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To report a case of a pituitary macroadenoma that presented with bilateral intraretinal hyporeflective spaces located primarily in the inner nuclear layer on the macular SD-optical coherence tomography.Case report.Based on the findings of a macular SD-optical coherence tomography, a 53-year-old man was considered as having cystoid macular edema secondary to a retinovascular condition. He was treated with intravitreal vascular endothelial growth factor inhibitors and corticosteroids with no improvement. Confrontation visual fields suggested a bitemporal defect. MRI confirmed the presence of a nonsecreting pituitary macroadenoma compressing the optic chiasm.Not all intraretinal hyporeflective spaces in the optical coherence tomography are secondary to a retinal vascular condition. Hyporeflective spaces in the inner nuclear layer on optical coherence tomography imaging that do not leak on fluorescein angiography may be secondary to optic atrophy from chiasmal compression.

Pneumatic retinopexy (PR) is a minimally invasive, non-incisional procedure for repairing uncomplicated rhegmatogenous retinal detachment. It consists of an intravitreal gas injection followed by the maintenance of a postoperative head position and the use of laser or cryopexy to seal the retinal breaks. It was initially indicated for a single or a group of retinal breaks no larger than 1 clock hour involving the superior 8 clock hours in phakic eyes with no proliferative vitreoretinopathy. We aim to perform a narrative review on pneumatic retinopexy since the last major review of 2008, based on a Medline search up to June 20 2021 using multiple search words including pneumatic retinopexy, pneumoretinopexy, retinal detachment, and pars plana vitrectomy. Indications for PR have been expanded and include pseudophakic eyes, eyes with mild PVR, and even breaks in the inferior fundus. Depending on the case selection, PR has a single-operation success rate ranging from 45 to 80%. Despite the lower single operation success rate, the functional outcomes of those eyes repaired successfully by primary PR exceed those of scleral buckling (SB) and pars plana vitrectomy (PPV). Best corrected visual acuity, metamorphopsia scores, mental health scores, and vision-related functioning scores were all better in PR-treated eyes compared to PPV-treated eyes. PR should be strongly considered for eligible patients with a primary uncomplicated rhegmatogenous retinal detachments.

Purpose. To assess the risk for capsular rupture during routine phacoemulsification in patients with a history of anti-VEGF injections and other possible risk modifiers such as treatment patterns, type of anti-VEGF agent, and experience of the surgeon, among others. Methods. This study reviewed the medical records of 11,129 patients from 7 different hospitals in 5 countries. The study included 939 patients that underwent routine phacoemulsification and had a history of anti-VEGF therapy. We excluded patients with known risk factors for capsular rupture, as well as patients with a history of other retinal procedures. The study extracted data regarding general demographics, the number of previous injections, type of anti-VEGF agent, details of cataract surgery, and anti-VEGF treatment patterns. Results. Overall prevalence of posterior capsular rupture: 7.45% (95% CI: 5.9–9.32%). The mean number of injections per patient was 3.37 ± 2.8. More than 50% of the patients received their last anti-VEGF injection within three months before cataract surgery. The complication rate during intravitreal injections was 1.07%. In the univariate analysis, the experience of the cataract surgeon (inexperience surgeons; OR: 2.93) and the history of prior anti-VEGF therapy (OR: 1.77) were significant risk indicators for PCR ( p < 0.05 ). However, after controlling for age in the multivariate analysis, the trend did not reach a statistical significance. Conclusion. The risk for capsular rupture is higher in patients with a history of intravitreal anti-VEGF injections.

The purpose of this study was to report the 5-year outcomes of treatment-naive eyes with cystoid macular edema secondary to central retinal vein occlusion treated with intravitreal bevacizumab in routine clinical practice. We conducted multicenter retrospective non-comparative case series of 102 eyes. The main outcome measured was the change in best-corrected visual acuity (BCVA) at 5 years. Secondary outcomes included the number of injections and the change in CMT at 5 years. At 5 years, the mean BCVA improved from 1.22 ± 0.58 (Snellen 20/428) at baseline to 1.00 ± 0.68 logMAR (Snellen 20/200; p

To report the epidemiology, clinical characteristics, treatment and outcomes of patients with ocular toxocariasis.Retrospective review of patients diagnosed with ocular toxocariasis at a pediatric ...

To report our experience in non-contact wide-angled visualization with chandelier-assisted scleral buckling (SB) in uncomplicated primary rhegmatogenous retinal detachments (RRD). Retrospective case series of 282 eyes that underwent non-contact wide-angled visualization with chandelier-assisted SB and were followed for a mean of 13.5 months. There were 160 male patients. The average age was 42.6 years old. There were 262 eyes that were phakic, 18 pseudophakic, and 2 aphakic. Two-thirds of eyes presented with the macula detached. Eyes had an average of 1.6 breaks. The single operation anatomic success rate was 85.1% (240/282). The pre-op visual acuity improved from 1.21 to 0.76 logMAR at 6 months (p < 0.0001). Complications included a case of scleral laceration, choroidal hemorrhage, 3 epiretinal membranes, 1 macular fold, and 4 eyes with buckle exposure. Non-contact wide-angled visualization with chandelier-assisted SB compares favorably with conventional SB for primary uncomplicated primary RRD.

Purpose To establish the prevalence and risk factors for intravitreal dexamethasone implant migration into the anterior chamber in eyes with macular edema. Methods This was a multicenter, retrospective, observational chart review of data that included patients with macular edema who had been treated with at least one intravitreal dexamethasone injection. Patients with incomplete chart information during the follow-up period were excluded. Results The prevalence of implant migration in 468 patients, considering the number of injections, was 1.6%, with significant associations between implant migration and cataract surgery (P = 0.043) and intraocular lens status (P = 0.005) and a trend toward statistical significance (P = 0.057) with vitrectomy. A higher rate of implant migration into the anterior chamber was observed in vitrectomized eyes (4.8%) when compared with patients who did not undergo a vitrectomy (1.6%). The implants that migrated were removed with forceps with/without viscoelastic expression or with 20-gauge cannulas connected to the vitreous cutter machine. Conclusion The risk of implant migration into the anterior chamber was 1.6%. Risk factors were a history of cataract surgery or vitrectomy and aphakia. When anterior migration occurs, rapid removal is advised, especially if corneal edema is present.

Purpose: To describe the the appearance and behavior of subretinal hyperreflective material (SHRM) in eyes with central serous chorioretinopathy (CSCR). Methods: This retrospective study included 20 eyes of 20 patients with CSCR presenting with SHRM, defined as sub-retinal deposits that appear hyper-reflective on OCT The eyes underwent either laser (15 eyes) or observation (5 eyes). Optical coherence tomography and fundus fluorescein angiography (FFA) characteristics were analyzed at baseline and resolution of neurosensory detachment, which were then co-related with the visual acuity at resolution. Results: Improvement in vision was seen in 16 eyes. Ellipsoid zone damage (P = 0.03) and external limiting membrane (ELM) damage (P = 0.000) at resolution; diffuse retinal pigment epithelium (RPE) abnormalities on FFA (P = 0.04), and the presence of scar (P = 0.000), were associated with poor visual outcome in univariate analysis. ELM damage at resolution was statistically significant (P = 0.001) in multivariate analysis. Conclusion: CSCR with SHRM have a good visual prognosis. ELM damage at resolution corelates with a poor visual acuity at resolution.

