Background/aimsTo evaluate the outcomes of eyes with macular oedema due to retinal vein occlusion (RVO) that are lost to follow-up (LTFU) after antivascular endothelial growth factor (VEGF) injections.MethodA retrospective, single-centre, consecutive case series of RVO patients receiving injections who were LTFU >6 months was conducted. Data were collected from the visit before LTFU; return visit; 3 months, 6 months and 12 months after return; and the final visit.ResultsNinety eyes of 83 patients were included. Fifty (55.5%) eyes had branch RVO and 40 (44.5%) had central RVO. Mean LTFU duration was 277.8 days with additional mean follow-up for 748.1 days after return. Mean logarithm of the minimum angle of resolution visual acuity (VA) (Snellen) at the visit before LTFU was 0.72 (20/105) which worsened on return [1.04 (20/219), pConclusionRVO patients receiving anti-VEGF injections who were LTFU experienced a decline in VA that did not return to the levels seen before LTFU despite improvement in CFT after restarting therapy, underscoring the importance of ongoing treatment.

Purpose To evaluate the safety and efficacy of the Port Delivery System with ranibizumab (PDS) for the treatment of neovascular age-related macular degeneration (nAMD). Design Phase 3, open-label, randomized, visual acuity assessor–masked noninferiority and equivalence trial. Participants Patients with nAMD diagnosed within 9 months of screening previously treated with and responsive to anti–vascular endothelial growth factor therapy. Methods Patients were randomized 3:2 to treatment with the PDS with ranibizumab 100 mg/ml with fixed 24-week (Q24W) refill-exchanges (PDS Q24W) or intravitreal ranibizumab 0.5-mg injections every 4 weeks (monthly ranibizumab). Main Outcome Measures Primary end point was change in best-corrected visual acuity (BCVA) Early Treatment Diabetic Retinopathy Study letter (letters) score from baseline averaged over weeks 36 and 40 (noninferiority margin,–4.5 letters; equivalence margin, ±4.5 letters). Results Archway enrolled 418 patients; 251 were randomized to and 248 received treatment with the PDS Q24W, and 167 were randomized to and received treatment with monthly ranibizumab. Baseline BCVA was 74.4 letters (PDS Q24W arm) and 75.5 letters (monthly ranibizumab arm; Snellen equivalent, 20/32). Adjusted mean change in BCVA score from baseline averaged over weeks 36 and 40 was +0.2 letters (standard error [SE], 0.5 letters) in the PDS Q24W arm and +0.5 letters (SE, 0.6 letters) in the monthly ranibizumab arm (difference, –0.3 letters; 95% confidence interval, –1.7 to 1.1 letters). PDS Q24W was both noninferior and equivalent to monthly ranibizumab. Of 246 PDS-treated patients assessed for supplemental ranibizumab treatment, 242 (98.4%) did not receive supplemental ranibizumab treatment before the first refill-exchange procedure, including 4 patients who discontinued treatment before the first refill-exchange procedure. Prespecified ocular adverse events of special interest were reported in 47 patients (19.0%) in the PDS Q24W arm and 10 patients (6.0%) in the monthly ranibizumab arm, which included, in the former arm, 4 (1.6%) endophthalmitis cases, 2 (0.8%) retinal detachments, 13 (5.2%) vitreous hemorrhages, 6 (2.4%) conjunctival erosions, and 5 (2.0%) conjunctival retractions. Most ocular adverse events in the PDS Q24W arm occurred within 1 month of implantation. Conclusions Archway met its primary objective and PDS Q24W demonstrated noninferior and equivalent efficacy to monthly ranibizumab, with 98.4% of PDS-treated patients not receiving supplemental treatment in the first 24-week interval.

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.

