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Purpose To determine the recurrence rate of exudative age-related macular degeneration (wet AMD) in patients on 12-week dosing interval anti-vascular endothelial growth factor (anti-VEGF) bevacizumab therapy. Methods A retrospective chart review was performed on wet AMD patients treated with anti-VEGF therapy using a "treat-and-extend" methodology at one physician's practice site over 2 years (2012-2014). Charts were evaluated for visual acuity, anti-VEGF agent used, treatment interval, duration of treatment, trials off of anti-VEGF therapy, evidence of exudation, and wet AMD recurrence characteristics. Results Three hundred and twenty-one wet AMD patients were treated. Fifty-seven eyes were without active exudation by clinical examination or optical coherence tomography (OCT) and were maintained on repeating 12-week interval suppressive anti-VEGF therapy. Sixteen percent (8/49) showed exudation recurrence with an average 10% cumulative recurrence rate per year for eyes on bevacizumab. Eight eyes without active exudation were discontinued off of bevacizumab therapy. Sixty-three percent (5/8) demonstrated recurrence on average 4 months after stopping therapy. Conclusion The findings in this study suggest that if a patient can be extended to 12-week interval bevacizumab therapy, there is on average a 10% chance of recurrence with each successive year. If anti-VEGF therapy is discontinued in these patients, there is an increased chance of recurrence by 4 months.

Purpose To study new and existing risk factors related to age-related macular degeneration (AMD) phenotypes in a Colorado cohort. Methods Age-related macular degeneration was categorized into early, intermediate, or advanced forms. Controls (n = 180) were patients with cataract and no AMD. Demographic and clinical data were gathered by patient interview and verified by chart review. Image data were reviewed by vitreoretinal specialists. Statistical analysis included univariable and multivariate logistic regression analysis (P Results Among the 456 patients with AMD, 157 (34.4%), 80 (17.6%), and 219 (48.0%) had the early/intermediate, geographic atrophy, and neovascular forms of the disease, respectively. Adjusted for age, African-American race was associated with a reduced risk of early/intermediate (adjusted odds ratio [AOR] = 0.08, confidence interval [CI] = 0.01-0.67) and neovascular AMD (AOR = 0.15, CI = 0.03-0.72). A family history of AMD was a risk factor for early/intermediate (AOR = 4.08, CI = 2.30-7.25), geographic atrophy (AOR = 8.62, CI = 3.77-19.7), and neovascular AMD (AOR = 3.76, CI = 2.16-6.56). A history of asthma was related to the early/intermediate form of AMD (AOR = 2.34, CI = 1.22-4.46). Conclusion Studying AMD in specific populations may reveal novel risk factors such as our finding of a relationship between asthma history and AMD.

To determine predictors of best-corrected postoperative visual acuity (VA) in patients who underwent surgical intervention for macula-off rhegmatogenous retinal detachment. Primary macula-off retinal detachments from the University of Colorado Primary Rhegmatogenous Retinal Detachment Database (2012–2017) were reviewed. The primary outcome measure was a postoperative VA of 20/40 or better at least 6 months after surgery. Patient demographics, medical history, duration of central vision loss before surgery, examination findings, operative technique, and postoperative findings were analyzed as possible predictors of postoperative visual recovery to 20/40 or better. Chi-square or Fisher’s exact test was used to compare categorical variables, and Wilcoxon rank sum test was used for continuous variables. A multivariable logistic regression analysis was used to determine the adjusted odds ratios and 95% confidence intervals for variables that were significant in the univariable analyses. Statistical significance was set at p

The association between combined methylmalonic acidemia and homocystinuria of cblC type (cobalamin C defect, cblC) and ocular disease is now well recognized, and is a significant component of morbidity and disability associated with the condition. In this review, through collation of historically reported cases of early- and late-onset cblC and previously unreported cases, we have attempted to characterize the epidemiology, clinical features, and pathomechanisms of individual ocular features of cblC. These data suggest that maculopathy and nystagmus with abnormal vision are extremely common and affect the majority of children with early-onset cblC, usually before school age; strabismus and optic atrophy are also seen at relatively high frequency. The timing of progression of macular disease may coincide with a critical period of postnatal foveal development. Maculopathy and retinal disease may be subclinical and show only partial correlation with the extent of visual deficits, and visual deterioration may be relentlessly progressive in spite of aggressive treatment of biochemical abnormalities. In later-onset forms of the disease, visual loss and ocular complications appear to be infrequent. Finally, we discuss investigational strategies in diagnosing and characterizing eye disease in individuals with cblC, explore possible therapeutic avenues that may attenuate progression and severity of eye disease, and propose a clinical surveillance guideline for monitoring progression of ocular disease in children and adults with cblC.