Diabetic macular edema (DME) is a chronic condition with a multifactorial pathogenesis. Vascular endothelial growth factor (VEGF) and several inflammatory mediators are upregulated in eyes with DME. VEGF inhibitors and corticosteroids have all been used successfully in the management of DME. Currently available corticosteroids include triamcinolone acetonide (TA), the dexamethasone (DEX) intravitreal implant, and the fluocinolone acetonide (FA) intravitreal implant. The response to treatment can vary substantially with each treatment modality. Some cases of DME are VEGF driven, and in others, inflammation plays a key role. Chronicity appears to favor corticosteroid treatment. There are no clear guidelines to guide switching from an anti-VEGF to a corticosteroid. Combination therapy of an anti-VEGF drug and a corticosteroid does not appear to provide additional benefit over monotherapy with either drug. The main advantage of corticosteroids over VEGF inhibitors is their longer duration of action. Vitrectomy does not affect the pharmacokinetics of the corticosteroid implants. Common adverse events of corticosteroids include cataract formation, cataract progression, and ocular hypertension. TA may cause a sterile endophthalmitis and pseudoendophthalmitis. Migration of the intravitreal DEX and FA implants into the anterior chamber can be problematic. Because of their less favorable safety profile, corticosteroids are generally used as a second-line treatment for DME. Advantages of using an intravitreal corticosteroid implant include the reduction of treatment burden and predictable pharmacokinetics even in vitrectomized eyes. Pseudophakic eyes, previously vitrectomized eyes and eyes with long-standing DME, particularly of patients who have difficulty in maintaining a monthly appointment, may benefit from primary treatment with a corticosteroid intravitreal implant.

Background To compare the functional and anatomic outcomes at 24 months of eyes with a primary macular hole that failed to close after a prior surgery and were treated with either an autologous transplantation of internal limiting membrane (AT-ILM) or the retina expansion (RE) technique. Methods Retrospective, single center, comparative study of 28 eyes with a macular hole that failed to close after a prior vitrectomy. All eyes had a size of ≥ 500 μm. Participants were divided into two groups according to the type of intervention performed: AT-ILM group (n = 14) and RE group (n = 14). Main outcomes measured were the MH closure rate assessed by spectral-domain optical coherence tomography (SD-OCT) and the best-corrected visual acuity (BCVA) at 24 months after surgery. Results Patients in the AT-ILM group experienced a statistically significantly improved post-operative BCVA (median 49.50 letters, range 20–66 letters) over the pre-operative BCVA (median 39 letters, range 18–52 letters) (p-value = 0.006 Wilcoxon paired sample test). In contrast, patients in the RE group did not achieve a statistically significant improvement (p-value = 0.328, Wilcoxon paired sample test). The median pre-operative BCVA was 35 letters (range 18–52 letters), whereas the median post-operative BCVA was 39 letters (range 16–66 letters). At 24 months of follow-up, 85.7% of patients in the AT-ILM group achieved closure compared to 57.1% in the RE group (p-value = 0.209, Fisher’s exact test). Multivariate analysis showed that MH size and baseline BCVA were important determinants of post-operative BCVA. The baseline MH size was the only significant pre-operative factor that influenced MH closure. Conclusions This study demonstrates similar closure rates for both groups however better visual outcomes were obtained with the AT-ILM.

Introduction: The indications for pars plana vitrectomy (PPV) have increased over the years. The vitreous is no longer considered an inert ocular structure and it is well known that its removal has anatomical and physiological consequences. The vitreous is no longer considered an inert ocular structure. The vitreous plays a key role as an intraocular physiologic oxygen regulator. In order to maintain its transparency, the crystalline lens needs protection from an excessive oxygen exposure. PPV leads to progression of nuclear sclerosis in most eyes.Methods: A systematic review of the literature was conducted using Embase and Medline databases. Articles studying the physiology, pathogenesis and surgical treatment of cataract after PPV were included in this review.Results: The pathogenesis of cataract formation after PPV remains unclear. Predisposing factors include advanced patient age, preexisting nuclear sclerosis, light toxicity, intraoperative oxidation of lens proteins, use of silicone oil or intravitreal gas, mechanical trauma and the duration of exposure to an irrigating solution.Conclusion: Cataract surgery in vitrectomized eyes presents with more technical difficulties, is more challenging and often has a higher risk of intraoperative and postoperative complications than in non vitrectomized eyes. There is no standardized technique or management in these cases; therefore, it requires more precautions during surgery.

To report two cases of acute syphilitic posterior placoid chorioretinitis (ASPPC) with choriocapillaris flow voids that partially resolved with systemic antibiotic treatment.Observational case report with multimodal imaging.Two young healthy men suffered an acute monocular loss of vision. Spectral domain optical coherence tomography (SD-OCT) and OCT angiography (OCT-A) revealed outer retinitis with loss of the ellipsoid layer and choriocapillaris flow voids. Systemic work-up revealed syphilis. Upon systemic treatment with antibiotics, the patients recovered their vision and the OCT and OCT-A abnormalities partially resolved.Transient choriocapillaris flow voids characterize ASPPC and may be responsible for the visual loss seen in these patients.

Chagas disease is an inflammatory, infectious disease caused by the parasite Trypanosoma cruzi found in the feces of the triatomine bug, which can cause a sudden, brief acute illness, or it may become a long-lasting chronic condition. Chagas disease is common in South America and Central America, however, the constantly expanding global community has brought Chagas disease to the forefront of non-endemic areas, particularly the United States and Europe. The authors present a case of a 47-year-old healthy farmer diagnosed with a right orbital cellulitis refractory to systemic antibiotics. Based on clinical symptoms, the patient's medical/demographical history and a proper differential diagnosis, an acute phase of Chagas disease was diagnosed. After antiparasitic treatment, the patient had a proper recovery and continued with a regular follow-up to monitor the possible development of a chronic phase.

Purpose: To characterize retinopathy of prematurity (ROP) training practices in international residency and fellowship programs. Methods: A publicly available online-based platform ( http://www.SurveyMonkey.com ) was used to develop a 28-question multiple-choice survey that targeted ROP screening and treatment methods. The authors solicited training programs in the Philippines, Thailand, and Taiwan. Results: Programs from three countries participated in the survey, and a total of 95 responses collected from residents, fellows, and attending ophthalmologists were analyzed. A descriptive analysis demonstrated that 45 participants (47%) reported 1% to 33% of ROP screenings were performed under direct supervision of attending ophthalmologists, and 35 (37%) reported the use of formal assessments. The majority of participants (Country A: 87%, Country B: 71%, and Country C: 75%) estimated 1% to 33% of their practice was spent screening for ROP. Notably, 44 participants (46%) reported performing zero laser photocoagulation treatments for ROP during training (Country A: 65%, Country B: 38%, and Country C: 38%). Conclusions: International ophthalmology trainees perform a limited number of ROP examinations and laser interventions. ROP screenings are often unsupervised and lead to no formal evaluation by an attending ophthalmologist. Limited ROP training among ophthalmologists may lead to misdiagnosis and ultimately mismanagement of a patient. Loss of vision and exposure to unwarranted treatments are among the implications of such errors. The findings highlight the need to improve ROP training in international ophthalmology residency and fellowship programs. [ J Pediatr Ophthalmol Strabismus . 2019;56(5):282–287.]

