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PURPOSE To present a new technique to treat refractory retinal detachment secondary to optic disc pit. METHODS An interventional case report. RESULTS A 25-year-old man with congenital optic disc pit had two failed vitrectomies involving laser around the optic disc, internal limiting membrane peel and flap to plug the disc pit, and gas tamponade to reattach the retina. With all options running out, a further vitrectomy with autologous retinal transplant and silicone oil tamponade was carried out to treat the refractory serous retinal detachment; the silicone oil was removed at 6 weeks after the last procedure. The retina remained successfully attached at 6 months post-surgery with the patient maintaining his baseline visual acuity. CONCLUSION The use of autologous retinal transplant is a new approach to treat refractory retinal detachment secondary to congenital optic disc anomalies, and adds to our options of dealing with this complex condition when first-line approaches have failed.

Patients with Stickler syndrome are at high risk of giant retinal tears (GRTs) and detachments. Vitreoretinal interventions can reduce this risk but there is presently no consensus about the optimal prophylactic approach. The aim of our study was to determine whether 360° laser prophylaxis is a safe and effective procedure to prevent GRT detachments in Stickler syndrome patients.Study subjects were recruited retrospectively through the databases of the vitreoretinal and ophthalmic genetic tertiary services in Manchester, UK. Clinical data were collected including on prophylactic intervention, the occurrence of retinal detachment and the presence/type of retinal breaks.113 eyes from 63 patients with Stickler syndrome were studied; 72.6% (82/113) of these eyes received 360° laser prophylaxis. Of these 9% had a retinal detachment, but no GRTs occurred. Among the 27.4% (31/113) of eyes that had no prophylactic treatment, 23% suffered a retinal detachment and 42.9% of these were associated with a GRT.Patients who underwent laser prophylaxis had fewer retinal detachments and no GRTs during an average of 6.1 years follow-up (median 5 years), suggesting that this is a safe and effective approach for individuals with Stickler syndrome.

Purpose To investigate the direct contribution to carbon emissions of fluorinated gases used in all vitreoretinal (VR) procedures utilising gas tamponade and assess the respective carbon footprint of the three different gas delivery systems. Design A multicenter, retrospective, environmental impact study Methods All VR procedures using fluorinated gases between 2017-2020 at the Manchester Royal Eye Hospital (MREH) and Birmingham and Midland Eye Centre (BMEC) (the second and third largest VR centres in the UK), and between 2019-2020 at the University Hospitals Coventry and Warwickshire (UHCW) were included. CO2 equivalent mass (CO2EM) was calculated from mass of each gas used according to the Intergovernmental Panel on Climate Change. Results : A total of 4,877 (1,883 SF6[38.6%], 2,096 C2F6[43.0%], 897 C3F8[18.4%]) procedures were analysed. UHCW and BMEC utilise single use 30ml and 75ml canisters, respectively. MREH used four cylinders of each gas over four years (2kg SF6, 1kg C2F6, 1kg C3F8). Mean CO2EM per patient was MREH:111.8kg, BMEC:7.5kg for BMEC and UHCW:2.7kg. For MREH and BMEC, the CO2EM was 73.4 metric tonnes annually (if all cases performed with i)30ml:3.7tonnes and ii)cylinders:148.0 tonnes, x40 fold difference); equating to 599.4thousand (30.5thousand-1.2 million)km travelled by a passenger car. Current use of SF6 in VR surgery accounts for 0.11% of total SF6 use; if 30ml cylinders were exclusively used in the UK, this could be lowered to 0.01%. Conclusions We highlight the significant waste associated with large gas cylinders and demonstrate that 30 ml canisters can lead to a marked reduction in carbon emissions, even after accounting for the increased carbon footprint involved in their manufacture and disposal.

Voretigene neparvovec (VN) is a gene therapeutic agent for treatment of retinal dystrophies caused by bi-allelic RPE65 mutations. We illustrate, both the benefits and pitfalls associated with ocular gene therapy in the same patient.Two eyes of one patient with bi-allelic RPE65 mutations have been treated with VN. The clinical examinations included visual acuity (VA, in normal and low luminance), colour vision, contrast sensitivity, International Society for Clinical Electrophysiology of Vision (ISCEV) standard retinal electrophysiology and dark-adapted full-field stimulus threshold (FST), Goldmann VF analysis and imaging studies, including optical coherence tomography (OCT) and autofluorescence. These were performed at baseline, 2-weeks, 3 and 6-months, 1 and 2-years follow-up.The first eye showed improvement in rod photoreceptor function with increased peripheral and low luminance vision (baseline VA: 0.9 logMAR and 2-years post-operative VA: 0.7 logMAR). The second eye, whilst showing increased light sensitivity, suffered a drop in central vision (at 2-weeks) with loss of foveal photoreceptors as shown by the loss of ellipsoid zone on OCT scan (baseline VA: 0.6, 2-year post-operative VA: 1.2). FST improvements were maintained in both eyes indicating a sustained efficacy of VN with little waning of its effect.We present a previously unreported adverse complication of subretinal VN therapy in bi-allelic RPE65, indicating a probable immune response in treatment of the second eye, resulting in loss of foveal photoreceptors. This case-series highlights the potential and pitfalls of retinal gene therapy in the same patient. The immune responses of the body to a 'foreign vector', remains a challenge.

