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Purpose The purpose of the study was to study the prevalence of macular epiretinal membrane (ERM) formation for retinal tears treated with laser retinopexy and cryoretinopexy. The study sought to identify whether there is a difference in ERM formation prevalence between these 2 treatments. Design Retrospective, single-center, chart review study. Participants Patients seeking treatment at a private practice institution (The Retina Institute, St. Louis, Missouri) over a 10-year period between 2006 and 2016 for the evaluation and treatment of a retinal tear. Methods A chart review was conducted comprising all patients undergoing procedures for Current Procedural Terminology codes 67141 (prophylaxis of retinal detachment, cryotherapy) and 67145 (prophylaxis of retinal detachment, photocoagulation) and patients with an International Classification of Diseases, Ninth Edition, Clinical Modification, diagnosis code of 362.56 (macular puckering), who underwent procedures identified with Current Procedural Terminology codes 67141 and 67145. Main Outcome Measures Epiretinal membrane development, time between treatment and ERM development, and surgical intervention for ERM progression. Results A total of 2257 eyes underwent treatment for retinal breaks with 1655 eyes treated by laser retinopexy and 602 eyes treated by cryoretinopexy. The mean age of the cryoretinopexy group was 59.4±1.5 years and in the laser retinopexy group was 61.4±0.8 years. A total of 74 patients (3.2%) demonstrated an ERM after treatment for a retinal tear during an 11-year period (2006–2016). A total of 26 cryoretinopexy eyes (4.32%) and 48 laser retinopexy eyes (2.90%) demonstrated an ERM after treatment of retinal breaks (P = 0.094). The average time to ERM development was 11.5 months for the cryoretinopexy group and 12 months in the laser retinopexy group (P = 0.878). Seven ERMs progressed to requiring surgical intervention: 2 in the cryoretinopexy group and 5 in the laser retinopexy group. There was no statistically significant difference between the groups with regard to ERM progression resulting in surgical intervention (P = 0.707). Conclusions Treatment of retinal breaks with either cryoretinopexy or laser retinopexy showed no statistically significant difference in the incidence, timing, or severity of ERM formation between these treatment methods.

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 explore the safety, comfort, and feasibility of topical anesthesia in 27-gauge pars plana vitrectomy surgery. Methods: A prospective, observational case series of 37 nonconsecutive patients undergoing 3-port, 27-gauge pars plana vitrectomy under topical anesthesia with lid block from July 2016 to March 2017 with a single surgeon was performed. Topical anesthesia was achieved with proparacaine 0.5% drops and 2% lidocaine gel. Surgery was performed for select indications with carefully selected patients amenable to topical anesthesia. Patients were queried and observed to identify the most painful steps of the case and to rate their intraoperative and postoperative pain scores on a 1- to 10-point pain scale. Results: The mean intraoperative pain score was 2.1 with the most painful steps rated as scleral depression (37.8%), trocar/cannula insertion (24.3%), and conjunctival coaptation (24.3%). When correlating the overall intraoperative pain score with the self-identified most painful step, the mean pain scores were highest for endolaser (2.6), scleral depression (2.1), conjunctival coaptation (2.1), and trocar/cannula insertion (1.6). Supplemental intravenous anesthesia was requested once by the surgeon in 54% of the cases. No rescue with local infiltrative anesthesia was required. The mean pain scores were 0.7 and 0 at postoperative day 1 and week 1. No intraoperative or postoperative complications were encountered. Conclusions: Topical anesthesia for 27-gauge pars plana vitrectomy is a safe and feasible anesthesia option for carefully selected patients for certain surgical indications.

Purpose: To describe 2 techniques facilitating the potentially challenging removal of the anterior hyaloid during phakic pars plana vitrectomy. Methods: Observational surgical series describing the 2 techniques. The hydrodissection technique applies an injection of balanced salt solution into the anterior chamber to displace the anterior hyaloid posteriorly for facile removal. The bubble technique is a novel method that utilizes air bubbles to visualize the anterior vitreous, allowing closer placement of the vitrectomy cutter to facilitate anterior hyaloid removal. Results: Both techniques were successful for the safe, efficient removal of the anterior vitreous. Conclusion: Removal of the anterior vitreous in a phakic patient is a difficult maneuver which may lead to potential damage to the lens. The hydrodissection and bubble techniques may be used to efficiently and safely remove the anterior vitreous.

The identification of an infectious or noninfectious uveitis syndrome is important to determine the range of therapeutic and prognostic implications of that disease entity. Diagnostic dilemmas arise with atypical history, atypical clinical presentations, inconclusive diagnostic workup, and persistent or worsened inflammation despite appropriate immunosuppression. More invasive intraocular testing is indicated in these situations particularly in infectious uveitis where a delay in treatment may result in worsening of the patient’s disease and a poor visual outcome. Laboratory analysis of vitreous fluid via diagnostic pars plana vitrectomy is an important technique in the diagnostic armamentarium, but the most important aspects of sample collection include rapid processing, close coordination with an ophthalmic pathology laboratory, and directed testing on this limited collected sample. Culture and staining has utility in bacterial, fungal, and nocardial infection. Polymerase chain reaction (PCR) analysis has shown promising results for bacterial endophthalmitis and infection with mycobacterium tuberculosis whereas PCR testing for viral retinitides and ocular toxoplasmosis has a more established role. Antibody testing is appropriate for toxoplasmosis and toxocariasis, and may be complementary to PCR for viral retinitis. Masquerade syndromes represent neoplastic conditions that clinically appear as infectious or inflammatory conditions and should be considered as part of the differential diagnosis. Diagnostic vitrectomy and chorioretinal biopsy are thus critical tools for the management of patients in whom an infectious etiology of uveitis is suspected.

