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Purpose: To examine the relationship between central macular thickness (CMT) measured by optical coherence tomography (OCT) and visual acuity (VA) in patients with center-involving diabetic macular edema (DME) receiving antivascular endothelial growth factor (anti-VEGF) treatment. Methods: Peer-reviewed articles from 2016 to 2020 reporting intravitreal injections of bevacizumab, ranibizumab, or aflibercept that provided data on pretreatment (baseline) and final retinal thickness (CMT) and visual acuity (VA) were identified. The relationship between relative changes was assessed via a linear random-effects regression model controlling for treatment group. Results: No significant association between the logarithm of the minimum angle of resolution (logMAR) VA and CMT was found in 41 eligible studies evaluating 2667 eyes. The observed effect estimate was a 0.12 increase (95% CI, −0.124 to 2.47) in logMAR VA per 100 µm reduction in CMT after treatment change. There were no significant differences in logMAR VA between the anti-VEGF treatment groups. Conclusions: There was no statistically significant relationship between the change in logMAR VA and change in CMT as well as no significant effect of the type of anti-VEGF treatment on the change in logMAR VA. Although OCT analysis, including measurements of CMT, will continue to be an integral part of the management of DME, further exploration is needed on additional anatomic factors that might contribute to visual outcomes.

Our case emphasizes the approach of a single-dose of intraoperative methotrexate (MTX) – applied directly into silicone oil – to arrest the anomalous progression of proliferative vitreoretinopathy (PVR). A 78-year-old male presented with severe vision loss secondary to a pseudophakic macula-off rhegmatogenous retinal detachment oculus sinister (OS). He was initially treated with primary pars plana vitrectomy and intraocular gas; however, the patient developed recurrent macula-off retinal detachment complicated by proliferative vitreoretinopathy OS. Subsequent management involved vitrectomy with membrane removal, silicone oil tamponade, and adjuvant intravitreal MTX. The patient had an uneventful postoperative recovery with a dramatic vision improvement after silicone oil removal OS. Here, we highlight the use of silicone oil tamponade with single-dose adjuvant MTX for the management of complex retinal detachment associated with proliferative vitreoretinopathy.

Purpose: Systemic amyloidosis is a group of rare, life-threatening disorders characterized by the deposition of amyloid plaques in numerous tissues. Vitreous involvement can occur in amyloidosis and here we describe critical diagnostic findings. Methods: Case report of vitreous amyloidosis diagnosis confounded by non-specific presentation. Results: Despite false-negative vitreous biopsies, in the setting of previous vitreoretinal surgery, the case reveals vitreous opacities, decreased visual acuity, and retinal neovascularization as critical signs in ocular amyloidosis. Conclusions: Here we present the signs and symptoms that raise suspicion for vitreous amyloidosis and how to approach diagnosis early in the disease presentation.

Purpose: Suprachoroidal hemorrhage is an uncommon but serious ocular condition that typically occurs in the setting of intraocular surgery and trauma. We present an external trans-conjunctival vitreoretinal trocar-cannula-based drainage of suprachoroidal hemorrhage as a viable surgical approach. Methods: Case report. Results: Trans-conjunctival trocar-cannula-based drainage of suprachoroidal hemorrhage is a safe and efficacious surgical approach to drainage of large choroidal hemorrhages. Conclusions: Although discrepancies persist regarding the optimal surgical approach to suprachoroidal hemorrhage management; herein, we describe the successful execution of an external trans-conjunctival vitreoretinal trocar-cannula-based drainage of suprachoroidal hemorrhage.

This case report describes a diagnosis of retinoschisis and retinal detachment in a patient in their 40s who presented with acute onset of flashes and floaters.

This report describes a unique case of chronic unilateral anterior uveitis associated with macular edema while on oral dabrafenib treatment for chronic recurrent pilocytic astrocytoma. After gradual taper of prednisolone acetate OS, the patient developed recurrent mild low-grade anterior uveitis and macular edema OS that required low dose of prednisolone acetate OS to prevent recurrences while on oral dabrafenib. When oral dabrafenib was temporarily discontinued for 3 months due to her ocular inflammation, she had no flares of her uveitis; however, her tumor increased significantly in size. The collaborative decision was made to continue her oral dabrafenib while on topical anti-inflammatory therapy for her uveitis. Clinicians should be aware of this potential unilateral sequela of uveitis secondary to dabrafenib. Further investigation should be conducted to identify factors that may place certain patients at higher risk for this complication.