PurposeTo report the visual and anatomical outcomes in eyes with peripapillary choroidal neovascularisation (CNV) through 12 months.MethodsThis was a multicentre, retrospective, interventional case series which included treatment-naïve cases of peripapillary choroidal neovascular membrane (CNVM) with a minimum follow-up of 12 months. Multimodal imaging which comprised optical coherence tomography (OCT), fluorescein angiography and/or indocyanine green angiography was performed at baseline and follow-up visits. OCT parameters included central macular thickness (CMT), subfoveal choroidal thickness (SFCT) and retinal and choroidal thickness at site of CNV. Patients were treated with anti-vascular endothelial growth factors (VEGF) on pro re nata protocol, photodynamic therapy, laser photocoagulation or a combination. Main outcome measures were change in best corrected visual acuity (BCVA) and OCT parameters.ResultsA total of 77 eyes (74 patients; mean age: 61.9±21.8 years) with a mean disease duration of 9.2±14.1 months were included. BCVA improved significantly from 0.55±0.54 logMAR (20/70) at baseline to 0.29±0.39 logMAR (20/40) at 12 months (pConclusionPeripapillary CNVM, though uncommon, is associated with diverse aetiologies. Anti-VEGF agents lead to significant visual acuity and anatomical improvement in these eyes over long term irrespective of the aetiology.

PURPOSE: There is no established therapy for exudative-hemorrhagic complications in primary retinal arteriolar macroaneurysm (RAM). METHODS: Retrospective multicenter interventional study of anti-vascular endothelial growth factor in symptomatic RAMs. Central macular thickness in mum and best-corrected visual acuity in logMar were correlated with the RAM size and distance to the macula. Statistical analyses were performed using paired comparisons and Pearson correlation. RESULTS: Thirty-two eyes (32 patients) were treated with a mean of 2.7 injections over a mean follow-up of 16.6 months. Initial best-corrected visual acuity correlated with the RAM size and distance to the macula (P = 0.02). Central macular thickness decreased by 131,180, and 211 mum at 1, 2, and 3 months after the first injection (P < 0.001). Best-corrected visual acuity improved by 0.47 and 0.38 Early Treatment Diabetic Retinopathy Study lines at 2 and 3 months (P = 0.005). Anti-vascular endothelial growth factor response correlated with the RAM size (P = 0.04) and the distance to the macula (P = 0.009). CONCLUSION: Symptomatic RAMs can be treated successfully with anti-vascular endothelial growth factor injections, leading to a decrease in macular edema.

Purpose: To evaluate medium and large choroidal vessel layer thickness (MCVT and LCVT, respectively) in eyes with acute and chronic central serous chorioretinopathy (CSC) in comparison with age-matched controls. Methods: The study included 96 eyes of 96 patients with CSC, including 53 eyes with acute CSC, 43 eyes with chronic CSC, and 30 eyes of 30 age-matched normal subjects. Manual measurements of subfoveal choroidal thickness (SFCT), MCVT, and LCVT at subfoveal and 750 μm nasal and temporal to the fovea locations were made on enhanced depth imaging optical coherence tomography (EDI-OCT) of the macula in all subjects using ImageJ software (National Institutes of Health, Bethesda, MD, USA). Results: SFCT in acute CSC was significantly larger than that in healthy eyes (P = 0.0001). SFCT in acute CSC did not differ significantly from that in chronic CSC eyes. Subfoveal LCVT and MCVT in acute CSC eyes were greater than those in healthy eyes (P = 0.02 and P = 0.03, respectively). Mean SFCT and MCVT in chronic CSC eyes were significantly larger than those in control eyes (P = 0.01 and P = 0.04, respectively). No significant difference in LCVT was observed between chronic and control eyes. Conclusion: Choroidal vasculature is altered in both acute and chronic CSC. SFCT, MCVT, and LCVT are higher in eyes with acute CSC. The thickening of medium choroidal vessels is still detectable in chronic CSC compared to control eyes.

Prior to the development of panretinal photocoagulation (PRP) in the 1970s, proliferative diabetic retinopathy (PDR) was the most common cause of blindness in diabetic patients. The diabetic retinopathy study demonstrated that PRP could decrease severe visual loss from PDR by 50%. Since then and for the past four decades, PRP has been the treatment of choice for eyes with PDR. In the past decade, vascular endothelial growth factor (VEGF) inhibition has become the treatment of choice for diabetic macular edema (DME). When treated intensively with anti-VEGF drugs, about one-third of eyes with DME experience an improvement in their diabetic retinopathy severity scale. Randomized clinical trials comparing ranibizumab to PRP and aflibercept to PRP have shown that VEGF inhibitors cause regression of intraocular neovascularization but need to be given on a fairly regular basis. Despite these promising results, concerns about treatment adherence have surfaced. Patients with PDR that are treated solely with anti-VEGF drugs and somehow interrupt their treatment are at a high risk of developing irreversible blindness. Combination treatment of PRP plus an anti-VEGF drug may be the treatment of choice for PDR.

Purpose Following the first wave of the COVID-19 pandemic in early 2020, the easing of strict measures to reduce its spread has led to a resurgence of cases in many countries at both the national and local level. This article addresses how guidance for ophthalmologists on managing patients with retinal disease receiving intravitreal injections of anti-vascular endothelial growth factor (VEGF) during the pandemic should be adapted to the local epidemic pressure, with more or less stringent measures implemented according to the ebb and flow of the pandemic. Methods The Vision Academy’s membership of international retinal disease experts analyzed guidance for anti-VEGF intravitreal injections during the COVID-19 pandemic and graded the recommendations according to three levels of increasing epidemic pressure. The revised recommendations were discussed, refined, and voted on by the 14-member Vision Academy Steering Committee for consensus. Results Protocols to minimize the exposure of patients and healthcare staff to COVID-19, including use of personal protective equipment, physical distancing, and hygiene measures, should be routinely implemented and intensified according to local infection rates and pressure on the hospital/clinic or healthcare system. In areas with many COVID-19-positive clusters, additional measures including pre-screening of patients, postponement of non-urgent appointments, and simplification of complex intravitreal anti-VEGF regimens should be considered. Treatment prioritization for those at greatest risk of irreversible vision loss should be implemented in areas where COVID-19 cases are increasing exponentially and healthcare resources are strained. Conclusion Consistency in monitoring of local infection rates and adjustment of clinical practice accordingly will be required as we move forward through the COVID-19 era. Ophthalmologists must continue to carefully weigh the risk–benefits to minimize the exposure of patients and healthcare staff to COVID-19, ensure that patients receive sight-saving treatment, and avoid the potential long-term impact of prolonged treatment postponement.