PURPOSE To demonstrate a case of spontaneous resolution of submacular heavy liquid. METHODS This is a case report analyzing consecutive data and optical coherence tomography scans of a patient who underwent revisional retinal detachment surgery with pars plana vitrectomy using perfluorocarbon liquid (PFCL) as an adjunct. Postoperatively submacular PFCL bubbles were noted, and after an only partially successful surgical attempt to remove them, the residual PFCL bubbles were monitored over the course of several months. The primary outcome measure was the anatomical appearance and size of the PFCL bubbles on optical coherence tomography. The secondary outcome measure was the functional outcome based on the best-corrected visual acuity. RESULTS We present a case of retained submacular PFCL after complex retinal detachment repair, which could only partially be removed surgically. However, the remaining PFCL droplets resolved spontaneously over several months, with partial anatomical restoration of the retinal layers and improvement in visual acuity. CONCLUSION We hypothesize that the PFCL bubble was resorbed presumably by the retinal pigment epithelium.

PURPOSE To evaluate the efficacy of repeat pars plana vitrectomy and gas tamponade for persistent macular holes (MHs), especially looking at a predictive value of optical coherence tomography parameters in revisional surgery. METHODS Retrospective, nonrandomized interventional case series of consecutive patients with a persistent MH that underwent revisional pars plana vitrectomy and gas tamponade. The primary outcome measure was anatomical closure of the MH after revisional surgery. The secondary outcome measure was a functional outcome of the MH closure based on the best-corrected visual acuity. The changes of minimum linear diameter and MH index after the primary surgery were evaluated to see if they were prognostic markers of success for the revisional surgery. RESULTS A total of 27 patients with a persistent MH after primary MH surgery were identified, all of whom underwent a second operation with pars plana vitrectomy and gas tamponade with an internal limiting membrane peel extension in 20 cases. The MH closure rate after revisional surgery was 89% (24/27). Twenty-two cases were included in the optical coherence tomography analysis, of which 14 MHs that showed both a reduction of the minimum linear diameter and an increase in the MH index after the primary repair closed after revisional surgery. The mean best-corrected visual acuity before revisional surgery was 0.86 logMAR (20/145 Snellen) but increased significantly postoperatively to 0.69 (±0.15) logMAR (20/98 Snellen) at 3 months and to 0.49 logMAR (20/62 Snellen) at 12 months. CONCLUSION For a persistent idiopathic MH, simple repeat pars plana vitrectomy with gas tamponade has a good anatomical and functional success rate in selected cases. The minimum linear diameter and MH index can be useful optical coherence tomography markers for prognostic guidance.

To compare phakic and pseudophakic primary rhegmatogenous retinal detachments (RD) and, within phakic RD, eyes with and without cataract.Retrospective comparative clinical study.Setting: Online database of prospectively collected data. StudyPopulation: Patients aged ≥50 years who had undergone RD repair.Data included baseline demographic and clinical features, surgical details, and anatomical and functional outcomes. Univariate analysis was performed to compare pseudophakic with phakic RD, and phakic RD with and without cataract. Age and sex dependency of variables was analyzed and the association of preoperative variables with final visual acuity was assessed using multivariate analysis. MainOutcomeMeasures: Preoperative features, intraoperative management, postoperative outcomes, association of preoperative features with postoperative outcomes.Of 4,231 eyes, 1,212 were pseudophakic and 3,019 phakic, among which 310 had cataract. Pseudophakic RD showed significant differences compared with phakic RD, including older age, higher prevalence of male sex, foveal detachment, grade C proliferative vitreoretinopathy (PVR), inferior retinal breaks, inferior retinal involvement, and greater RD extent. Despite the more advanced features of pseudophakic RD, pseudophakia was a positive factor for visual outcome. Contralateral RD was more frequent in pseudophakic than phakic RD eyes (P.0001). Within phakic RD, phakic RD with cataract exhibited several similarities with pseudophakic RD, including greater age, more frequent foveal detachment, PVR, and greater RD extent.The presenting features differed significantly between pseudophakic and phakic RD, with greater occurrence of inferior retinal breaks and inferior retinal involvement in particular. Phakic RD with cataract shared several features in common with pseudophakic RD.