Retinal tissue is prone to oxidant burden and oxidative stress secondary to the generation of reactive oxygen species from high metabolic demand. The formation of reactive oxygen species occurs primarily from the mitochondrial respiratory chain as well as several enzymatic and oxidation reactions that occur in the neurosensory retina and retinal pigment epithelium. This oxidative stress has been implicated in the pathogenesis of several retinal diseases and the role of antioxidants as a therapeutic treatment shows promise in slowing the progression of certain diseases. The aim of this narrative review is to describe the mechanisms of retinal oxidative stress and summarize the current available evidence for antioxidants as a treatment for vitreoretinal disorders.

Purpose: We describe the outcome of a 23-year-old man undergoing vitreoretinal surgery for a macula-off rhegmatogenous retinal detachment secondary to a giant retinal tear. Methods: Patient underwent combined 25- gauge 3-port pars plana vitrectomy with scleral buckle, perfluorocarbon liquid, and perfluoropropane gas tamponade. During surgery, triamcinolone inadvertently entered the subretinal space and was retained. Results: The subretinal triamcinolone deposits spontaneously absorbed over a 2-month period. No adverse sequelae were associated with this complication. Conclusion: This may support avoiding aggressive mechanical removal of iatrogenic subretinal triamcinolone in the context of retinal detachment repair.

Purpose: We report a case of recurrent macular hole (MH) formation and spontaneous closure in the absence of any vitreoretinal interface abnormality. Methods: A 49-year-old man presented for his annual ocular examination with no specific ocular complaints. He had a history of retinal detachment in the left eye, which was treated years prior with vitrectomy and scleral buckle. During a routine follow-up, the patient was discovered to have a full-thickness MH. Optical coherence tomography revealed the formation of an MH with spontaneous closure after 3 months without intervention. One month later, the MH recurred but once again closed spontaneously over 4 months. Results: The patient remained asymptomatic during the entire follow-up without any symptoms, vision changes, or therapeutic intervention. Conclusions: To our knowledge, this is the first known case report of recurrent spontaneous opening and closure of an MH in the absence of any vitreoretinal interface abnormality, as revealed by macular optical coherence tomography imaging.

Purpose: This work identifies predictive variables associated with culture-positive cases of acute endophthalmitis after vascular endothelial growth factor (VEGF) inhibitor injection. Methods: A retrospective review of cases of endophthalmitis following intravitreal anti-VEGF injection was performed. All patients received a vitreous biopsy or anterior chamber aqueous biopsy (if vitreous biopsy was not successful) that was sent for microbial cultures before initiation of treatment. Results: During a 10-year period, 258 357 anti-VEGF agent injections were performed, of which 40 patients (0.016%) developed presumed endophthalmitis. Sixty percent (n = 24) of the presumed endophthalmitis patients had a positive culture. In multivariable logistic analysis, patients who had a best-corrected visual acuity (BCVA) worse than 20/400 were 35.3 times (adjusted odds ratio [AOR], 95% CI, 2.2-576.1, P = .012) more likely to have a positive culture compared with those who had a BCVA of 20/400 or better. Patients who had pain at initial presentation were 27.0 times (AOR, 95% CI, 1.4-523.9, P = .029) more likely to have a positive culture compared with those who did not have pain at initial presentation. Age, sex, clinical diagnosis, smoking status, anti-VEGF agent injected, duration between last anti-VEGF injection and symptoms of endophthalmitis, duration between endophthalmitis symptoms and initial treatment, intraocular pressure at initial presentation, and presence of hypopyon were not associated with a difference in positive-culture yield. Conclusions: Visual acuity worse than 20/400 and pain at time of initial presentation secondary to endophthalmitis following anti-VEGF injection were strongly associated with a positive culture. Our data support consideration of vitrectomy in cases in which microbe identification is paramount.