To purpose if this study was to determine whether the horizontal rectus muscle tendons (HRMTs) can be observed using anterior segment optical coherence tomography (AS-OCT) and to determine the repeatability of its measurements. Also, this study aimed to observe and measure the different external ocular structures at the level of the horizontal rectus muscle (HRM) insertion. This was a retrospective, observational, descriptive and comparative study. Images were obtained utilizing the RTVue 100 CAM system. Eyes were analyzed at the three and nine o’clock position. Scans were performed for three different locations: the limbus, the ciliary body and the equator. All scans were analyzed by two graders, separately and blinded. Measurements were performed for: HRMT length; HRM thickness; conjunctival epithelium thickness; conjunctiva and Tenon’s capsule thickness; scleral thickness; and external ocular thickness. Results were obtained from twenty eyes of ten volunteers. The conjunctival epithelium thickness was 52.33 μm, the total conjunctiva/Tenon’s capsule thickness was 313.54 μm, the medial rectus (MR) thickness was 136.63 μm and the lateral rectus (LR) thickness was 181.65 μm. The MR tendon length was 1,426.88 μm, the LR tendon length was 1,433.65 μm, the scleral thickness was 489.91 μm and the total external ocular structure thickness was 785.17 μm. Intra-observer reproducibility (intraclass correlation coefficient [ICC]) for tendon length was 0.993 for grader #1, 0.989 for grader #2; the muscle thickness ICC was 0.990 for grader #1 and 0.981 for grader #2. The inter-observer reproducibility ICC for tendon length was 0.557; the ICC for muscle thickness was 0.834. It is possible to visualize and measure HRMTs using AS-OCT. Measurements of the HRM, as well as the surrounding external ocular tissues, can be achieved.

Importance Checkpoint inhibition in cancer immunotherapy related to T-cell–driven mechanisms of action associated with acute macular neuroretinopathy (AMN) and diffuse retinal venulitis, an adverse event not previously described, is reported here. Objective To describe 2 patients who developed ophthalmologic events after treatment with the programmed death 1 axis inhibitor, atezolizumab. Design, Setting, and Participants Retrospective review of 2 patients treated with atezolizumab for metastatic breast cancer and colon cancer, respectively, who presented with AMN and diffuse retinal venulitis conducted at 2 tertiary medical centers. Main Outcomes and Measures Multimodal imaging including near infrared, optical coherence tomography, and fluorescein angiography were used to characterize retinal vascular abnormalities. Results Based on optical coherence tomography and multimodal imaging findings, the clinical diagnosis of AMN associated with diffuse retinal venulitis was made in these 2 patients receiving atezolizumab. Conclusions and Relevance While only 2 cases of patients receiving the programmed death ligand 1 inhibitor atezolizumab who experienced AMN and diffuse retinal venulitis are described here, these findings suggest that patients receiving programmed death 1 axis inhibitor therapies may need to be monitored for unexpected immune-related ocular toxicity including abnormalities of the microvasculature and large retinal vessels. Further studies might investigate the potential mechanisms of retinal vascular changes associated with these therapies.