The management and outcome of retinal disorders was revolutionised with the advent of ocular anti-vascular endothelial growth factor (VEGF) therapies including US Food and Drug Administration (FDA)-approved ranibizumab (Lucentis; Genentech, South San Francisco, CA, USA) and aflibercept (Eylea; Regeneron, Tarrytown, NY, USA) and off-label bevacizumab (Avastin; Genentech). With the widespread adoption of these treatments over the last decade or so, the blindness attributable to neovascular age-related macular degeneration (nAMD) has been reduced by 50%–72%.1 The real-world studies though have highlighted a few restrictions to the approved regimens, primarily the required monthly injections and follow-up visits.2 Multiple treatment regimens have been introduced in recent years to reduce the frequency of anti-VEGF agent dosing while attempting to maintain efficacy comparable to monthly or bimonthly fixed treatment protocols by individualising therapy. The most practised individualised approaches are treat-and-extend and pro-re-nata protocols. Unfortunately, despite relatively good visual outcomes over 1–2 years in prospective studies with these individualised regimens, real-world studies typically show loss of initial visual gains over time.3 Brolucizumab (Beovu, Novartis), recently approved by the FDA on 7 October 2019, was followed by European Commission approval for use in the European Union on 17 February 2020, for the treatment of nAMD. To date, apart from FDA and European Medicines Agency, the molecule has also been granted marketing approval in Japan, Australia, Argentina, Switzerland and India. It gives another anti-VEGF option to treating physicians. Based on the clinical trial data from HAWK and HARRIER, brolucizumab demonstrated superior anatomic results with greater fluid resolution and similar best-corrected visual acuity compared to aflibercept with the possibility to extend the dosing regimen to q12-week intervals potentially reducing treatment burden.4 Brolucizumab is the first humanised single-chain antibody fragment to be approved for therapeutic use across the field of medicine. This is the smallest functional subunit …

Background: To compare the incidence and outcomes of ocular hypertension (OHT) after intravitreal injection of 0.7 mg dexamethasone (DEX) and 2 mg triamcinolone acetonide (IVT).Methods: In a single...

BACKGROUND AND OBJECTIVE: In 2018, cases of inflammation were reported after intravitreal aflibercept (IVA), which resulted in switches to intravitreal ranibizumab (IVR). The authors' purpose was to evaluate outcomes after switching from IVA to IVR in diabetic macular edema (DME). PATIENTS AND METHODS: Retrospective cohort study. Eyes switched from IVA to IVR for treating DME were included. Data were gathered from three visits before to three visits post-switch. Outcome measures included central subfoveal thickness (CFT) and Snellen visual acuity (VA). RESULTS: There was a statistically significant increase in CFT at the first visit (325 µm ± 234 µm; P = .006) compared to the switch visit, but no difference later visits (268 µm ± 103 µm; P = .32; 284 µm ± 118 µm; P = .11; n = 54). There was no statistically significant change in mean logarithm of the minimum angle of resolution VA between the switch and later visits (0.43 ± 0.38, P = .95; 0.38 ± 0.30, P = .12; 0.41 ± 0.37, P = .69). CONCLUSIONS: The authors observed transient worsening of macular edema in eyes treated for DME when switched from aflibercept to ranibizumab. [ Ophthalmic Surg Lasers Imaging Retina . 2020;51:691–697.]

BACKGROUND AND OBJECTIVE: Most surgeons now utilize small-gauge (23- or 25-gauge) pars plana vitrectomy (PPV) with or without scleral buckling for repair of rhegmatogenous retinal detachments (RRD), in addition to primary scleral buckle (SB), but comparative data between the two gauges are limited. PATIENTS AND METHODS: This study is an analysis of primary RRD repairs comparing 23- versus 25-gauge vitrectomy for PPV or combination PPV/SB from January 1, 2015, through December 31, 2015, across multiple institutions. The primary outcome was single-surgery success and secondary outcomes included postoperative complications. RESULTS: There were 1,932 eyes that met inclusion criteria. There was no statistically significant difference in single-surgery success (82.9% vs. 83.8%; P = 0.6329). There were similar rates of postoperative hypotony, endophthalmitis, vitreous hemorrhage, and choroidal detachment. The findings were similar when analyzing only eyes that underwent primary PPV without SB. CONCLUSION: Both 23- and 25-gauge vitrectomy systems have similar anatomic and visual outcomes in the primary repair of RRD. [ Ophthalmic Surg Lasers Imaging Retina. 2021;52:70–76.]