Purpose To determine predictive factors of proliferative vitreoretinopathy (PVR) formation after uncomplicated primary retinal detachment repair. Methods Retrospective, single-center, case-control study of 74 consecutive patients with (37 eyes) and without (37 eyes) PVR formation after undergoing uncomplicated primary surgery for retinal detachment repair. Logistic regression was used to assess factors associated with PVR formation. Results Retinal detachment involving the macula was 4.2 times (adjusted odds ratio; 95% confidence interval, 1.4-12.9; P = 0.0119) more likely to have PVR formation compared with those without. Patients who were current or former smokers were 3.6 times (adjusted odds ratio; 95% confidence interval, 1.1-11.7; P = 0.0352) more likely to have PVR formation compared with nonsmokers. Compared with 25-gauge (g) vitrectomy, larger gauge vitrectomy (20 g or 23 g) was 3.6 times (adjusted odds ratio; 95% confidence interval, 1.2-11.3; P = 0.0276) more likely to have PVR formation. Duration of retinal detachment symptoms, high myopia, lens status, lattice degeneration, location of retinal break, number of retinal breaks, and surgical technique (e.g., scleral buckle with or without vitrectomy versus vitrectomy alone) were not found to be predictive of PVR formation. Conclusion Cigarette smoking and macular involvement are significant risk factors predictive of PVR formation after uncomplicated primary retinal detachment repair.

Purpose We present a patient with vaso-occlusive retinal vasculitis to summarize this uncommon entity and review the clinical features and management challenges applicable to patients with retinal vasculitis. Observations A 76-year-old male presented with sudden-onset severe central vision loss. On examination, vitreous hemorrhage, neovascularization of the optic nerve, peripheral segmental periphlebitis, vessel sclerosis, vascular sheathing, and retinal hemorrhages were observed, and a diagnosis of active vaso-occlusive retinal vasculitis was made. The patient then underwent a complete infectious, inflammatory, and neoplastic workup which returned negative. The patient was treated with locally with a sub-Tenon's injection of 40 mg triamcinolone on presentation and later with oral prednisone. At three-month follow-up, vision improved to 20/300 with regressing neovascularization and clearing of vitreous hemorrhage in the right eye (OD). Conclusions Considering novel associations of occlusive retinal vasculitis, it is important to recognize that idiopathic occlusive retinal vasculitis, although uncommon, can occur and represents a prototypical disease form. It is imperative that these patients have a complete infectious, inflammatory, and neoplastic workup owing to the possible overlap of masquerade clinical signs and symptoms.

David RP Almeida,1 Jessica Ruzicki,2 Kunyong Xu,3 Eric K Chin4 1Vitreoretinal Diseases & Surgery, Erie Retinal Surgery, Erie, PA, USA; 2Department of Ophthalmology, Queen’s University, Kingston, Ontario, Canada; 3Department of Ophthalmology and Visual Sciences, University of Arizona, Arizona, AZ, USA; 4Vitreoretinal Diseases & Surgery, Retina Consultants of Southern California, Redlands, CA, USA; 5Vitreoretinal Diseases & Surgery, Loma Linda University Medical Center, Veterans Affairs Hospital, Loma Linda, CA, USACorrespondence: David RP AlmeidaErie Retinal Surgery, 300 State Street, Suite 201, Erie, PA 16507, USATel +1 814 456-4241Fax +1 814 453-3354Email drpa@pm.mePurpose: Currently, varying treatment paradigms and different clinical trial constructs preclude cross-trial comparison between different available vascular endothelial growth factor (VEGF) inhibitors. This study aimed to review the evidence and compare the efficacy of anti-VEGF therapies for neovascular age-related macular degeneration (nAMD), and to develop metrics as a means of facilitating standardized comparison between different anti-VEGF agents within the Advanced VitreoRetinal Analytics (AVRA) model.Methods: The study analyzed key outcomes in clinical trials of bevacizumab, ranibizumab, aflibercept, and brolucizumab, including best corrected visual acuity (BCVA), number of injections, and duration of follow-up (minimum follow-up of 48 weeks).Results: The AVRA model includes 1) vision recovery velocity (VRV; letters per unit time), which provides a metric of letters gained or lost over time (or the speed of improvement); 2) injection momentum (InjMom; number of injections multiplied by letters per unit time; units of injections•(letters/time)), which is defined as the number of injections multiplied by VRV and describes the quantity of treatment needed to achieve a vision outcome; and 3) vision recovery acceleration (VRA; letters per unit time squared; units of letters/time2), which denotes final VRV minus initial VRV, per unit time, and describes the rate of change in letters gained or lost over time.Conclusion: AVRA stipulates that the ideal VEGF inhibitor to treat nAMD would have a higher positive VRV (more letters gained per unit time), low InjMom (lower treatment burden requiring fewer interventions for a given visual acuity outcome), and VRA approximating zero (indicating stable vision over time). AVRA allows comparisons across different trials to determine the optimal anti-VEGF agent for the treatment of nAMD.Keywords: vascular endothelial growth factor inhibitors, neovascular age-related macular degeneration