PurposeTo ascertain the anatomic factors that help achieve non-surgical sealing in full thickness macular hole (FTMH).MethodsRetrospective collaborative study of FTMH that closed without surgical intervention.ResultsA total of 78 patients (mean age 57.9 years) included 18 patients with blunt ocular trauma, 18 patients that received topical or intravitreal therapies and 42 patients with idiopathic FTMH. Mean±SD of the initial corrected visual acuity (VA) in logMAR improved from 0.65±0.54 to 0.34±0.45 (pConclusionOur data suggest an observation period in new onset FTMH for non-surgical closure, in the setting of trauma, treatment of CME and size

To assess the effects of weekly post-operative intravitreal methotrexate injections on eyes with grade C proliferative vitreoretinopathy (PVR) that underwent surgical repair. Retrospective case–control study of 16 eyes with retinal detachment and grade C PVR. Seven eyes received weekly intravitreal MTX injections post-operatively as an adjunct and 9 eyes served as the control. The main outcome measure was the retinal re-attachment rate. In the MTX group, 86% (6/7) of eyes had a complete retinal re-attachment at the end of the follow-up period. In contrast in the no MTX group, only 22.2% (2/9) of eyes had a complete retinal re-attachment (p = 0.0406). The patients in the MTX group received a mean of 6 injections (range 4–8). There were no cases of corneal epitheliopathy. Serial intravitreal MTX as an adjunct to surgical repair holds promise for the management of PVR.

Report the foveal avascular zone (FAZ) area imaged by OCT angiography (OCTA) using a full spectrum probabilistic algorithm in eyes of healthy individuals from Costa Rica without any ocular or systemic pathology. Retrospective chart review of consecutive healthy patients that were evaluated from January 2018 to October 2018 that underwent OCTA of the macular area. The OCTA consisted of a 10° × 10° cube of 512 A scans separated by 6 µm each with an automated real time mode of 5. The FAZ area of the superficial vascular complex (SVC), the deep vascular complex (DVC), superficial vascular plexus (SVP), intermediate vascular plexus (IVP) and the deep vascular plexus (DVP) were measured manually by 2 different observers at 3 different times. A total of 234 eyes of 121 patients were included in this study. Mean age was 50 years (range, 15–89), 85 patients (70%) were female. Inter- and intra-observer agreements were excellent. The mean FAZ areas in the different layers were 0.258 ± 0.0035 mm2 for the SVC, 0.205 ± 0.01 mm2 for the DVC, 0.415 ± 0.01 mm2 for the SVP, 0.305 ± 0.01 mm2 for the ICP and 0.420 ± 0.01 mm2 for the DCP. The mean FAZ areas in most of the measured layers increased with age and decreased with CMT. Gender and spherical equivalence were not correlated with FAZ area. Manual measurements of the FAZ imaged by OCT-A using a full spectrum probabilistic algorithm are widely reproducible both by the same observer and between observers. The FAZ increases with age and decreases with CMT in normal individuals.

Macular laser photocoagulation (MLP) is inferior to intravitreal vascular endothelial growth factor (VEGF) inhibitors in the treatment of center-involved diabetic macular edema (DME). Ultra-widefield fluorescein angiography-guided laser photocoagulation to presumed ischemic areas of the peripheral retina or MLP do not reduce the treatment burden nor improve the visual outcomes of eyes treated with anti-VEGF drugs. Destruction of retinal tissue is not necessary to induce a therapeutic response in DME. Modern lasers are capable of producing invisible laser “burns” that do not destroy the targeted tissue using micropulse subthreshold (ST) mode where the laser's duty cycle is modified or alternatively selective retinal therapy (SRT) where ultrashort pulses of continuous wave laser selectively target the RPE. The best results with micropulse ST laser are obtained in eyes with a central macular thickness ≤400 μm. Eyes need to be treated in a continuous manner with no spaces between burns in the edematous area. Micropulse ST-MLP downregulates inflammatory biomarkers produced by activated microglial cells and Müller cells. Micropulse ST-MLP may reduce the anti-VEGF injection burden in DME. In SRT, the diseased RPE is targeted and heated with the laser with the hope that the adjacent RPE migrates and proliferates into these areas to heal the diseased RPE. There is much less experience with SRT, but the results are promising and deserve further study.

Purpose There is an urgent need to address how to best provide ophthalmic care for patients with retinal disease receiving intravitreal injections with anti-vascular endothelial growth factor agents during the ongoing global COVID-19 pandemic. This article provides guidance for ophthalmologists on how to deliver the best possible care for patients while minimizing the risk of infection. Methods The Vision Academy’s Steering Committee of international retinal disease experts convened to discuss key considerations for managing patients with retinal disease during the COVID-19 pandemic. After reviewing the existing literature on the issue, members put forward recommendations that were systematically refined and voted on to develop this guidance. Results The considerations focus on the implementation of steps to minimize the exposure of patients and healthcare staff to COVID-19. These include the use of personal protective equipment, adherence to scrupulous hygiene and disinfection protocols, pre-screening to identify symptomatic patients, and reducing the number of people in waiting rooms. Other important measures include triaging of patients to identify those at the greatest risk of irreversible vision loss and prioritization of treatment visits over monitoring visits where possible. In order to limit patient exposure, ophthalmologists should refrain from using treatment regimens that require frequent monitoring. Conclusion Management of patients with retinal disease receiving intravitreal injections during the COVID-19 pandemic will require adjustment to regular clinical practice to minimize the risk of exposure of patients and healthcare staff, and to prioritize those with the greatest medical need. The safety of patients and healthcare staff should be of paramount importance in all decision-making.

BACKGROUND AND OBJECTIVE: Diabetic macular edema (DME) is a leading cause of vision loss worldwide. The object of this study is to compare global differences of baseline characteristics of patients undergoing initiation of anti-vascular endothelial growth factor (VEGF) therapy for DME. PATIENTS AND METHODS: This multicenter, cross-sectional study included diabetic patients with foveal-involving retinal edema secondary to DME as documented by fundus exam and optical coherence tomography who were undergoing initiation of intravitreal anti-VEGF drugs. Variables were collected to find possible risk factors and to create an epidemiological profile of DME patients undergoing initiation of anti-VEGF agents. RESULTS: Nine hundred two patients were selected. Mean age was 62.4 (±11) years, 49.7% were Caucasians, 57.6% were male, and 96% had type two diabetes with an average disease duration of 181.7 months ± 113 months. Of the patients included, 74.7% suffered from hypertension, 26.6% from cardiovascular disease, 12.1% from cerebrovascular disease, 12.8% from peripheral vascular disease, and 12.8% from renal insufficiency. Best-corrected visual acuity (BCVA) was 65 (±20) Early Treatment Diabetic Retinopathy Study letters, central subfield thickness was 364 (±162) μm, cube volume 11.1 ± 3.1 mm 3 , cube average thickness 328.8 μm ± 61 μm, and 63.9% had nonproliferative diabetic retinopathy. Comparison between U.S. versus international patients, and patients with BCVA 70 letters or less versus more than 70 letters were performed, significant differences were acknowledged, and risk factors were recognized. CONCLUSION: There were key differences in the epidemiologic profile between patients presenting with DME in the U.S. and internationally. [ Ophthalmic Surg Lasers Imaging Retina . 2019;50:e300–e310.]