Purpose: To explore the association of angiographic nonperfusion with anterior segment and posterior segment neovascularization in central retinal vein occlusion (CRVO). Methods: An imaging database at one institution was searched for the diagnosis of central retinal vein occlusion. Ultra wide field fluorescein angiograms were graded for image quality, the presence of retinal neovascularization, and the quantity of nonperfusion; an ischemic index (ISI) was calculated. Charts were reviewed to exclude eyes with previous treatment and to determine which eyes had anterior segment or posterior segment neovascularization on the day of the angiogram. Time from onset to presentation could not accurately be ascertained. Results: In a 39-month period, there were 69 eyes that met inclusion criteria. The mean ISI was 25% (SD, 26%; range, 0-100%), and 15 eyes (21%) with neovascularization had a mean ISI of 75% (range, 47-100%) compared with eyes without neovascularization that had an ISI of 6% (range, 0-43%). Ischemic index significantly correlated to neovascularization, and eyes that had evidence of neovascularization had an ISI >45% (P Conclusion: Ultra wide field fluorescein angiography provides visualization of nonperfusion in eyes with central retinal vein occlusion. Eyes with neovascularization on the day of the angiogram were found to have significantly larger areas of retinal nonperfusion compared with eyes without neovascularization. A prospective study is indicated to know if early treatment of peripheral retinal nonperfusion in CRVO improves outcomes.

Paracentral occlusive retinopathy is an uncommon manifestation of sickle cell disease. If macular ischemia is not reversed, permanent vision loss can result. The authors report the successful use of exchange transfusion to treat unilateral paracentral occlusive retinopathy secondary to sickle cell disease in a 23-year-old man with hemoglobin SS disease. Initial presentation demonstrated arteriolar occlusion, perivenous hemorrhages, vessel tortuosity, and areas of retinal ischemia. Visual acuity was count fingers, and the patient noted a paracentral scotoma. Following transfusion, there was restoration of arteriolar flow as documented with fluorescein angiogram, and visual acuity returned to 20/20. [ Ophthalmic Surg Lasers Imaging Retina . 2013;44:505–507.]

Purpose: To propose a model that measures the effect of intravitreal bevacizumab (IVB) on relatively healthy retina. The purpose is to analyze the remote effect of a branch retinal vein occlusion in the healthy retina, to determine the response it may have to IVB, and to determine if IVB has an atrophic effect on the healthy retina. Methods: Retrospective, longitudinal comparative analysis of patients with branch retinal vein occlusion treated with IVB. Eyes were divided into experimental (branch retinal vein occlusion eye) and control (contralateral eye) groups. Each eye was analyzed for thickness and area. Thickness measurements were performed for total retinal thickness, inner retina thickness, and outer retina thickness. Area was measured for photoreceptors, choroid, and total retina. Results: Eighteen eyes of 9 patients. For thickness analysis, 1,050 scans were studied, and 126 measurements were performed on 42 scans for area analysis. No difference was observed for thickness, except for inner retina thickness. No difference was observed for area. No difference was observed when analyzing a cumulative exposure to IVB. Conclusion: There is no evidence to suggest an atrophic effect caused by IVB when analyzing thickness or area in this experiment. This model could be used to analyze the long-term safety of IVB in larger studies.

To evaluate the efficacy and safety of the fluocinolone acetonide intravitreal implant in pediatric patients with intractable noninfectious posterior uveitis.A retrospective chart review was performed on all patients aged18 years on whom a fluocinolone implant was used to treat intractable posterior uveitis at our institution. Conventional treatment with topical and systemic steroids and/or systemic steroid-sparing agents failed in all patients before proceeding with an implant. Each implant contained 0.59 mg of fluocinolone acetonide. Implants were placed in the inferonasal quadrant through a pars plana incision and sutured in place with 8-0 proline suture. Postoperatively, patients were followed for improvement in Snellen visual acuity, control of inflammation, and development of complications such as infection or uncontrolled intraocular pressure in the eyes.The study included six eyes of four patients. Mean age at implant placement was 9.2 years (range, 6-13 years). Four eyes were pseudophakic at the time of surgery; one eye had pars plana lensectomy at the time of surgery. Mean follow-up duration was 698 days (range, 376-1,189 days). Postoperative visual acuity improved by ≥3 lines in 3 eyes. Four eyes had postoperative intraocular spikes ≥30 mmHg, with 2 eyes having ≥40 mmHg. Two of these patients required glaucoma shunting procedures postoperatively for intraocular pressure control. Inflammation was well controlled postoperatively in all six eyes with all eyes successfully weaned off of topical steroids. The single phakic eye developed a visually significant cataract 18 months postoperatively requiring cataract extraction. There were no cases of postoperative infection. There were no postoperative complications of surgical technique including no instances of wound leakage or implant dislocation.The fluocinolone implant can be used effectively for control of posterior inflammation in pediatric patients. As in adults, concerns for development of cataract and secondary glaucoma remain. No other safety concerns were evident in this pilot study.