Purpose: Acute macular neuroretinopathy (AMN) is a rare clinical entity with an uncertain etiology. We report an atypical case presenting with retinal hemorrhages (RH) and cotton-wool spots (CWS) following non-ocular trauma. Observations: A 49-year-old male presented with an acute onset of a paracentral scotoma in his left eye, immediately following a motor vehicle accident 1 day prior. Fundus findings revealed a unilateral nasal petalloid perifoveal lesion with the tip pointing toward the fovea associated with CWS and RH. Optical coherence tomography demonstrated disruption of the ellipsoid zone. Symptoms and exam findings improved at 2-week follow-up without any intervention, consistent with the natural history of the disease process. Conclusion: We report a rare case of AMN following non-ocular trauma with the unique fundus findings of CWS and RH. This presentation supports the role of ischemia in the retinal deep capillary plexus, of which trauma contributed to the pathophysiological process. Summary: AMN is a rare condition whose pathophysiological process remains speculative. We report an atypical case of AMN, which supports the role of trauma in the pathophysiology of deep retinal capillary plexus compromise.

Purpose: The purpose of this review is to provide an update on etiologies, preventive practices, management options, and surgical techniques for infectious endophthalmitis. Methods: A literature search was conducted for studies published over the past 5 years. Results: Endophthalmitis continues to be an uncommon but dangerous complication following cataract surgery. Recently, intravitreal injections have become heavily utilized as a treatment for various ocular diseases, leading to a greater incidence of postinjection infections. Likewise, long-term risk of endophthalmitis should always be a consideration following glaucoma surgery and implanted drainage devices. Although significant overlap exists for causative organisms among the different etiologies, more targeted studies are needed to better optimize treatment. There has been a lack of updates to treatment guidelines since the Endophthalmitis Vitrectomy Study was published in 1995. Despite promising outcomes seen with newer surgical techniques, the lack of randomized clinical trials represents a major barrier to widespread implementation of these approaches. Conclusions: Povidone-iodine prophylaxis remains the primary evidence-based technique for decreasing the rates of endophthalmitis following intraocular procedures. Intracameral antibiotics have gained momentum in recent years and represent a step forward in mitigating the risk of infection with cataract surgery, although some debate still exists. Newer surgical techniques for vitrectomy that improve visualization, minimize surgical trauma, and decrease operative time would benefit from large-scale randomized trials.

Purpose We describe the presentation of patients developing endophthalmitis after intravitreal injection with vascular endothelial growth factor (VEGF) inhibitors. Moreover, we evaluate the management by comparing the outcomes of immediate tap and injection of intravitreal antibiotics (TAI) versus initial surgical pars plana vitrectomy (PPV). Finally, we analyze the predictive factors of visual outcomes at 6-month follow-up. Design Retrospective, single-center, nonrandomized interventional study. Participants Patients developing endophthalmitis after receiving an intravitreal injection of anti-VEGF agent between 2006 and 2016. Methods All patients received a vitreous biopsy sent for cultures before the initiation of treatment: TAI group versus PPV with intravitreal antibiotics (PPV group). Main Outcome Measures Best-corrected visual acuity (BCVA) at 6-month follow-up after treatment for endophthalmitis. Results A total of 258 357 intravitreal injections occurred over the course of the 10-year period, of which 40 patients (0.016%) had endophthalmitis within 3 weeks after injection. In total, 34 patients (85.0%) had pain and 25 patients (62.5%) had hypopyon on initial examination. Among 24 culture-positive cases, 66.7% of the causative organisms were coagulase-negative Staphylococcus , followed by Streptococcus species (10.0%). The best-corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution [logMAR]) at 6-month follow-up was significantly worse for patients who had a positive culture for Streptococcus species (4.0; standard deviation [SD], 0.8) (approximately light perception) compared with those who had a positive culture for coagulase-negative Staphylococcus (0.4; SD, 0.3) (∼20/50) ( P P = 0.03). There was no statistically significant difference in BCVA at 6-month follow-up between the TAI and PPV groups. Younger age ( Conclusions No significant difference in BCVA at 6-month follow-up was detected between the TAI and PPV groups. Younger age and lower IOP at presentation were associated with better visual outcomes at 6-month follow-up.