Introduction: The UK Government imposed a COVID19 lockdown (LD) restricting all but essential activities from 24th March 2020. Subsequently, there has been a significant reduction in casualty attendances nationwide including for ophthalmic emergencies. We aim to study the presentation of rhegmatogenous retinal detachments (RRD) and significant vitreous haemorrhage caused by posterior vitreous detachment (PVD-VH) in three tertiary centres covering most of the North West of England in the 6 weeks before and during the lockdown. Methods: A retrospective multicenter non-randomised consecutive case series study was designed to collect information on all cases of RRD and PVD-VH requiring surgery presenting to the vitreoretinal departments of Manchester Royal Eye Hospital, East Lancashire NHS Foundation Trust and the Lancashire NHS Foundation Trust from 11th February to 4th May 2020. Results: A total of 137 eyes of 137 patients were identified between the three centres of which 132 eyes were operated for RRD. Of these, 86 (64.7%) were operated pre-LD compared with 46 eyes (34.8%) during LD. Forty-five out of 86 eyes (52.3%) were macula-off pre-LD compared with 31 out of 46 eyes (67.3%) during LD ( p = 0.06). There was lower proportion of non-PVD related RRD during LD (11 pre-LD to 1 during LD, p = 0.05). PVR was present in four cases during LD compared to 2 before ( p = 0.19). Conclusion: There was a clinically significant reduction in the overall incidence of RRD in our centres with an increase in the proportion of macula-off and proliferative vitreoretinopathy during the LD period compared to a similar period before.

Aim: To evaluate the effectiveness of pars plana vitrectomy (PPV) without macular intervention on uveitis eyes with persistent vitreous inflammation/opacities in terms of visual acuity (VA), intraocular inflammation and macular profile. Methods: We carried out a single-center retrospective study of patients with uveitic eyes that underwent PPV without intervention on the macula due to persistent vitreous inflammation/opacities. The primary outcome measures were best-corrected visual acuity (BCVA), intraocular inflammation and macular profile at 3, 12 and 24 months after surgery. Results: Twenty-seven eyes of twenty-six patients were analyzed. Overall, 77.8% had an improvement of VA (55% by 0.3 LogMAR or more); 62.5% of patients had no intraocular inflammation, and the number of patients on systemic steroids and second-line immunosuppressives was reduced by 26% at 12 months; 87.5% of patients had resolution of macular oedema at 12 months. Conclusion: PPV for persistent vitreous inflammation/opacities is safe and effective, showing beneficial outcomes in terms of improvement of BCVA and the reduction in inflammation.

BACKGROUND AND OBJECTIVE: Current literature lacks good-quality evidence regarding the outcomes of early pars plana vitrectomy (PPV) for acute exogenous endophthalmitis. The aim for this study was to analyze and discuss the outcomes of PPV for endophthalmitis in a UK tertiary hospital. PATIENTS AND METHODS: This study was a retrospective case series. The clinical records of consecutive patients who had PPV for acute exogenous endophthalmitis were reviewed. Demographic data, etiology, timing of onset, timing of PPV, intraand postoperative complications, baseline and final best-corrected visual acuity (BCVA), therapeutic regimens, and microbiology details were collected. Primary efficacy and safety outcome measures were BCVA improvement of two or more logMAR lines and intra- or postoperative complications, respectively. RESULTS: Forty-one patients with a median age of 76 (interquartile range, 64 to 82) years were studied. The most common etiology was intravitreal injection (41%), followed by phacoemulsification (34%). Median interval to PPV was 1.0 (interquartile range, 1.0 to 3.0) days. In a multivariate model controlling for age, baseline BCVA, microbiology positivity, and etiology (post-intravitreal injection), PPV after 24 hours was seven times more likely to achieve significant BCVA improvement (odds ratio, 7.47; 95% confidence interval, 1.12 to 49.66; P = .038). PPV within 24 hours of presentation was associated with more intraoperative complications. CONCLUSIONS: Favorable outcomes may be achieved with current antibiotic regimens and PPV for endophthalmitis. The series suggests that an early surgical intervention may be associated with poorer functional outcomes. Tap and inject at presentation, followed by a semi-urgent PPV as required, seems to be a sensible approach. [ Ophthalmic Surg Lasers Imaging Retina. 2022;53:96–102.]

To report the contribution to carbon dioxide equivalent mass [CORetrospective, continuous, comparative multicentre study of all procedures using fluorinated gases between 01/01/17-31/12/20 at the Manchester Royal Eye Hospital and Birmingham and Midland Eye Centre, and between 01/01/19-31/12/2020 at the University Hospitals Coventry and Warwickshire.Across 4877 procedures, the use of fluorinated gases produced 284.2 tonnes (71.2 tonnes annually) COWe demonstrated that SF

To present a new technique to treat refractory retinal detachment secondary to optic disc pit.An interventional case report.A 25-year-old man with congenital optic disc pit had two failed vitrectomies involving laser around the optic disc, internal limiting membrane peel and flap to plug the disc pit, and gas tamponade to reattach the retina. With all options running out, a further vitrectomy with autologous retinal transplant and silicone oil tamponade was carried out to treat the refractory serous retinal detachment; the silicone oil was removed at 6 weeks after the last procedure. The retina remained successfully attached at 6 months post-surgery with the patient maintaining his baseline visual acuity.The use of autologous retinal transplant is a new approach to treat refractory retinal detachment secondary to congenital optic disc anomalies, and adds to our options of dealing with this complex condition when first-line approaches have failed.