The objective of this study was to compare the reduction in size of experimentally induced choroidal neovascularization (CNV) in rat eyes treated with bevacizumab, poly(ethylene-glycol) (PEG)-bevacizumab conjugate (b-PEG), and poly(lactic-co-glycolic acid) (PLGA)-encapsulated bevacizumab (b-PLGA).Forty-eight eyes from 24 rats were divided into 4 groups of 12 eyes. In each group, 3 eyes were assigned to a treatment subgroup, each receiving a different injection-control, bevacizumab, b-PEG, and b-PLGA. In all eyes, laser photocoagulation was used to rupture Bruch's membrane. In group 1, laser was followed by injection, which was then followed by harvesting the rats to assess the CNV area. All 3 steps were separated by a 2-week interval. In groups 2, 3, and 4, injection preceded laser photocoagulation by a variable interval and all rats were harvested 2 weeks postlaser treatment. In group 2, laser and injection were separated by 2 weeks. In group 3, laser followed injection by 4 weeks. In group 4, laser followed injection by 6 weeks. The CNV area was measured for each subgroup and compared against its control. Pairwise comparisons were conducted to assess for statistically significant differences between subgroups.All subgroups in groups 1, 2, and 4 showed statistically significant reduction of CNV area (P0.05). In group 3, the b-PEG and b-PLGA subgroups showed a 9.0% (P=0.384) and 20.3% (P=0.077) reduction in CNV area versus control, whereas there was no reduction in CNV area in the bevacizumab subgroup. However, this was not found to be statistically significant. In group 4, b-PEG was more effective than bevacizumab and b-PLGA.The reduction in CNV area in all treatment subgroups, with the exception of those in group 3, suggests successful creation of the 2 bevacizumab formulations while retaining its active antiangiogenic properties. Further studies varying in dosages and timing of injection and laser are needed to evaluate the formulations' long-acting efficacy.

To characterize the relationship between peripheral vessel leakage and other angiographic features of diabetic retinopathy.Retrospective, consecutive case series.Consecutive ultra wide-field angiographs obtained at a single institution for diabetic retinopathy were graded for angiographic characteristics including macular edema, retinal neovascularization, retinal vascular perfusion abnormalities, and retinal vascular staining and leakage.Angiographic characteristics of 264 eyes of 143 patients were evaluated. Findings included focal and diffuse angiographic macular edema (150/264, 57%), neovascularization (107/264, 41%), late peripheral vascular leakage (PVL) (107/264, 41%), and peripheral non-perfusion (142/264, 54%). Amongst all subjects untreated peripheral non-perfusion was associated with anterior neovascularization (78% vs. 48%, p = 0.0001, Fisher exact test) and posterior neovascularization (78% vs. 43%, p0.0001), but not with macular edema (p = 0.71). PVL was associated with peripheral non-perfusion (78% vs. 38%, p0.0001) and posterior neovascularization (53% vs. 35%, p = 0.01), but not with macular edema (p = 0.449). However, focal macular edema was strongly associated with PVL (33% vs. 13%, p = 0.008) in eyes without peripheral non-perfusion. Amongst untreated eyes with non-proliferative retinopathy and macular edema, there was a trend for association between macular edema and peripheral non-perfusion (p = 0.065).Untreated peripheral non-perfusion and late peripheral vascular leakage detected using ultra wide-field FA are associated with neovascularization in diabetic retinopathy. PVL may be associated with focal diabetic macular leakage in this cohort.