To study the effect of changing perfusion pressures on retinal and choroidal structure in central serous chorioretinopathy (CSC).This prospective observational case series included seven healthy volunteers (14 eyes) and seven patients (14 eyes) with CSC. Each patient underwent spectral domain optical coherence tomography with enhanced depth imaging in the upright (sitting) and supine positions. Image segmentation focused on central macular thickness, subretinal fluid, total macular volume, choroidal thickness, and choriocapillaris thickness. Blood pressure and heart rate were measured in the upright and supine positions.Choriocapillaris thickness was thicker in CSC participants (34.23 μm; range, 30.9-36.5 μm) compared with healthy controls (13.96 μm; range, 7.15-23.87 μm) (P ≤ 0.001). The choroid was similarly thicker in CSC participants (371.4 μm; range, 200.2-459.4 μm) compared with healthy controls (231.4 μm; range 161.8-287.5 μm) (P ≤ 0.001). Choroidal thickness increased in patients with CSC when transitioning from upright (371.4 μm) to supine (377.8 μm) (P ≤ 0.01). By contrast, there was an 11.97% decrease in choroid thickness in normal controls when transitioning from upright (231.4 μm) to supine (203.9 μm). There were no significant hemodynamic changes.We demonstrated that choroidal thickness increased in response to increased perfusion pressures in patients with CSC and not in normal controls. These findings likely represent an autonomic dysregulation of choroidal blood flow in patients with CSC.

To evaluate ocular hypertension (OHT) after Ozurdex injection to determine the incidence of OHT, therapy for OHT, and any associative factors such as diagnosis, underlying glaucoma and therapy, or sequential Ozurdex injection(s). Retrospective consecutive case series with patients receiving one or more intravitreal Ozurdex implantations at a tertiary care academic center. Ocular hypertension was defined as a single measurement of ≥30 mmHg or an increase of ≥10 mmHg from baseline. Ninety-four injections in 52 patients (59 eyes) were reviewed. Forty eyes received a single injection, and 19 eyes received multiple injections. Ocular hypertension developed in 14 patients (26.9%). Thirteen patients (25%) had preexisting glaucoma or suspicion of glaucoma, and 6 of these developed OHT. Glaucoma eye drops were initiated after 13 injections (13.8%). Invasive surgery for glaucoma was required in 3 patients (3.2%): all had glaucoma or suspicion of glaucoma (one case was related to neovascular glaucoma and unlikely related to steroid response after Ozurdex). There was no difference in relative intraocular pressure increase (i.e., difference between final follow-up or subsequent intravitreal injection vs. baseline) between single versus multiple Ozurdex injections (P = 0.883). Patients (26.9%) who received Ozurdex developed OHT. Glaucoma or glaucoma-suspicion factors were present in all patients who required invasive surgery for glaucoma. A greater proportion of patients who received multiple injections had an intraocular pressure elevation, but the relative intraocular pressure increase was not significant.

Purpose:To provide an update on current surgical techniques and emerging medical management in proliferative vitreoretinopathy (PVR).Methods:A literature search was conducted on studies in the past decade with the inclusion of historical, landmark studies.Results:Proliferative vitreoretinopathy remains the primary obstacle to successful retinal detachment (RD) surgery, despite increasing knowledge on its pathophysiology and efforts to reduce its occurrence. A number of recent visualization and surgical advancements, including smaller gauge vitrectomies, have shown promising results. Likely, effective PVR prevention and treatment may rest on a multimodal approach, with particular attention toward adjunct pharmacological use. There is a growing body of literature on effective anti-inflammatory, antineoplastic/proliferative, antigrowth factor, and antioxidant adjunct therapy. Nonetheless, a number of preoperative and perioperative risk factors must be assessed before considering any surgical or medical manag...