To evaluate a sequential approach of pneumatic displacement followed by vitrectomy (pars plana vitrectomy) in failed cases to deal with submacular hemorrhage (SMH) of various etiologies.Retrospective, nonrandomized interventional case series of consecutive patients with SMH of up to 2 weeks' duration, who were treated with a stepwise approach. Step 1 involved intravitreal injection of 0.3 mL 100% C3F8 and recombinant tissue plasminogen activator 50 μg/0.1 mL. If unsuccessful, a prompt pars plana vitrectomy with subretinal recombinant tissue plasminogen activator 50 μg/0.1 mL and 20% SF6 gas tamponade was performed as a second attempt to displace the SMH.Thirty-one patients with SMH underwent pneumatic displacement; 24 (77.4%) had a successful outcome without further intervention. The mean presenting visual acuity of the "successful cohort" was 1.34 logMAR (20/440 Snellen), improving to 0.83 logMAR (20/135 Snellen) 1 month after treatment. Five of the seven patients with failed pneumatic displacement underwent pars plana vitrectomy with subretinal recombinant tissue plasminogen activator at an average of 5 days poststep 1, with successful SMH displacement in 3 patients, giving an overall success of 87.1% for this treatment protocol.A sequential approach of expansile gas injection followed by prompt pars plana vitrectomy, aided by recombinant tissue plasminogen activator at both steps, is a coherent, logical pathway to treat SMH with high anatomical and functional success.

Purpose To evaluate a sequential approach of pneumatic displacement followed by vitrectomy (PPV) in failed cases to deal with submacular haemorrhage (SMH) of various aetiologies. Methods Retrospective, non-randomised interventional case series of consecutive patients with SMH of up to 2-weeks' duration, who were treated with a stepwise approach. Step 1 involved intravitreal injection of 0.3ml 100% C3F8 and rt-PA 50mcg/0.1ml. If unsuccessful, a prompt PPV with subretinal rt-PA 50mcg/0.1ml and 20% SF6 gas tamponade was carried out as a second attempt to displace the SMH. Results Thirty-one patients with SMH underwent pneumatic displacement; 24 (77.4%) had a successful outcome without further intervention. The mean presenting visual acuity (VA) of the 'successful cohort' was 1.34 logMAR (20/440 snellen), improving to 0.83 logMAR (20/135 snellen) 1-month after treatment. Five out of the 7 patients with failed pneumatic displacement underwent PPV with subretinal rt-PA at an average of 5 days post-step 1, with successful SMH displacement in 3 patients, giving an overall success of 87.1% for this treatment protocol. Conclusion A sequential approach of expansile gas injection followed by prompt PPV, aided by rt-PA at both steps, is a coherent, logical pathway to treat submacular haemorrhage with high anatomical and functional success.

To analyze the outcomes of revision surgery for idiopathic full-thickness macular holes that have failed to close after primary surgery, and also to assess factors predicting success and to review the relative effect of adjunctive surgical techniques.A multicenter retrospective study. Anatomical closure rates and visual acuity change between pre and postrevision surgery were assessed. Hole size, age, symptom duration, surgical interval, and reduced hole size were analyzed as predictive factors for success. Effectiveness of adjunctive surgical techniques was reviewed.Seventy-seven eyes were included in the study. Anatomical closure was achieved in 71% (55/77) cases. There was a median gain of 11 Early Treatment of Diabetic Retinopathy Score letters in all holes and 14 letters in closed holes. Full-thickness macular holes that increased in size by more than 10% following primary surgery had a closure rate of 50% compared with 80% in holes that reduced by 10% or stayed the same (P = 0.015). Increasing hole size is associated with a modest reduction in odds of closure (odds ratio = 0.99; P = 0.04). Surgical interval2 months is not associated with better outcomes compared with2 months (P = 0.14).Revision surgery for full-thickness macular holes that have failed to close after primary surgery is associated with high closure rates and significant visual gains.