BACKGROUND: Comparison of presentation and outcomes of central serous chorioretinopathy (CSC) between male and female subjects in different ethnic populations. METHODS: Retrospective comparison between male and female subjects with CSC was completed. Demographic details, clinical presentations, imaging features and treatment outcomes were compared at baseline and at last follow-up. RESULTS: This study included 155 male and 155 female subjects with a mean (CSD) age of 43.8 ± 10.3 and 57.0 ± 12.1 years, respectively, and a mean duration of follow-up of 8.49 ± 12.6 months. At presentation, there was no difference in visual acuity; however, visual acuity was significantly higher for female subjects at last follow-up (p = 0.02). Optical coherence tomography (OCT) analysis showed that subretinal deposits (p

To compare the efficacy and safety of subthreshold micropulse laser (SML) with threshold conventional laser (TCL) in central serous chorioretinopathy (CSC).Prospective, randomized, double-masked, non-inferiority, 12-week clinical trial. Patients were randomly assigned 1:1 to SML group or TCL group. Patients in the SML group were treated with 577 nm micropulse laser. The spot size was 160 µm, the duty cycle was 5% and exposure time was 0.2 s. The power was 50% threshold tested. Patients in the TCL group were treated with 577 nm continuous laser. The power was 100% threshold tested. The primary outcome was the mean change in best-corrected visual acuity (BCVA) at week 12, with a non-inferiority limit of five letters on the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity charts.Eighty-eight patients were enroled. Seventy-seven patients were male. Forty-four patients were in SML group and 44 in TCL group. At week 12, SML was equivalent to TCL with a gain of 6.23 ± 8.59 and 6.61 ± 6.35 letters, respectively, (SML-TCL difference: -0.38 letters; 95% confidence interval (CI):-3.58-2.81; PBoth SML and TCL can improve visual acuity in CSC. SML was non-inferior to TCL in the improvement of BCVA.

PURPOSE To evaluate the effects of intravitreal bevacizumab (IVB) on retinal neovascularization in patients with proliferative diabetic retinopathy (PDR). METHODS Retrospective multicenter interventional case series. A chart review was performed of 81 consecutive patients (97 eyes) with retinal neovascularization due to PDR, who received at least 1 IVB injection. RESULTS The mean age of the patients was 55.6 ± 11.6 years. The mean number of IVB injections was 4 ± 2.5 injections (range, 1-8 injections) per eye. The mean interval between IVB applications was 3 ± 7 months. The mean duration of follow-up was 29.6 ± 2 months (range, 24-30 months). Best-corrected visual acuity and optical coherence tomography improved statistically significantly (P < 0.0001, both comparisons). Three eyes without previous panretinal photocoagulation ("naive" eyes) and with vitreous hemorrhage did not require vitreoretinal surgery. Five (5.2%) eyes with PDR progressed to tractional retinal detachment requiring vitrectomy. No systemic adverse events were noted. CONCLUSION Intravitreal bevacizumab resulted in marked regression of retinal neovascularization in patients with PDR and previous panretinal photocoagulation. Intravitreal bevacizumab in naive eyes resulted in control or regression of 42.1% of eyes without adjunctive laser or vitrectomy during 24 months of follow-up. There were no safety concerns during the 2 years of follow-up of IVB for PDR.

To describe the natural history of eyes with symptomatic idiopathic vitreomacular traction (VMT).Retrospective multicenter study of 168 eyes with spectral-domain optical coherence tomography (SD-OCT) findings consistent with idiopathic VMT. All eyes were graded according to SD-OCT findings. Grade 1 was defined as incomplete cortical vitreous separation with foveal attachment. Grade 2 was defined as Grade 1 plus intraretinal cysts or clefts. Grade 3 was defined as Grade 2 plus a foveal detachment. All patients were followed for at least 6 months.There were 168 patients (51 men) with a mean age of 68.8 ± 10.7 years. Patients were followed for a mean of 22.7 ± 20.1 months. The mean duration of symptoms before the initial presentation was 3.65 ± 5.42 months. At baseline, 72 eyes had Grade 1, 74 eyes had Grade 2, and 22 eyes had Grade 3 SD-OCT findings. Over the follow-up period, 36 eyes (21.4%) had spontaneous resolution of the VMT with normalization of the foveal anatomy. The mean time to resolution was 12.3 ± 12.6 months. An unfavorable anatomical outcome occurred in 7.7% (13 of 168) of the eyes, with 6 eyes developing a lamellar macular hole and 7 eyes developing a full-thickness macular hole. This occurred at a mean of 10.3 ± 10.7 months after the presentation. Subgroup analysis based on baseline SD-OCT grade showed that 4.1% (3 of 73) of Grade 1 eyes compared with 6.8% (5 of 74) of Grade 2 eyes, and 23.8% (5 of 21) of Grade 3 eyes developed a full-thickness macular hole or lamellar macular hole (P = 0.0109, chi-square test). In the remaining 119 eyes, at the last follow-up, 65 eyes had Grade 1, 42 eyes had Grade 2, and 12 eyes had Grade 3 VMT. On average, the best-corrected visual acuity improved from 0.40 ± 0.35 logarithm of the minimum angle of resolution (Snellen, 20/50) at baseline to 0.35 ± 0.36 logarithm of the minimum angle of resolution (Snellen, 20/45; P = 0.0372), and the mean central macular thickness improved from 350 ± 132 μm to 323 ± 121 μm.Spontaneous resolution of VMT occurred in 21.4% (36 of 168) of eyes after a mean follow-up of 11.4 ± 12.6 months. An unfavorable anatomical outcome occurred in 7.7% (13 of 168) of eyes. The baseline SD-OCT grade may predict the progression to full-thickness macular hole.