Purpose: To describe the clinical course of foveal West Nile virus (WNV) chorioretinitis with longitudinal spectral domain optical coherence tomography (SD-OCT) imaging. Methods: Case report. Results: A 41-year-old man with diabetes mellitus presented with flashes and floaters of both eyes (OU) and decreased vision of the right eye (OD) 2 weeks after being discharged from a local hospital. He had been treated for WNV meningoencephalitis, and he recovered systemically with supportive therapy. Ophthalmic examination revealed WNV chorioretinitis bilaterally, with predominantly foveal involvement OD. His best-corrected visual acuity (BCVA) was 8/200 OD and 20/20 of the left eye (OS). Spectral domain optical coherence tomography revealed 2 distinct lesion types—the “classic” outer retinal lesion and an intraretinal lesion. Both lesions had associated disruption of the normal outer hyperreflective retinal layers on SD-OCT. Longitudinal SD-OCT over the ensuing 6 weeks revealed a gradual reconstitution of these layers, with BCVA concurrently improving to 20/40 OD. Conclusion: We describe the consecutive findings seen on SD-OCT of retinal lesions in WNV chorioretinitis. The tomographic natural history of these lesions involved reconstitution of OCT deficits, with corresponding improvement in functional visual status.

BACKGROUND AND OBJECTIVE: To assess the effect on best-corrected visual acuity (BCVA) and efficacy of the intravitreal sustained-release 0.7 mg dexamethasone implant (Ozurdex; Allergan, Irvine, CA) in patients with recalcitrant diabetic macular edema (DME). PATIENTS AND METHODS: Meta-analysis utilizing the MOOSE framework and a random effects model. Studies included adults undergoing treatment with Ozurdex for DME. The methodologic quality of each study was assessed using the MINORS and the Cochrane Collaboration Risk of Bias for randomized studies. RESULTS: A total of 3,859 patients among 15 studies were included in the final analysis. The mean difference in BCVA was a gain of four lines or 20 Early Treatment of Diabetic Retinopathy Study letters with Ozurdex at a mean follow-up period of 6 months. CONCLUSIONS: Treatment with Ozurdex is associated with significant mean improvement in visual acuity. Clinicians should have a multimodality approach to treating DME and be aware of this treatment option in those who have a suboptimal response to anti-VEGF therapy. [ Ophthalmic Surg Lasers Imaging Retina . 2017;48:160–166.]

Purpose To describe a case of fungal endophthalmitis secondary to Curvularia after cataract surgery. Observations This case showed delayed and recalcitrant fungal endophthalmitis secondary to Curvularia despite treatment with pars plana vitrectomy, intravitreal antifungal therapy, and systemic antifungals. Conclusions and importance Curvularia -associated endophthalmitis should be considered in the differential diagnosis of delayed post-cataract endophthalmitis, especially in tropical or subtropical geographical areas. Awareness and early identification, timely removal of the nidi of sequestration, and prolonged antifungal treatments are important for the eradication of Curvularia -associated endophthalmitis.

A 45-year-old female with a history of hypertension presented with complaints of intermittent vision loss and blurred vision. Clinical examination revealed diffuse retinal whitening in the peripapillary area with multiple visible emboli in the first- and second-order arteries. The patient’s retinal findings were keeping within features of lipemia retinalis, and serum lipids were ordered which returned a triglyceride level of 1504 mg/dL. The patient was referred to primary care for vascular risk factor management and potential genetic testing. Ocular signs of hypertriglyceridemia manifest as lipemia retinalis, characterized by white vascular lesions and retinal lipid infiltration. The high comorbidity of hypertriglyceridemia and hypertension may warrant close monitoring hypertensive complications such as hypertensive retinopathy.

To report a case of central retinal artery occlusion (CRAO) in a young human immunodeficiency virus (HIV)-infected patient recently started on highly active antiretroviral therapy.Case report observation of a 33-year-old HIV-infected patient who developed a CRAO after starting highly active antiretroviral therapy.Elevated triglycerides caused by starting highly active antiretroviral therapy preceded the development of CRAO in an HIV-infected patient.Atherosclerotic vascular disease is an important complication of HIV therapy, which can ultimately lead to cardiovascular disease. An unusual case of a young patient developing a CRAO after the initiation of highly active antiretroviral therapy is reported. In the patient, the authors expound that elevated lipids from efavirenz/emtricitabine/tenofovir resulted in carotid atherosclerosis, ultimately leading to CRAO. Eye care providers, as well as the internal medicine colleagues, should be aware of the possibility of this devastating condition in HIV-infected patients on antiretroviral therapy.