Purpose To study the peripheral angiographic features of branch retinal vein occlusions (BRVO) and hemicentral retinal vein occlusions (HRVO) and explore associations with macular edema and neovascularization. Design Retrospective observational case series. Participants Seventy-eight outpatients. Methods An imaging database of angiograms performed at a single academic institution was searched for patients with a diagnosis of BRVO or HRVO. Images were graded for the presence of untreated nonperfusion (areas without evidence of laser photocoagulation), late peripheral vascular leakage (LPVL), neovascularization, macular edema, and prior laser treatment. Optical coherence tomography images were reviewed for all patients to confirm the presence of macular thickening and to exclude eyes with vitreomacular traction. Main Outcome Measures Angiographic evidence of nonperfusion, neovascularization, macular edema, LPVL, and prior laser treatment. Results Angiograms from 80 eyes of 78 patients were analyzed with a diagnosis of BRVO (86%) or HRVO (14%). Angiographic macular edema (80%), untreated nonperfusion (82%), neovascularization (21%), and LPVL (58%) were observed. Untreated nonperfusion at any location was significantly associated with macular edema ( P = 0.043). Untreated nonperfusion anterior to the globe equator was significantly associated with macular edema ( P = 0.007). Untreated nonperfusion was significantly associated with the presence of neovascularization ( P = 0.033). Late peripheral vascular leakage was not associated with other angiographic or clinical findings studied. Conclusions Ultra wide-field angiography provides visualization of peripheral retinal pathology in BRVO and HRVO patients, which may be useful in their evaluation and treatment. Our findings support the hypothesis that areas of untreated retinal nonperfusion may be the source of production of biochemical mediators that promote neovascularization and macular edema. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

OBJECTIVES To prospectively report standardized visual function and macular structural assessment in patients undergoing iodine-125 brachytherapy for choroidal and ciliary body melanoma. MATERIALS AND METHODS Patients were enrolled for pretreatment and annual posttreatment assessment. Evaluations included ophthalmic history; standardized refraction; visual acuity, contrast sensitivity, and color vision measurement; comprehensive ophthalmic examination; fundus photography; fluorescein angiography; optical coherence tomography; and ultrasonography. Radiation doses to the foveola and optic disc margin were calculated. RESULTS Forty-two patients were enrolled. Melanoma location included 3 in the ciliary body, 7 anterior, 11 equatorial, 13 posterior, and 8 macular tumors. Mean apical tumor height was 4.45 mm (range 1.79-9.83 mm) and mean longitudinal tumor diameter was 9.41 mm (range 4.52-4.73 mm). Pretreatment mean best-corrected Ferris-Bailey early treatment diabetic retinopathy study visual acuity was 50 (standard deviation +/- 15) letters (Snellen equivalent 20/32, range 20/15 to hand motions). The mean Pelli-Robson contrast threshold percentage was 4.1% (+/- 2.5%). The mean Hardy-Rand-Rittler color vision score was 13/14 (+/- 2.7). Mean distances from the posterior edge of the tumor to the foveola and the optic disc margin were 6.99 mm (+/- 6.22 mm) and 7.28 mm (+/- 5.98 mm), respectively. At the foveola, median total radiation dose was 36.2 Gy (+/-50.6 Gy) and median dose rate was 31.6 cGy/h (+/- 39.8 cGy/h). At the optic nerve, median total radiation dose was 42.8 Gy (+/- 30.8 Gy) and median dose rate was 36.2 cGy/h (+/- 21.4 cGy/h). CONCLUSION This prospective assessment of macular structure and function will provide more complete understanding of the ocular effects of radiation therapy for ocular melanoma.

Objectives To document ophthalmic morbidity of golf-related injuries in children and to report specific injury patterns. Design A noncomparative, interventional, retrospective case series of 11 pediatric patients treated at 2 institutions for ophthalmic trauma resulting from golf-related injuries during 15 years. Results Eleven eyes of 11 patients were injured. There were 6 boys and 5 girls, with a mean age of 10.2 years (age range, 7-14 years). Ten patients were injured by golf clubs and 1 patient by a golf ball. One injury occurred on a golf course. At the initial ophthalmic examination, visual acuity was 20/20 in 4 eyes (36%), 20/25 to 20/80 in 3 eyes (27%), no light perception in 3 eyes (27%), and undeterminable in 1 eye (9%). Nine of 11 patients required surgery. Follow-up ranged from 0 to 66 months (mean follow-up, 12 months). Three of 11 subjects had permanent deficits, including blindness, decreased vision, and anophthalmia. Final visual acuity was no light perception in 2 eyes (18%), 20/70 in 1 eye (9%), and 20/20 or better in 8 eyes (73%). Conclusions The findings from this series reveal that pediatric ophthalmic golf injuries, although rare, may be devastating to the eye, periocular adnexa, and visual system. Among our cases, most injuries occurred off the golf course, many required surgery, and some resulted in permanent loss of vision.