To assess the effectiveness and safety of an intravitreal injection of 1.25 mg bevacizumab (IVB) as a preoperative adjunct to small-gauge pars plana vitrectomy (PPV) compared with PPV alone in eyes with tractional retinal detachment secondary to proliferative diabetic retinopathy.This prospective, double-masked, randomized, multicenter, active-controlled clinical trial enrolled 224 eyes of 224 patients between November 2013 and July 2015. All eyes underwent a baseline examination including best-corrected visual acuity, color photos, optical coherence tomography, and fluorescein angiography. Data were collected on intraoperative bleeding, total surgical time, early (1 month) postoperative vitreous hemorrhage, and mean change in best-corrected visual acuity at 12 months. P.05 was considered statistically significant.A total of 214 patients (214 eyes) were randomized in a 1:1 ratio to PPV plus IVB ([study group] 102 eyes) or PPV plus sham ([control] 112 eyes). Iatrogenic retinal breaks were noted intraoperatively in 35 eyes (34.3%) in the study group, and 66 eyes (58.9%) in the control group (P = .001). Grade 2 intraoperative bleeding was noted in 32 (31.3%) eyes in the study group and 58 (51.7 %) eyes in the control group (P = .001). Endodiathermy was necessary in 28 (27.4 %) eyes in the study group, compared with 75 (66.9%) eyes in the control group (P = .0001). Mean surgical time was 71.3 ± 32.1 minutes in the study group and 83.6 ± 38.7 minutes in the control group (P = .061).Preoperative IVB seems to reduce intraoperative bleeding, improving surgical field visualization, and reducing intraoperative and postoperative complications. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Purpose: To report the demand of ophthalmic services and the prevalence of the main ophthalmic pathologies in a rural population of Costa Rica. Study Design: A cross-sectional study of all individuals seen at the ophthalmology outpatient clinic during March 2016 to February 2017. Methods: All cases presenting to the ophthalmology outpatient clinic during March 2016 to February 2017 were reviewed (n = 895 patients, 1790 eyes). Visual acuity was measured using the Snellen chart. Results: The most common reasons for consultation were decreased visual acuity in 37.7% (326/865), foreign-body sensation 20.2% (175/865), glaucoma control 5.9% (51/865), screening or follow-up of diabetes mellitus (DM) 5.8% (50/865), and blunt trauma in 5% (43/865) of patients. A total of 252 (14.1%) eyes presented with a best-corrected visual acuity (BCVA) ≤20/200; 357 (19.9%) eyes had a BCVA 20/200; and 1181 (65.9%) had a BCVA ≥20/40. There were 40 (4.5%) patients that had a BCVA ≤20/200 bilaterally. The most common ophthalmic findings included cataract in 552 (30.8%) eyes, pterygium in 296 (16.5%) eyes, primary open angle glaucoma (POAG) in 187 (10.4%) eyes, age-related macular degeneration in 168 (9.4%) eyes, and 131 (7.3%) eyes with diabetic retinopathy (DR). Conclusions: The most common cause of ophthalmic consultation was decreased vision, of which 14% had a BCVA ≤20/200. The common findings included cataract, pterygia, POAG, age-related macular degeneration, and DR. Seventy-five percent of bilateral visual loss is avoidable.

The aim of the study was to describe the ocular findings following an accidental high-voltage electrical discharge. A 32-year-old male suffered an accidental electric discharge of 10,000 volts of direct current. He developed cortical, nuclear, and posterior subcapsular opacities in both the eyes. The retinal examination showed bilateral macular cysts. Four months after the event, the macular cyst in the OD spontaneously regressed without visual improvement. The macular cyst in the OS remained unchanged. High-voltage electrical discharge can lead to bilateral maculopathy and cataracts. The visual prognosis is reserved. The visual acuity may not improve despite macular cyst regression.

PurposeThe purpose of the study was to evaluate the role of subfoveal choroidal thickness (CT) measurements as a predictor for the course of central serous chorioretinopathy (CSC).Patients and methodsThirty-eight eyes of 33 patients with CSC were analyzed retrospectively. Key inclusion criteria were naive (acute or recurrent) CSC; a minimum of 12 months of follow up; and the availability of good quality enhanced depth imaging SD-OCT images at each visit. Eyes with changes suggestive of chronic CSC and history of any treatment were excluded. Collected data included demographic profile, visual acuity, subfoveal CT, central macular thickness (CMT), and treatment details. Univariate and multivariate analyses for association of baseline features with need for treatment were performed. On the basis of results of this analysis, the 38 eyes were divided into two groups: Group A (subfoveal CT≤356 μm) and Group B (subfoveal CT356 μm).ResultsOn univariate analysis, the need for treatment had significantly positive correlation with duration of symptoms (P=0.02), negative correlation with the baseline CT (P0.01), and no significant correlation with CMT (P=0.13). On multivariate regression analysis, only baseline CT had a statistically significant association with the need for treatment (odds ratio (OR), 0.989; CI, 0.979-0.999; P=0.048). Group A eyes were more likely to require treatment (Group A: 54.55%, 12 of 22 eyes; Group B: 18.75%, 3 of 16 eyes; OR: 5.2, 95% CI, 1.15-23.54; P=0.04). There was a significant decrease in subfoveal CT in Group B (-105.62±108.91 μm; P=0.002).ConclusionCSC with a subfoveal CT≤356 μm is of chronic nature and is more likely to require treatment rather than observation.

Purpose. To evaluate the best-corrected visual acuity (BCVA), central retinal thickness (CRT), and the number of dexamethasone implants needed to treat cystoid macular edema (CME) from various etiologies over 12 months in vitrectomized and nonvitrectomized eyes.Methods. This multicenter retrospective cohort study included 112 patients with CME secondary to retinal diseases treated pro re nata (PRN) with a 0.7 mg intravitreal dexamethasone implant for 12 months. The BCVA, CRT, adverse events, safety data, and number of implants were recorded.Results. Vitrectomized and nonvitrectomized eyes received means of three implants and one implant, respectively, over 12 months (P<0.001). The mean BCVA of all patients improved from 0.13 at baseline to 0.33 (P<0.001) 12 months after one (P=0.001), two (P=0.041), and three (P<0.001) implants but not four implants (P=0.068). The mean baseline CRT decreased significantly (P<0.001) from 463 to 254 microns after 12 months with one (P<0.001), two (P=0.002), and three (P=0.001) implants but not with four implants (P=0.114). The anatomic and functional outcomes were not significantly different between vitrectomized and nonvitrectomized eyes. Increased IOP was the most common adverse event (23.2%).Conclusions. Dexamethasone implant administered PRN improved VA and decreased CRT in CME, with possible long-term clinically relevant benefits for treating CME from various etiologies. Vitrectomized eyes needed more implants compared with nonvitrectomized eyes.

To report clinical characteristics and treatment outcomes from the largest case series of choroidal neovascularization secondary to central serous chorioretinopathy.Retrospective analysis of 46 eyes of 43 consecutive subjects. Collected data included demographic details, history of presenting illness, clinical examination details including visual acuity at presentation and follow-up with imaging and treatment details. Main outcome measures were the proportion of eyes that had improved (3 or more lines), stable (within ±1 line), or decreased (3 or more lines) vision at the final visit as compared with baseline examination. Secondary efficacy outcomes included change in visual acuity at final follow-up, number of injections, treatment-free interval, and adverse events.Mean age was 57.56 years (range 29-79 years). Mean follow-up duration was 38.3 months ± 58.9 months. More than 3 lines of improvement in 12 eyes (26%), vision was stable (within ±1 line) in 19 eyes (41.3%), and3 lines of loss was noted in 6 eyes (13%). Mean change in the number of lines was 1.16 ± 3.74. Mean number of anti-vascular endothelial growth factor injections during the follow-up was 4.45 ± 4.1. The longest treatment-free interval was 8.9 months ± 7.5 months. There were no adverse events noted.Anti-vascular endothelial growth factor therapy as a primary therapy for choroidal neovascularization secondary to central serous chorioretinopathy is safe and efficacious, without any serious adverse events.