The management of suprachoroidal haemorrhage (SCH) remains a challenge. We aimed to analyse and discuss the safety and efficacy outcomes of SCH drainage surgery over a 10-year period in one of the largest tertiary centres in the UK. Retrospective observational study of consecutive patients who underwent SCH drainage in Manchester Royal Eye Hospital over a 10-year period (from 2008 to 2018). Safety and efficacy were assessed by analysing surgery-related complications and functional and anatomical success. Outcomes of those who underwent external drainage alone versus combined drainage and vitrectomy were compared. Twenty consecutive patients with a mean age of 70 ± 19 years were studied. Age over 70 years, hypertension, cardiovascular disease, and glaucoma were the most common risk factors for SCH. Eleven patients underwent external drainage alone and nine patients had combined vitrectomy and drainage. Overall, mean pre-operative BCVA improved from 2.22 ± 0.26 logMAR (20/3319 Snellen) to 1.42 ± 1.02 LogMAR (20/526 Snellen) at last follow-up visit (p = 0.002). Severe hypotony occurred in 4 patients. Overall anatomical and functional success rates were both 75%. Drainage of SCH with or without vitrectomy is a valuable approach in the management of extensive SCH, a condition generally associated with poor prognosis. Suprachoroidal haemorrhage (SCH) is a sight threatening condition with a guarded visual prognosis. We present the functional and anatomical outcomes together with surgery-related complications of patients who underwent external drainage surgery alone or combined drainage and vitrectomy for SCH.

Objective To identify risk factors affecting visual outcomes in successfully re-attached macula-off rhegmatogenous retinal detachment (RD) surgery. Design A prospective study, using online databases, of visual outcomes for 2074 macula-off retinal detachments that were successfully re-attached by vitrectomy and internal tamponade. The database included detailed retinal diagrams of each detachment. Main outcome measure The probability of achieving a post-operative visual acuity (VA) of ≤0.30 LogMAR (Snellen 6/12 or better). Results Male patients accounted for 64.9% of the sample and the median age was 63 years old. The median pre-operative VA was counting fingers (LogMAR 1.98); this improved to 0.41 LogMAR post-operatively. A post-operative VA of ≤0.30 LogMAR was achieved for 1012 (48.8%) eyes and the factors affecting this were the patient age and gender, pre-operative VA, duration of central vision loss, PVR grade, lens status, total RD and the presence of any ocular co-pathology where the model area under the receiver operator curve was 71.6%. Conclusions From the identified risk factors that decrease the probability of achieving a post-operative visual acuity of ≤0.30 LogMAR, the most important modifiable risk factor was the duration of central vision loss. Recent macula-off retinal detachments should be repaired within 72 h of the loss of central vision.

Purpose To evaluate anatomic and functional outcomes of full-thickness macular holes (FTMH) larger than 400 μm following vitrectomy, internal limiting membrane peel, gas tamponade, and face-down posturing. Design A retrospective interventional case series. Methods A total of 258 consecutive eyes with FTMH larger than 400 μm were enrolled at the Manchester Royal Eye Hospital study over a 5-year period from 2012 to 2017. All eyes underwent pars plana vitrectomy, ILM peel, and gas tamponade. Anatomic success rates were measured. A correlation between macular hole size and closure was evaluated. Results A total of 258 eyes were analyzed. The anatomic closure rate was 89.92%. When divided into quartiles, the closure rate of FTMH was 98% (64/65) in the 400–477 μm quartile, 91% (59/65) in the 478–558 μm quartile, 94% (60/64) in the 559–649 μm quartile, and 76% (49/64) in the 650–1416 μm quartile. Using receiver operating characteristic and area under the curve analysis, the maximum sensitivity and specificity was obtained with a cutoff ≤ 630 μm (sensitivity 76.7%, specificity 69.2%) giving a Youden index (J) of 0.46. One hundred and forty-six eyes (56.6%) improved by 0.3 logMAR units from their preoperative best-corrected visual acuity at 3 months following surgery. Conclusion This study shows that standard FTMH surgical repair has very high success rate up to 650 μm. It may suggest that there is a need for a reclassification of large FTMH, and new surgical techniques such as internal limiting membrane flaps should be reserved for macular holes larger than 650 μm.

Retinitis pigmentosa and age-related macular degeneration are two significant causes of severe visual dysfunction. In both, the retinal photoreceptors degenerate, preventing successful conversion of light into electrical energy that is interpreted in the visual cortex as visual function. Artificial vision or visual function began over two centuries ago with the idea of creating artificial light pulses, or phosphenes, through cortical stimulation. The pursuit is now on to improve artificial visual function. Two retinal implants appear the most likely to succeed in the future having undergone multicentre human trials: the Argus II electronic epiretinal device (Second Sight Medical Products, CA, USA) and Alpha-IMS electronic subretinal device (Retina Implant AG, Germany). The trial results to date are encouraging with visual improvement and acceptable safety profiles reported for both devices. At present, the visual function generated by either device does not offer high enough resolution or acuity for a patient to regain a fully functional life. Despite this, both devices not only have the potential, but have actually improved the vision-related quality of life in a significant number of patients implanted. With this in mind, the economic argument is clear. Provided device-life is long enough, its cost should be acceptable for the obtained improvement in the quality of life. The aim of this Review Article is to assist those readers that may be considering offering any of these devices as a treatment for blindness in Retinitis Pigmentosa.

Penetrating ocular injuries from writing instruments that are thrown, especially by children, in the community can result in significant ocular morbidity. Often these cases present to the accident and emergency department. Accurate and prompt assessment is key in saving sight. We present a case of one such injury and how it was surgically managed.