Recent retrospective analyses have suggested that postoperative endophthalmitis may be more frequent with 25- than 20-gauge pars plana vitrectomy (PPV). Because the infection risk may depend on the suturing status of the sclerotomy, and the perioperative anti-infection protocol, we compared the incidence rate of endophthalmitis after sutureless 25-gauge versus sutured 20-gauge PPV on a large cohort of patients operated with a standardized perioperative anti-infection protocol.Retrospective comparative case series.Consecutive patients who underwent 20- or 25-gauge PPVs at a single center over a multi-year period.We analyzed 3597 consecutive PPVs. Patients with a pre-PPV diagnosis of endophthalmitis, PPVs performed for implantation of drug delivery devices, or 25-gauge PPVs with all sclerotomies sutured closed were excluded. Patients withor =1 week of follow-up were divided into 2 study groups by sclerotomy status at the end of surgery: the 20-gauge group had 3 sutured 20-gauge sclerotomies, and the 25-gauge group hador =1 unsutured 25-gauge sclerotomy. Endophthalmitis was defined by clinical criteria independent of microbiological results.The incidence of endophthalmitis was compared between 25- versus 20-gauge groups.Of 3372 PPV surgeries meeting inclusion and exclusion criteria, 1948 and 1424 surgeries were 20- and 25-gauge PPVs, respectively. Average age (+/- standard deviation) of patients was 54.6 (+/- 22.6) and 64.4 (+/- 16.5) years in the 20- and 25-gauge PPV groups, respectively (P0.0001). Median post-PPV follow-up time was not significantly different between the 2 groups (12.5 vs 13.0 months; P = 0.69). Endophthalmitis was observed in 1 patient (0.07%; 95% confidence interval, 0%-0.21%) from the 25-gauge group and none in the 20-gauge group (P = 0.42; Fisher exact test, 2-tailed). The use of air/gas endotamponade (P0.0001) and intravitreal triamcinolone (P0.001) was more common in 25- versus 20-gauge PPV.The incidence of endophthalmitis was low in both groups. We were unable to show a significant difference in the incidence of endophthalmitis between sutureless 25-gauge and sutured 20-gauge PPV, and conclude that a careful perioperative anti-infection protocol may reduce 25-gauge PPV endophthalmitis risk to that of 20-gauge PPV.

A 57-year-old man of Dutch-Indonesian ancestry presented with a 1-month history of bilateral iritis, optic nerve head swelling and decreased vision. He was initially seen by his local ophthalmologist and was treated with prednisolone acetate 1% drops with no improvement, and transferred to our tertiary care institution. On presentation, the patient had an acuity of 20/60 bilaterally with no evidence of anterior chamber inflammation and normal angle structures. On dilated exam, no vitritis was evident; however, optic nerve head swelling and a diffuse bilateral choroidal infiltrate with choroidal folds but without serous retinal detachment was present (figure 1A). Extra ocular symptoms included meningismus and tinitus. Serum testing was negative for cryptococcal antigen, rapid plasma reagin (RPR), human immunodeficiency virus (HIV), bartonella IgM/IgG, quantiferon gold tuberculosis and polymerase chain reaction (PCR) for herpes simplex (HSV), herpes zoster (HZV), and cytomegalovirus (CMV). Serum lysozyme and angiotensin converting enzyme (ACE) levels were normal. The lumbar puncture revealed elevated cerebrospinal fluid (CSF) protein (88 mg/dL), normal glucose and CSF lymphocytosis (253 nucleated cells with 94% lymphocytes) with normal flow cytometry. B-scan ultrasound revealed bilateral diffuse choroidal infiltrates most prominent near the ciliary body (figure 1B). The circumferential infiltrate, the choroidal folds and the lack of serous retinal detachment were suspicious for a lymphoproliferative process of the uvea. However, the infiltrate was bilateral and the human leukocyte antigen (HLA) typing revealed HLA-DRB104 which has been associated with Vogt–Koyanagi–Harada (VKH) disease. The patient was then treated with 1 g intravenous methylprednisolone q day for 3 days with a marked decrease in the circumferential infiltrate and diffuse choroidal thickening …