Susac’s syndrome (SS) is a relatively rare cause of multiple recurrent branch retinal arterial occlusions (BRAO). SS is frequently misdiagnosed and probably underdiagnosed. Ophthalmic manifestations may be the sole presenting sign of SS. Comprehensive literature review The typical triad of encephalopathy, sensorineural hearing loss and multiple recurrent BRAO is seldom seen at presentation in SS. The characteristic ophthalmological feature in SS is the presence of recurrent multiple BRAO in the absence of intraocular inflammation. Yellow to yellow-white, non-refractile or refractile retinal arterial wall plaques (Gass plaques) found at midarteriolar segments not associated to bifurcations are commonly found in SS. Because of its ability to capture more peripheral retinal area, ultrawide field fluorescein angiography (FA) has definite advantages over conventional FA and its use should be encouraged in patients suspected of having SS. Optical coherence tomography (OCT), particularly spectral domain OCT complements FA. Patients with BRAO and hearing loss that do not develop encephalopathy during the initial 2 years will most likely not develop encephalopathy. However, these patients will be prone to recurrent BRAO and hearing loss. Imunosuppression is the cornerstone of treatment but the best regimen still needs to be defined. A minority of patients with SS present with the typical triad. A high index of suspicion is needed to make the diagnosis promptly. Early diagnosis and treatment are important to delay disease progression and prevent blindness, deafness and dementia.

To report the association of acute visual loss secondary to intraretinal hemorrhages and energy drink consumption. Case report and literature review. A 48-year-old hypertensive man developed an elevation in systemic blood pressure, tachycardia, and acute visual loss secondary to intraretinal hemorrhages shortly after drinking several cans of energy drinks. High consumption of energy drinks may lead to intraretinal hemorrhages and acute visual loss.

Throughout ophthalmic history it has been shown that progress has gone hand in hand with technological breakthroughs. In the past, fluorescein angiography and fundus photographs were the most commonly used imaging modalities in the management of diabetic macular edema (DME). Today, despite the moderate correlation between macular thickness and functional outcomes, spectral domain optical coherence tomography (SD-OCT) has become the DME workhorse in clinical practice. Several SD-OCT biomarkers have been looked at including presence of epiretinal membrane, vitreomacular adhesion, disorganization of the inner retinal layers, central macular thickness, integrity of the ellipsoid layer, and subretinal fluid, among others. Emerging imaging modalities include fundus autofluorescence, macular pigment optical density, fluorescence lifetime imaging ophthalmoscopy, OCT angiography, and adaptive optics. Technological advances in imaging of the posterior segment of the eye have enabled ophthalmologists to develop hypotheses about pathological mechanisms of disease, monitor disease progression, and assess response to treatment. Spectral domain OCT is the most commonly performed imaging modality in the management of DME. However, reliable biomarkers have yet to be identified. Machine learning may provide treatment algorithms based on multimodal imaging.

Ahmad M Mansour,1,2 Jay Chhablani,3 J Fernando Arevalo,4,5 Lihteh Wu,6 Ravi Sharma,3 Suthasinee Sinawat,7 Tharikarn Sujirakul,8 Alexandre Assi,9 Wandsy M Vélez-Vázquez,10 Mohamad A Mansour,1 Ozcan Kayikcioglu,11 Cem Kucukerdonmez,12 Ali Kal13 1Department of Ophthalmology, American University of Beirut, Beirut, Lebanon; 2Department of Ophthalmology, Rafic Hariri University Hospital, Beirut, Lebanon; 3L.V. Prasad Eye Institute, Banjara Hills, Hyderabad, India; 4Department of Ophthalmology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA; 5Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 6Asociados de Macula Vitreo y Retina de Costa Rica, San José, Costa Rica; 7Department of Ophthalmology, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand; 8Department of Ophthalmology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 9Beirut Eye and Ear Specialty Hospital, Beirut, Lebanon; 10Retina Associates, Guaynabo, Puerto Rico; 11Celal Bayar University, Manisa, Turkey; 12Ekol Eye Hospital, Izmir, Turkey; 13Department of Ophthalmology, Baskent University, Konya, Turkey Purpose: To report the visual and anatomic outcomes of albino retinal detachment (ARD) repair. Methods: Collaborative retrospective analysis of ARD. Outcome measures were number of surgical interventions, final retinal reattachment, and best corrected visual acuity (BCVA) at last follow-up. Results: Seventeen eyes of 16 patients (12 males; mean age =37.8 years) had the following complications at presentation: macula off (14), total (7) or inferior detachment (5), proliferative vitreoretinopathy (5), detectable break (16), lattice (5), horseshoe tears (9), and giant tear or dialysis (4). Mean number of interventions was 1.8 (range =1–5) and included cryopexy (15) with scleral buckle (11), and/or vitrectomy (8). Mean initial BCVA was counting finger (CF) 1m and at last follow-up (mean 77 months) CF4m with mean improvement of 4.5 lines (early treatment diabetic retinopathy study) (P=0.05). Intraoperative choroidal hemorrhage occurred in three eyes. The retina was finally attached in 14 eyes, with residual inferior detachment in three eyes with silicone oil in situ. Silicone oil was kept in six of seven eyes because of residual inferior detachment (3) and removal of silicone oil, which led to redetachment (1) or fear of redetachment (2). Conclusion: Repair of ARD may require several interventions, with the need to keep silicone oil in several cases due to nystagmus and reduced melanin pigment. Keywords: cryopexy, foveal hypoplasia, nystagmus, retinal detachment, scleral buckle, silicone oil, vitrectomy

PurposeTo compare the functional and anatomical outcomes of eyes with chronic central serous chorioretinopathy treated with yellow micropulse (MP) laser versus half-dose verteporfin photodynamic therapy (PDT).MethodsThis is a multicentre, retrospective comparative study of 92 eyes treated with yellow MP laser (duty cycle of 5%, zero spacing between spots, spot size varied from 100 to 200 µm, power varied from 320 to 660 mW, and the pulse burst duration was 200 ms) and 67 eyes treated with PDT (half-dose verteporfin (3 mg/m2) infused over 10 min), followed by laser activation for 83 s. Spot sizes varied from 400 to 2000 µm.ResultsIn the MP group, at 12 months of follow-up, the mean best corrected visual acuity (BCVA) improved from the logarithm of the minimum angle of resolution (logMAR) of 0.41±0.27 at baseline to 0.21±0.26 (PConclusionsBoth PDT and MP are effective in restoring the macular anatomy. In places where PDT is not available, yellow MP laser may be an adequate treatment alternative.

Epiretinal membranes (ERMs) have been described for more than 150 years. Currently, they are a common indication for vitreoretinal surgery. Recently, there has been an increasing trend to peel the internal limiting membrane (ILM). Although ILM peeling has generally been accepted as a fundamental step in macular hole repair, its current role in ERM remains controversial.Literature review.Proponents of ILM peeling argue that peeling of the ILM reduces the recurrence rate and facilitates a greater resolution of retinal folds. Opponents of ILM peeling show that the visual outcomes between eyes that undergo ILM peeling and those that do not have their ILM peeled are the same. Stripping of the ILM removes the Müller cell footplates, so it is reasonable to expect some Müller cell dysfunction. Adverse events such as eccentric paracentral macular holes, macular microscotomata, and retinal dimpling have been associated with ILM peeling.Internal limiting membrane peeling does not improve the functional outcomes after ERM surgery. Internal limiting membrane peeling reduces ERM recurrences, but many recurrences are not clinically significant. It remains unclear what the long-term effects of ILM peeling are. We should err on the side of caution and avoid routine ILM peeling in primary idiopathic ERM cases and should reserve it for recurrent and high risk of recurrence cases.