Purpose of review The purpose of this review is to describe the current clinical landscape of potential future therapies for both nonexudative (dry) and exudative (wet) age-related macular degeneration (AMD). We highlight some of the more promising treatments that are furthest along in development. Recent findings Patients with dry AMD have long been hoping for a highly efficacious treatment that may slow disease progression or even help regain vision. Patients with wet AMD have many effective treatment options but still there are those who have suboptimal responses or are burdened by the high frequency of treatment. We detail exciting new concepts and targets for novel medications. Specifically, for dry AMD we discuss research looking at complement inhibition, neuroprotection, visual cycle modulators, cell-based therapies, and anti-inflammatory agents. For wet AMD we summarize new, potentially more durable anti-vascular endothelial growth factor agents, extended release options, and gene therapy. Summary There are promising new strategies for AMD. Many of the potential new treatments are in or have recently completed phase 2 or phase 3 clinical trials with promising results thus far, including some that have received US Food and Drug Administration approval. Additional therapeutic breakthroughs will likely continue to occur thanks to the number of clinical trials that are nearing the finish line.

BACKGROUND AND OBJECTIVE: Non-causal macular holes (MHs) can occur concurrently with rhegmatogenous retinal detachments (RRDs). The visual outcomes and surgical approach for these eyes are variable. PATIENTS AND METHODS: This was a multi-institutional, retrospective review of all primary retinal detachment surgeries from January 1, 2015, through December 31, 2015. Pre-, intra-, and postoperative metrics were recorded. RESULTS: There were 2,242 eyes that had pars plana vitrectomy for primary RRD, 43 (1.9%) of which had a MH at the time of surgery. The mean postoperative logMAR visual acuity (VA) for the MH cohort was 0.87 ± 0.64 (20/148) and for eyes without a MH was 0.47 ± 0.63 (20/59; P < .0001). The single-surgery re-attachment rate for the MH cohort and no MH cohort was 86.1% and 84.9%, respectively ( P = 1.0000). CONCLUSIONS: Patients with noncausal MHs and RRD had significantly worse VA than patients without a MH. Preoperative counseling is imperative in patients with both RRD and MH. [ Ophthalmic Surg Lasers Imaging Retina . 2020;51:500–505.]

PurposeTo examine the effect of low-dose, oral isotretinoin in lowering the risk of proliferative vitreoretinopathy (PVR) following rhegmatogenous retinal detachment (RRD) repair.MethodsProspective, open label, dual-cohort study with pathology-matched historical controls. The prospective experimental arms included two cohorts, composed of 51 eyes with recurrent PVR-related RRD and 58 eyes with primary RRD associated with high-risk features for developing PVR. Eyes in the experimental arms received 20 mg of isotretinoin by mouth once daily for 12 weeks starting the day after surgical repair. The primary outcome measure was single surgery anatomical success rate at 3 months following the study surgery.ResultsThe single surgery anatomic success rate was 78.4% versus 70.0% (p=0.358) in eyes with recurrent PVR-related retinal detachment exposed to isotretinoin versus historical controls, respectively. In eyes with RRD at high risk for developing PVR, the single surgery success rate was 84.5% versus 61.1% (p=0.005) for eyes exposed to isotretinoin versus historical controls, respectively. For eyes enrolled in the experimental arms, the most common isotretinoin-related side effects were dry skin/mucus membranes in 106 patients (97.2%), abnormal sleep/dreams in 4 patients (3.7%) and fatigue in 3 patients (2.8%).ConclusionThe management and prevention of PVR is challenging and complex. At the dose and duration given in this study, oral istotretinoin may reduce the risk of PVR-associated recurrent retinal detachment in eyes with primary RRD at high risk of developing PVR.