Floaters are a common ocular condition which form as a consequence of aging changes in the vitreous. Although in most patients the symptoms are minimal, they can cause significant impairment in vision-related quality of life in a small population of patients. Recently there has been an increase in awareness of the visual disability caused by floaters, and the evidence-base for treatment of this condition using small-gauge vitrectomy has increased. In this review, we define the term 'floaters' as symptomatic vitreous opacities (SVO). We suggest a classification dependent on the presence or absence of posterior vitreous detachment and discuss their pathogenesis and natural history. We review their impact on patients' quality of life related to visual function. We review the psychological factors that may have a role in some patients who appear to be affected by SVO to the extent that they pursue all options including surgery with all its attendant risks. We summarise the available evidence-base of treatment options available for SVO with special emphasis on the safety and efficacy of vitrectomy for this condition.

Francesco Stringa,1,2 Emmanouli Tsamis,1,3 Alessandro Papayannis,1 Katarzyna Chwiejczak,1 Assad Jalil,2 Susmito Biswas,1,2,4 Hassan Ahmad,1 Paulo Eduardo Stanga1,2,4 1Manchester Vision Regeneration (MVR) at NIHR/Wellcome Trust Manchester Clinical Research Facility, 2Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, 3Division of Pharmacy and Optometry, School of Health Sciences, 4Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester,UK Purpose: To describe perifoveal microvascular changes occurring in X-linked juvenile retinoschisis (XLRS) using swept source optical coherence tomography angiography (SS OCTA).Patients and methods: This is a serial case report of three patients. Retrospective data of patients affected by XLRS were collected. Structural optical coherence tomography (OCT) and color fundus photography (CFPh) were carried out with Topcon® OCT 2000 3D OCT as part of the standard care. Two patients were imaged on Topcon Atlantis® SS OCTA and one on Topcon Triton® SS OCTA. SS OCTA images were acquired using the 3 × 3 mm fovea-centered cubes scanning protocol. Analysis of both perifoveal superficial vascular plexus (pSVP) and perifoveal deep vascular plexus (pDVP) was performed by two observers after automated segmentation.Results: Four eyes of three males (mean age 14 ± 3.8 years) were analyzed. All eyes showed foveoschisis on CFPh images. OCT B-scans of three eyes showed schistic cysts in the ganglion cell layer, inner nuclear layer (INL) and outer nuclear layer (ONL); in one eye, cysts were depicted in INL and ONL only. In two eyes, SS OCTA showed abnormal foveal avascular zone (FAZ) shape in the pSVP, and in the other two, FAZ shape was abnormal in both plexuses. In all eyes, retinal vascular abnormalities (ie, microvascular protrusions) were present in pDVP.Conclusion: SS OCTA can depict perifoveal microvascular changes in young patients affected by XLRS. In this study, the structural and vascular changes seem to be more evident in the pDVP and may represent a useful biomarker of prognosis. Keywords: retina, pediatric ophthalmology, swept source OCT, OCT angiography, X-linked retinoschisis

The objective of this study was to present the results of combined phacovitrectomy using 1.8 mm microincision cataract surgery (MICS) with special emphasis on the anterior segment complications in this group. Retrospective, single-centre case series involving consecutive patients undergoing phacovitrectomy in a single centre in the United Kingdom during a 6-month period. A total of 52 eyes underwent combined MICS and pars plana vitrectomy. Intraoperative complications included posterior capsule rupture (n=2), minor iris trauma during phacoemulsification (n=1), iatrogenic retinal tears (n=2), and entry site break (n=1). Postoperatively two cases had significant inflammation, one of which resulted in 360° posterior synaechiea, iris bombe, and raised intraocular pressure. Other complications included mild posterior synaechiae (n=2), posterior capsular opacification (n=3), cystoid macular oedema (n=1), and hyphaema (n=1), which spontaneously resolved. There were no cases of intraocular lens decentration. Two patients who underwent surgery for retinal detachment repair subsequently redetached. Among those having surgery for macular hole, non-closure was seen in one patient and one patient developed a retinal detachment. In conclusion, sub-2 mm MICS is a safe and effective technique in dealing with vitreoretinal disorders necessitating cataract surgery at the same time.

We present an 11-year-old girl with sudden, severe, sequential optic neuropathy. Investigations revealed severe vitamin B12 deficiency, and identified a novel mitochondrial ND5 variant. She was treated with steroids followed by plasma exchange, but the vision continued to deteriorate to eventual bilateral blindness over the next few months. Vitamin B12 deficiency can rarely cause severe irreversible visual loss secondary to optic neuropathy. The significance of the concurrent mitochondrial ND5 variant remains undetermined.