To determine the effects of lens status on the success rate of primary pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment using either perfluoropropane gas (C3F8) or silicone oil (SO) tamponade.A retrospective chart analysis was made of 97 eyes from 92 patients with rhegmatogenous retinal detachment with no proliferative vitreoretinopathy that were treated with primary 23-gauge PPV. Eyes included in this were phakic (n = 28), pseudophakic (n = 41), or phakic eyes subject to simultaneous phacoemulsification, intraocular lens implantation, and PPV during primary rhegmatogenous retinal detachment repair (n = 28). Tamponade at the end of PPV was with either C3F8 (n = 65) or SO (n = 32). Success was defined as retinal reattachment at 1 year follow-up after a single procedure in eyes submitted to C3F8 injection; in eyes treated with SO injection, the success rate was defined as retina reattached 1 year after oil removal. Statistical comparisons were made between groups using chi-square, Fisher's exact test, Kruskal-Wallis, Mann-Whitney, and multivariate analysis. All eyes were operated by 2 experienced retina surgeons and had a minimum follow-up of 12 months.The vitreoretinal redetachment rate in eyes subjected to C3F8 tamponade was significantly higher (28.6%) for phakic eyes (P = 0.011) compared with pseudophakic or phakic eyes that underwent to phacoemulsification and intraocular lens implantation (4.5%). Eyes in which SO was used at the end of the surgical procedure demonstrated a similar trend of higher reoperation rates in phakic eyes (28.6%) compared with pseudophakic or phakic eyes (8%) subjected to phacoemulsification and intraocular lens implantation; however, no statistically significant difference was observed (P = 0.201). No statistically significant differences were found between groups in relation to the number of tears (P = 0.863) and their location (inferior: P = 0.189, superior: P = 0.708, nasal: P = 0.756, and temporal: P = 0.08).The success rates of primary 23-gauge PPV with either C3F8 or SO tamponade in pseudophakic eyes with rhegmatogenous retinal detachment was higher than the same procedure performed in phakic eyes. Still, the retrospective and limited data presented is too preliminary to suggest or recommend that practitioners perform simultaneous combined cataract surgery with retinal detachment and requires further studies in a larger and prospective design to confirm these present findings.

Purpose: To report the incidence and clinical features of patients that experienced un-explained visual loss following silicone oil (SO) removal. Methods: Multicenter retrospective study of patients that underwent SO removal during 2000-2012. Visual loss of ≥2 lines was considered significant. Results: A total of 324 eyes of 324 patients underwent SO removal during the study period. Forty two (13%) eyes suffered a significant visual loss following SO removal. Twenty three (7.1%) of these eyes lost vision secondary to known causes. In the remaining 19 (5.9%) eyes, the loss of vision was not explained by any other pathology. Eleven of these 19 patients (57.9%) were male. The mean age of this group was 49.2 ± 16.4 years. Eyes that had an un-explained visual loss had a mean IOP while the eye was filled with SO of 19.6 ± 6.9 mm Hg. The length of time that the eye was filled with SO was 14.8 ± 4.4 months. In comparison, eyes that did not experience visual loss had a mean IOP of 14 ± 7.3 mm Hg (p < 0.0002) and a mean tamponade duration of 9.3 ± 10.9 months (p < 0.0001). Conclusions: An un-explained visual loss after SO removal was observed in 5.9% of eyes. Factors associated with this phenomenon included a higher IOP and longer SO tamponade duration. © The Author(s) 2017.

PurposeTo report the long-term anatomical and visual outcomes of intravitreal bevacizumab (IVB) monotherapy in naive choroidal neovascularisation (CNV) caused by myopia.MethodsRetrospective analysis of naive CNV secondary to myopia that underwent antivascular endothelial growth factor monotherapy was performed. Collected data included demographic details, clinical examination details including visual acuity at presentation and follow-up with imaging and treatment details. Main outcome measures were resolution of CNV activity at the last visit. Secondary outcomes included change in visual acuity, number of injections and adverse events.ResultsThirty-three eyes of 31 subjects with a mean age of 51.48±16.4 years were included. The mean follow-up was 66.47 months. 27 eyes had type 2 CNV and the rest seven eyes had type 1 CNV. The mean number of IVB injections per eye was 4.9. Mean visual acuity at baseline reduced from 0.65±0.33 logMAR units (Snellen equivalent=20/89) to 0.73±0.50 logMAR units (20/107) at final follow-up (p=0.003). The mean central macular thickness decreased from 309.31±86 µm at baseline to 267.5±70.89 µm at the last visit (p=0.03). However, visual acuity was maintained (±1 line of baseline) in 13 eyes (39.4%), ≥2 line improvement in nine (27.3%) eyes and more than two lines worsening in 11 eyes (33.3%). Foveal atrophy was observed at baseline and last visit in 6 (12.5%) and 14 (29.1%), respectively (p=0.007). No systemic adverse events were observed.ConclusionIVB monotherapy is safe and effective for long-term treatment of CNV secondary to myopia in real life.

Age-related macular degeneration (AMD) is considered one of the main causes of severe vision loss in older adults. The neovascular form (nAMD) is an advanced stage, which is responsible for the most severe vision loss. Vascular endothelial growth factor (VEGF) is at present the main factor that leads to the development of a neovascular membrane and the increased leakage from the membrane to the retina. At present, anti-VEGF therapy is the only treatment that achieves vision gains in many patients and halts progression in most of them. VEGF blockade can be achieved with several molecules and various treatment regimens, which have been studied with excellent results. Unfortunately, real-world data has shown to be far less efficacious than clinical trials. This gap between clinical trials and real-world results is an unmet medical need that supports the necessity of new treatment modalities for nAMD. Of the various treatments being studied, anti-VEGFs of higher efficacy and longer durability are those more advanced in their development. Brolucizumab and abicipar pegol are 2 new anti-VEGF drugs that had positive results in phase 2 studies and are being tested in phase 3 trials at present. Other promising therapies are antiangiopoietin 2 molecules, which are in phase 2 development. At earlier stages of development but with promising results are squalamine, anti-VEGF-C and -D, and gene therapy. The future will give retina specialists a broad armamentarium with which patients may achieve high visual gains for the long term with a low treatment burden. Copyright © 2017 by Asia Pacific Academy of Ophthalmology.

Diabetic macular edema (DME) is the most common cause of moderate visual loss in diabetic patients. The current treatment of choice for center-involved DME is anti-vascular endothelial growth factor (VEGF) treatment. Most patients that undergo pharmacological inhibition with anti-VEGF agents need multiple monitoring visits that include optical coherence tomography imaging and multiple injections. Despite this intensive treatment, up to 60% of eyes will have persistent DME after six consecutive monthly injections of an anti-VEGF. Its sustainability over the long term has been questioned. Pars plana vitrectomy (PPV) by increasing the vitreous cavity oxygenation, relieving vitreomacular traction, and removing cytokines from the vitreous cavity may cause long-term resolution of DME without the aforementioned concerns in selected cases. Eyes with vitreomacular traction clearly benefit from PPV as the primary treatment. The role of PPV for eyes with DME without tractional elements is less clear and needs to be explored further.