To review a population of degenerative retinoschisis (RS) patients, with attention to those with schisis cavity breaks and with retinal detachment complicating retinoschisis (RDRS), to identify management considerations and incidence for this rare clinical entity.Retrospective chart review of patients with RS and schisis cavity breaks over a 15-year period in a tertiary, multiple-physician vitreoretinal practice.A total of 587 cases of RS were confirmed on chart review, with 59 meeting inclusion criteria.Included charts required documented RS with schisis cavity breaks, a minimum of 3 months of follow-up, detailed fundus drawings and notes, and filed operative report if surgical interventions were performed. Charts were excluded if the patient had undergone any previous history of laser, cryotherapy, or intraocular surgery (except for cataract surgery).Incidence of RS with schisis cavity breaks and RDRS, time to development of symptomatic RDRS, clinical characteristics predisposing development of progressive RDRS.Sixty-seven cases (11.4%) presented with schisis cavity breaks, but only 59 met inclusion. Initially, 35 of the 59 included cases (59%) were observed with stability in 54.3% at a mean follow-up of 40.2 months. Only 10 of the initially observed 35 eyes (28.6%) exhibited new-onset symptoms of retinal detachment, with a mean time to progression of 20.6 months. Posterior progression involving the major arcades or macula occurred in 86.7% of symptomatic eyes, as compared with 11.4% of asymptomatic eyes (P0.0001). Of the 15 eyes with symptomatic RDRS, 14 eyes underwent vitreoretinal surgery for RDRS, with a single-procedure success rate of 86%.RDRS requiring vitreoretinal surgical repair is a rare, symptomatic, and progressive condition occurring in 2.4% of 587 cases of RS over a 15-year period in a large, tertiary referral, vitreoretinal-only practice. In cases with RS and outer wall breaks, 54.3% were nonprogressive at 3 years of follow-up, but 28.6% progressed to symptomatic RDRS at a mean of 20.6 months. Surgery is not recommended in asymptomatic individuals except in rare situations based on clinical judgement regarding the observed behavior of the RS. The presence of symptoms should warrant treatment.

Pediatric Vogt-Koyanagi-Harada syndrome (VKH) is rare, with limited cases of corticosteroid-sparing immunosuppression use reported. A 15-year-old Hispanic girl was referred for bilateral intraocular inflammation. Her initial best corrected visual acuity (BCVA) was 20/30 in the right eye and 20/200 in the left eye, with granulomatous keratic precipitates, anterior chamber and vitreous cell, optic disc edema, and nummular depigmented chorioretinal lesions on examination consistent with VKH after an unrevealing work-up. Inflammation was recurrent despite oral prednisone and methotrexate. Adalimumab, a TNF-alpha inhibitor, led to rapid resolution of inflammation, successful dose reduction of prednisone and methotrexate, and final BCVA of 20/25 in the right eye and 20/40 in the left at 26-month follow-up. [ Ophthalmic Surg Lasers Imaging Retina . 2014;45:332-333.]

Pulmonary alveolar proteinosis (PAP) has been associated with the immunosuppressant sirolimus in transplant patients. PAP is a progressive lung disease characterized by the accumulation of surfactant-like material in the lungs leading to decreased pulmonary function with shortness of breath and cough as common symptoms. We report a rare case of sirolimus-associated PAP in a kidney transplant recipient with a history of end-stage renal disease secondary to haemolytic uraemic syndrome (HUS) and review of the literature. Discontinuation of sirolimus and initiation of tacrolimus led to resolution of PAP without recurrence of HUS.

Although current therapies for pretransplant desensitization and treatment of antibody-mediated rejection (AMR) have had some success, they do not specifically deplete plasma cells that produce antihuman leukocyte antigen (HLA) antibodies. Bortezomib, a proteasome inhibitor approved for the treatment of multiple myeloma (a plasma cell neoplasm), induces plasma cell apoptosis. In this paper we review the current body of literature regarding the use of this biological agent in the field of transplantation. Although limited experience with bortezomib may seem to show promise in the realm of transplant recipients desensitization and treatment of AMR, there is also experience that may suggest otherwise. Bortezomib's role in desensitization protocols and treatment of AMR will be defined better as more clinical data and trials become available.

Retinal toxicity involving the macula as a complication of the antiretroviral protease inhibitor ritonavir has been described in a few cases. We report retinal pigment epitheliopathy involving the macula with a bull's eye pattern in a 36-year-old man with well-controlled HIV receiving ritonavir with gradually progressive bilateral vision loss.

The nephrotic syndrome (NS) has been associated with a variety of malignancies in a number of reports in the literature, but has been reported in only nine cases associated with ovarian neoplasms. Membranous nephropathy is the most common glomerular pathology causing the NS in patients with solid tumors. There has been only one report of an ovarian neoplasm associated with minimal change disease (MCD). We describe the case of a 36-year-old woman who presented with the NS secondary to biopsy-proven MCD, likely secondary to mature ovarian teratoma. Treatment by tumor removal and prednisone led to remission of the NS. To the best of our knowledge, this is the first report of an ovarian teratoma and the second report of an ovarian neoplasm associated with MCD.

Sympathetic ophthalmia (SO) is an autoimmune, bilateral, granulomatous panuveitis occurring after accidental or surgical trauma to the eye.1 Systemic corticosteroids are first-line therapy for SO with immunomodulatory therapy employed for corticosteroid-sparing immunosuppression and chronic, refractory cases. Biologic response modifiers (BRMs) are a class of therapeutics that target specific cytokines mediating inflammation, and TNF-α antagonist BRMs have shown promise for uveitis.2 Herein, we report the first use, to our knowledge, of adalimumab for refractory pediatric SO leading to resolution of inflammation.