The purpose of this study was to compare the incidence of iatrogenic anterior retinal breaks in 20-G vitrectomy (PPV) with transconjunctival 23-G PPV. Retrospective, observational review study involving consecutive patients undergoing PPV in a single center in the UK during a 2-year period. Sclerotomy-related entry-site breaks (ESB) were found in 50/628 (7.9 %) 20-G PPV cases and 5/296 (1.7 %) 23-G PPV eyes (p

Optical coherence tomography (OCT) angiography (OCTA) is a novel, noninvasive, three-dimensional imaging technique that allows for the visualization of intravascular flow in the microvasculature. Swept-source OCT technology utilizes longer-wavelength infrared light than conventional spectral-domain OCT. This enables improved penetration into tissue and imaging through optical opacities and is invisible to the subject. Topcon has recently developed an innovative OCTA algorithm, OCTARA (OCTA Ratio Analysis), which benefits from being paired with swept-source OCT. OCTARA aims to provide improved detection sensitivity of low blood flow and reduced motion artifacts without compromising axial resolution. In this chapter, we describe the implementation of OCTARA with swept-source OCT technology, the technical specifications of acquisition (e.g. the number of scans, area of examination field, etc.) along with the algorithm's function and principles for analysis of B-scan data to achieve angiographic visualization. Examples of OCTA scans performed using the OCTARA algorithm and a comparison of these scans with images obtained using other technologies are also presented.

To describe the optical coherence tomography (OCT) angiography (OCTA) features of diabetic retinopathy.Retrospective serial case reports were examined of patients who underwent routine clinical examination and OCTA with both DRI OCT Atlantis prototype and Triton Swept-Source OCT of the posterior pole and mid-periphery. When considered necessary, fluorescein fundus angiography (FFA) with OPTOS California wide-field imaging was performed. The findings were compared with the current literature.Forty-three consecutive patients (86 eyes) were evaluated. Fourteen of these patients (28 eyes) underwent an additional FFA examination due to advanced retinopathy signs, such as diabetic macular edema, ischemia or neovascularization (NV). OCTA was able to detect the microvascular lesions observed on color fundus images in the whole sample. Thirty-six of the 86 eyes showed foveal avascular zone enlargement on OCTA. Microvascular lesions, diabetic macular edema, and NV of the optic disc observed on FFA were also detected on OCTA in all cases (28/28 eyes). Features of NV elsewhere were detected on FFA in 16/28 eyes. Ten of the 16 eyes had signs of NV within the 100 central degrees, and OCTA was able to detect these signs in 9 of the eyes.OCTA is an effective noninvasive imaging technique that can provide additional information regarding the localization and morphology of vascular lesions in all cases of NV of the optic disc and in more than half of cases of NV elsewhere, suggesting that it is a noninferior technique for the study of posterior pole alterations compared with FFA, which remains the gold standard and is fundamental for the study of the retinal periphery.

To describe the optical coherence tomography (OCT) angiography (OCTA) features of paediatric macular pathologies.Retrospective serial case reports of patients who underwent routine clinical examination and OCTA of the posterior pole using both a DRI OCT Atlantis prototype and Triton Swept-Source OCT. When considered necessary, imaging was performed using Optos wide-field imaging or another non-invasive imaging system. The findings were compared with the current literature.Three cases with X-linked retinoschisis, 2 with epiretinal membrane, 1 with Best disease and 2 with Coats disease are fully illustrated.OCTA is an effective, non-invasive imaging technique that can offer additional information regarding the morphologies and vascular characteristics of macular lesions in paediatric ophthalmology. Because of the rarity and characteristics of many paediatric macular pathologies, further multi-centric research is required with regard to the utilisation and features of OCTA imaging.

Purpose: To explore the quality of life and employment status of patients with chronic uveitis using oral immunosuppression.Methods: A prospective questionnaire-based study.Results: Forty-six patients had a mean Vision Core Module 1 (VCM1) score of 1.4. The 41 patients with binocular acuity better than or equal to +0.3 logMAR (able to drive) achieved a mean score of 1.2. The 5 patients worse than +0.3 logMAR scored 2.6. This difference was highly significant. Six were unemployed (4 having lost their job because of uveitis-related problems); 3 felt at risk of losing their job; 13 believed their employers had concerns about their sick leave, and 7 used annual leave for hospital visits.Conclusion: Chronic uveitis, even if well controlled, can have substantial effects on a patient's social and psychological health, and can lead to significant work disability.

Purpose This study aims to address the lack of independent subjective efficacy data on artificial tear substitutes in the treatment of dry eye due to the anecdotal association of ‘thicker’ products being more effective. Methods This is an independent study of the subjective use and efficacy of topical treatments used by members of the British Sjogren's Syndrome Association (BSSA) related to product viscosity. 2000 members of the BSSA were sent a questionnaire regarding their physical condition and the use of artificial tear substitutes. Viscosity analysis was performed on the most popular preparations. Statistical comparison is made between subjective efficacies related to substitute tear viscosity. Results 1088 patients responded giving information regarding their condition together with the subjective use and efficacy data of artificial tear substitutes. Visco-analysis was performed on the most popular preparations; these had more than 50 patients using them. In terms of subjective benefits related to viscosity for ‘frequency’ and ‘duration’ the data suggests a general trend toward viscous preparations being instilled less frequently and lasting longer; however this was not shown to be significantly correlated and some interesting comparisons are reported. Conclusions The results confirm high levels of ocular lubricant use in the BSSA population. Our data investigates the often-anecdotal evidence that thicker preparations are more effective. However, we did not find this correlation to be statistically significant suggesting further study into factors related to subjective product efficacy. These results lay foundations for the development of future products in the treatment of severe dry eye.