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 compare clinical outcomes using angled versus straight trocar insertion during 27-gauge pars plana vitrectomy for epiretinal membrane. METHODS Pilot randomized controlled trial. Thirty eyes of 30 patients undergoing 27-gauge pars plana vitrectomy with membrane peeling for epiretinal membrane were randomized 1:1 to receive angled or straight trocar insertion. Intraocular pressure (IOP) and postoperative wound-related complications were compared. RESULTS Fifteen eyes were randomized to each the angled and straight incision groups. No significant difference in phakic status (P = 0.71) or preoperative IOP (15.1 ± 3.4 vs. 14.6 ± 3.0 mmHg, P = 0.67) existed between groups. On postoperative Day 1, eyes in the straight group had lower IOP compared with the angled group (11.8 ± 3.9 vs. 15.3 ± 5.2 mmHg, P = 0.04) and a relative decrease in IOP compared with preoperative values (11.8 ± 3.9 vs. 15.1 ± 3.4 mmHg, P < 0.01). No IOP difference between groups was present at Day 7 (P = 0.43) or Day 30 (P = 0.42). Postoperative complications included transient hypotony (1 eye, straight group) and serous choroidal detachment (1 eye, angled group). CONCLUSION Eyes with straight incisions had transiently lower IOP on postoperative Day 1, possibly suggestive of subclinical wound leak in the very early postoperative period. Overall, rates of hypotony and sclerotomy-related complications were similarly low between wound construction strategies.

PurposeTo evaluate the association between subfoveal choroidal thickness (SFCT) and branch retinal vein occlusion (BRVO) eyes treated with antivascular endothelial growth factor (anti-VEGF) therapy.MethodsRetrospective cohort study of treatment naïve BRVO eyes treated with 3 monthly anti-VEGF injections. All patients received enhanced depth imaging spectral-domain optical coherence tomography scans to determine SFCT and central macular thickness (CMT). Baseline predictors (particularly SFCT) for functional response (best-corrected visual acuity (BCVA) gain ≥2 lines) were assessed at 3 months using univariate and multivariate analyses.ResultsForty eyes from 39 patients were included. Mean baseline SFCT was higher in functional responders (240.4±73.1 µm), compared with both non-responders (193.3±63.6 µm; p=0.036) and their corresponding fellow eye (202.2±67.1 µm; p=0.022). A higher baseline SFCT (for every 100 µm increase in SFCT) was found to be a positive predictor for functional response (regression coefficient: 1.1; p=0.03) on univariate analysis but not multivariate analysis. A worse baseline BCVA (for every 0.1 logMAR increase) was a positive predictor for visual improvement with an adjusted OR of 1.30 (95% CI 1.03 to 1.63; p=0.0009) on multivariate analysis.ConclusionsPatients with BRVO with a worse initial BCVA are most likely to achieve visual improvement following anti-VEGF therapy. Additionally, baseline SFCT may also help predict which patients with BRVO have favourable visual outcomes. Patients with an initial choroidal thickness thicker than their fellow eye are more likely to have short-term visual improvement following treatment.

To explore a new treatment strategy referred to as subfoveal neurosensory detachment flattening and observe (SNF-Ob) in the management of center-involved diabetic macular edema (CiDME).