Purpose To describe the clinical course of a patient with Acanthamoeba keratitis, who despite prompt treatment progressed to histopathology-confirmed Acanthamoeba retinitis and endophthalmitis. Methods Case report. Results A healthy 30-year-old male wearing soft contact lens was diagnosed with Acanthamoeba keratitis and treated medically and surgically over the course of 1 year with presumed resolution of the infection. Yet, his infection recurred with documented spread to sclerokeratitis, and overwhelming endophthalmitis. Concerns about extra-ocular spread prompted a therapeutic enucleation with histopathologic evidence of Acanthamoeba organisms throughout the globe. Conclusion This is a case of a severe recurrent Acanthamoeba infection presenting initially as keratitis, followed by sclerokeratitis and histolopathology-confirmed endophthalmitis. This case demonstrates that despite persistent medical and surgical intervention, eradication of organisms may not be possible.

Pars plana vitrectomy for acute infectious endophthalmitis can be challenging due to severe inflammation in the anterior chamber creating significant media opacity. We describe a surgical technique combining limbal based vitrectomy and pars plana vitrectomy to manage acute infectious endophthalmitis. Limbal based vitrectomy facilitates removal of anterior chamber fibrin and inflammatory membranes for safe and optimal posterior pars plana vitrectomy.

Supplemental Digital Content is Available in the Text. The authors describe a surgical technique to facilitate the exposure and retrieval of embolus in cases of fovea-threatening retinal artery occlusion without a patent cilioretinal artery. The authors include a number of surgical pearls based on our experience that may facilitate intraocular emboli retrieval and minimize the common complication of vitreous hemorrhage associated with retinal embolectomy., Purpose: To describe a technique of surgical intraocular embolectomy in patients with acute fovea-threatening branch retinal artery occlusion. Methods: Pars plana vitrectomy with embolectomy involving embolus isolation, dissection, and removal in patients with an acute fovea-threatening arterial occlusion without a patent cilioretinal artery. Results: The surgical technique involves a core vitrectomy. The blocked artery is incised using a microvitreoretinal blade, and microsurgical forceps are used to retrieve the embolus. No significant complications were noted. The study technique offers an excellent safety profile and minimizes the risk of vitreous hemorrhage by carefully dissecting the vascular adventitial sheath and isolating the embolus. Conclusion: Surgical embolectomy is a viable technique for patients with acute fovea-threatening arterial occlusions without patent cilioretinal artery. Careful dissection and retrieval of the embolus minimizes the risk of vitreous hemorrhage, which is an important improvement in previous techniques for management of acute retinal arterial occlusions.

BACKGROUND AND OBJECTIVE: To describe a novel surgical technique using pars plana vitrectomy (PPV), internal limiting membrane (ILM) abrasion, and intravitreal fibrin glue for the treatment of optic disc pit maculopathy. PATIENTS AND METHODS: Surgical case series technique with scanning electron microscopy (SEM) of human post-mortem eyes. RESULTS: Using SEM, the authors demonstrate the persistent adherence of vitreous fragments to the optic disc following induction of posterior vitreous detachment in human postmortem eyes. The authors describe a surgical technique using PPV, Tano Diamond Dusted Membrane Scraper for an ILM abrasion, intravitreal fibrin glue (Tisseel), and gas-air exchange to seal optic disc pits. The authors report successful long-term visual and anatomical outcomes in three patients. CONCLUSIONS: Intravitreal fibrin glue, when combined with ILM abrasion, may be a viable treatment option for optic disc pit maculopathy with good short- and long-term visual acuity outcomes. SEM shows that ILM abrasion removes vitreous fragments, which are persistently adherent and may lead to failure with other interventional techniques. [ Ophthalmic Surg Lasers Imaging Retina. 2018;49:e271–e277.]