Background: To describe our experience of combined trabeculotomy–trabeculectomy in paediatric glaucomas with a special emphasis on the use of 5-fluorouracil and releasable sutures. Design: Retrospective review carried out at Manchester Royal Eye Hospital, UK, a tertiary referral centre. Participants: Twenty-nine eyes of 21 consecutive patients with congenital glaucoma undergoing combined trabeculotomy–trabeculectomy augmented with 5-fluorouracil. Methods: 5-Fluorouracil augmented combined trabeculotomy–trabeculectomy was carried out with intense postoperative management and suture adjustment of releasable sutures within the first 3 weeks after surgery. Peribleb 5-fluorouracil injections were given repeatedly if there were signs of aggressive bleb scarring. Main Outcome Measures: Absolute success was defined as intraocular pressure of 21 mmHg or less, clear cornea and absence of progressive glaucomatous optic disc changes at last follow up, whereas qualified success was defined as these endpoints with anti-glaucoma medication. Results: Absolute success was achieved in 19 out of 29 eyes (65.5%), and a further 4 (13.8%) had qualified success. There was no difference in the surgical outcomes of primary infantile glaucoma and secondary causes of paediatric glaucoma such as anterior segment dysgenesis. Combined trabeculotomy–trabeculectomy had a significantly greater success rate as a secondary procedure rather than as a primary procedure. Conclusion: 5-Fluorouracil-enhanced combined trabeculotomy–trabeculectomy with releasable sutures appears to be an effective procedure for congenital glaucoma refractory to goniotomy. It is less effective as a primary procedure when severe corneal haze prevents goniotomy in newborn congenital glaucoma. Intense postoperative monitoring including active bleb manipulation with needling and 5-fluorouracil injections may increase the success of the procedure.

PURPOSE Despite the increasing use of antivascular endothelial growth factors (anti-VEGF), photodynamic therapy (PDT) with Verteporfin is still considered the gold standard treatment of subfoveal and juxtafoveal classic choroidal neovascularization (CNV). METHODS Case report. RESULTS The authors report a case of a 72-year-old man who developed choroidal nonperfusion and significant subretinal fluid formation with associated severe visual loss following PDT of predominantly classic juxtafoveal CNV. CONCLUSIONS Although reported separately, these two complications have not been previously reported to occur in association after PDT treatment of classic CNV and may represent exaggeration of normal events occurring after PDT.

Optical coherence tomography (OCT) angiography (OCTA) is a novel, noninvasive, three-dimensional imaging technique that allows for the visualization of intravascular flow in the microvasculature. Swept-source OCT technology utilizes longer-wavelength infrared light than conventional spectral-domain OCT. This enables improved penetration into tissue and imaging through optical opacities and is invisible to the subject. Topcon has recently developed an innovative OCTA algorithm, OCTARA (OCTA Ratio Analysis), which benefits from being paired with swept-source OCT. OCTARA aims to provide improved detection sensitivity of low blood flow and reduced motion artifacts without compromising axial resolution. In this chapter, we describe the implementation of OCTARA with swept-source OCT technology, the technical specifications of acquisition (e.g. the number of scans, area of examination field, etc.) along with the algorithm's function and principles for analysis of B-scan data to achieve angiographic visualization. Examples of OCTA scans performed using the OCTARA algorithm and a comparison of these scans with images obtained using other technologies are also presented.

Purpose: To describe the optical coherence tomography (OCT) angiography (OCTA) features of paediatric macular pathologies. Methods: Retrospective serial case reports of patients who underwent routine clinical examination and OCTA of the posterior pole using both a DRI OCT Atlantis prototype and Triton Swept-Source OCT. When considered necessary, imaging was performed using Optos wide-field imaging or another non-invasive imaging system. The findings were compared with the current literature. Results: Three cases with X-linked retinoschisis, 2 with epiretinal membrane, 1 with Best disease and 2 with Coats disease are fully illustrated. Conclusion: OCTA is an effective, non-invasive imaging technique that can offer additional information regarding the morphologies and vascular characteristics of macular lesions in paediatric ophthalmology. Because of the rarity and characteristics of many paediatric macular pathologies, further multi-centric research is required with regard to the utilisation and features of OCTA imaging.

Purpose: To describe the optical coherence tomography (OCT) angiography (OCTA) features of diabetic retinopathy. Methods: Re