Importance Diabetic retinopathy (DR) is a leading cause of blindness in adults worldwide. Early detection and intervention can prevent blindness; however, many patients do not receive their recommended annual diabetic eye examinations, primarily owing to limited access. Objective To evaluate the safety and accuracy of an artificial intelligence (AI) system (the EyeArt Automated DR Detection System, version 2.1.0) in detecting both more-than-mild diabetic retinopathy (mtmDR) and vision-threatening diabetic retinopathy (vtDR). Design, Setting, and Participants A prospective multicenter cross-sectional diagnostic study was preregistered (NCT03112005) and conducted from April 17, 2017, to May 30, 2018. A total of 942 individuals aged 18 years or older who had diabetes gave consent to participate at 15 primary care and eye care facilities. Data analysis was performed from February 14 to July 10, 2019. Interventions Retinal imaging for the autonomous AI system and Early Treatment Diabetic Retinopathy Study (ETDRS) reference standard determination. Main Outcomes and Measures Primary outcome measures included the sensitivity and specificity of the AI system in identifying participants’ eyes with mtmDR and/or vtDR by 2-field undilated fundus photography vs a rigorous clinical reference standard comprising reading center grading of 4 wide-field dilated images using the ETDRS severity scale. Secondary outcome measures included the evaluation of imageability, dilated-if-needed analysis, enrichment correction analysis, worst-case imputation, and safety outcomes. Results Of 942 consenting individuals, 893 patients (1786 eyes) met the inclusion criteria and completed the study protocol. The population included 449 men (50.3%). Mean (SD) participant age was 53.9 (15.2) years (median, 56; range, 18-88 years), 655 were White (73.3%), and 206 had type 1 diabetes (23.1%). Sensitivity and specificity of the AI system were high in detecting mtmDR (sensitivity: 95.5%; 95% CI, 92.4%-98.5% and specificity: 85.0%; 95% CI, 82.6%-87.4%) and vtDR (sensitivity: 95.1%; 95% CI, 90.1%-100% and specificity: 89.0%; 95% CI, 87.0%-91.1%) without dilation. Imageability was high without dilation, with the AI system able to grade 87.4% (95% CI, 85.2%-89.6%) of the eyes with reading center grades. When eyes with ungradable results were dilated per the protocol, the imageability improved to 97.4% (95% CI, 96.4%-98.5%), with the sensitivity and specificity being similar. After correcting for enrichment, the mtmDR specificity increased to 87.8% (95% CI, 86.3%-89.5%) and the sensitivity remained similar; for vtDR, both sensitivity (97.0%; 95% CI, 91.2%-100%) and specificity (90.1%; 95% CI, 89.4%-91.5%) improved. Conclusions and Relevance This prospective multicenter cross-sectional diagnostic study noted safety and accuracy with use of the EyeArt Automated DR Detection System in detecting both mtmDR and, for the first time, vtDR, without physician assistance. These findings suggest that improved access to accurate, reliable diabetic eye examinations may increase adherence to recommended annual screenings and allow for accelerated referral of patients identified as having vtDR.

Purpose To describe a case of central retinal vein occlusion (CRVO) in a young adult found to have elevated homocysteine after bariatric surgery and to review risk factors for CRVO in younger patients. Observations An 18-year-old female presented with a CRVO and severe cystoid macular edema (CME). She was normotensive, not on medications, and without known heritable hypercoagulable disease. Her medical history was notable for bariatric surgery and subsequently she was found to have nutritional deficiency, anemia, and elevated homocysteine. Her elevated homocysteine may have induced a hypercoaguable state that predisposed her to developing a CRVO. Treatment with bevacizumab dramatically improved her macular edema and visual acuity. Nutritional supplementation was initiated. Conclusions Elevated homocysteine in the setting of nutritional deficiency from prior bariatric surgery may cause a hypercoaguable state and is a potential risk factor for CRVO. Importance With the increasing prevalence of obesity and bariatric surgery, it is important to consider associated nutrient deficiency as a potential cause of induced hypercoagulability and increased risk for CRVO. Identification of these at-risk patients is especially important given this condition is easily treatable and may be present in younger individuals. To the best of our knowledge, this is the first reported case of a CRVO with elevated homocysteine in the setting of nutrient deficiencies from laparoscopic sleeve gastrectomy.

To determine minimal endoillumination levels required to perform 3-dimensional heads-up vitreoretinal surgery and to correlate endoillumination levels used for measurements of heads-up display (HUD) luminous emittance.Prospective, observational surgical case series of 10 patients undergoing vitreoretinal surgery. Endoillumination levels were set to 40% of maximum output and were decreased at set intervals until the illumination level was 0%. Corresponding luminous emittance (lux) of the HUD was measured 40 cm from the display using a luxmeter (Dr. Meter, Model #LX1010BS).In 9 of 10 cases, the surgeon felt that they could operate comfortably at an endoillumination level of 10% of maximum output with corresponding HUD emittance of 14.3 ± 9.5 lux. In the remaining case, the surgeon felt comfortable at a 3% endoillumination level with corresponding HUD emittance of 15 lux. Below this threshold, subjective image dimness and digital noise limited visibility. Endoillumination levels were correlated with luminous emittance from the 3-dimensional HUD (P0.01). The average coefficient of variation of HUD luminance was 0.546. There were no intraoperative complications.With real-time digital processing and automated brightness control, 3-dimensional HUD platforms may allow for reduced intraoperative endoillumination levels and a theoretically reduced risk of retinal phototoxicity during vitreoretinal surgery.