Kunyong Xu,1 Eric K Chin,2 D Wilkin Parke III,3 David RP Almeida3 1Department of Ophthalmology, Weill Cornell Medicine, Cornell University, New York, NY, 2Retina Consultants of Southern California, Redlands, CA, 3VitreoRetinal Surgery, PA, Minneapolis, MN, USA Purpose: Proliferative vitreoretinopathy (PVR) is the most common cause of recurrent retinal detachment (RD). We sought to determine the predictive factors of recurrent PVR formation and the need for additional vitreoretinal surgical intervention after uncomplicated primary RD repair.Methods: This is a retrospective single-center case–control study of consecutive patients with PVR formation after uncomplicated RD repair. Logistic regression was used to assess factors associated with recurrent PVR formation.Results: Thirty-seven eyes (37 patients) who had recurrent RD secondary to PVR formation were included. Among those, 27 eyes needed one additional surgery, whereas the remainder 10 eyes required two or more additional surgeries. In the univariate analysis, patients who had cystoid macular edema (CME) after the second surgery were 8.33 times (crude odds ratio [COR], 95% confidence interval [CI]: 1.23–56.67, p=0.0302) more likely to have recurrent PVR formation compared to those who did not have CME after the second surgery. Similarly, those who had epiretinal membrane (ERM) after the second surgery were 8.00 times (COR, 95% CI: 1.43–44.92, p=0.0182) more likely to have recurrent PVR formation compared to those who did not have ERM after the second surgery. In the multivariate analysis, patients who had ERM after the second surgery were 8.20 times (adjusted odds ratio [AOR], 95% CI: 1.08–62.40, p=0.0422) more likely to develop recurrent PVR compared to those who did not have ERM after the second surgery, when adjusted for age, sex, and CME after the second surgery.Conclusion: ERM and CME are potential predictive factors for recurrent PVR formation after uncomplicated primary RD repair. Early recognition and treatment of ERM and CME may be critical to prevent subsequent PVR formation and improve visual outcomes. Keywords: epiretinal membrane, cystoid macular edema, proliferative vitreoretinopathy, retinal detachment, rhegmatogenous retinal detachment

We describe the presentation of patients developing endophthalmitis after intravitreal injection with vascular endothelial growth factor (VEGF) inhibitors. Moreover, we evaluate the management by comparing the outcomes of immediate tap and injection of intravitreal antibiotics (TAI) versus initial surgical pars plana vitrectomy (PPV). Finally, we analyze the predictive factors of visual outcomes at 6-month follow-up.Retrospective, single-center, nonrandomized interventional study.Patients developing endophthalmitis after receiving an intravitreal injection of anti-VEGF agent between 2006 and 2016.All patients received a vitreous biopsy sent for cultures before the initiation of treatment: TAI group versus PPV with intravitreal antibiotics (PPV group).Best-corrected visual acuity (BCVA) at 6-month follow-up after treatment for endophthalmitis.A total of 258 357 intravitreal injections occurred over the course of the 10-year period, of which 40 patients (0.016%) had endophthalmitis within 3 weeks after injection. In total, 34 patients (85.0%) had pain and 25 patients (62.5%) had hypopyon on initial examination. Among 24 culture-positive cases, 66.7% of the causative organisms were coagulase-negative Staphylococcus, followed by Streptococcus species (10.0%). The best-corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution [logMAR]) at 6-month follow-up was significantly worse for patients who had a positive culture for Streptococcus species (4.0; standard deviation [SD], 0.8) (approximately light perception) compared with those who had a positive culture for coagulase-negative Staphylococcus (0.4; SD, 0.3) (∼20/50) (P0.0001). Compared with the TAI group, a higher proportion of samples were culture-positive in the PPV group (90.9% vs. 48.3%, P = 0.03). There was no statistically significant difference in BCVA at 6-month follow-up between the TAI and PPV groups. Younger age (85 years) and lower intraocular pressure (IOP) (≤25 mmHg) at presentation were predictive of achieving a BCVA of 20/400 or better at 6-month follow-up after treatment. Initial management (TAI vs. PPV), duration of symptoms, presence of pain, presence of hypopyon, presenting BCVA, and culture status (positive vs. negative) were not found to be predictive of visual outcomes at 6-month follow-up.No significant difference in BCVA at 6-month follow-up was detected between the TAI and PPV groups. Younger age and lower IOP at presentation were associated with better visual outcomes at 6-month follow-up.

The nature of the vitreoretinal interface in conditions like diabetic macular edema (DME) remains incompletely understood. Furthermore, it is not clear what the role of pharmacological enzymatic vitreolysis will play in cases of vitreomacular traction (VMT) associated with macular disease like DME. We describe the spontaneous resolution of VMT in 2 patients with DME. As both surgical and pharmacologic interventions have been suggested to treat DME in the setting of VMT, we feel that a clarification of the nomenclature and reporting of these cases of natural history may be useful in more fully understanding the complex decision-making involved when determining whether to treat this subset of patients.

Macular hole (MH) is characterized by full-thickness anatomic defect at the fovea leading to loss of central vision. The majority (B85%) of MHs were once thought to be idiopathic with a smaller proportion being secondary to trauma, inflammation, or high myopia. However, recent optical coherence tomography (OCT) imaging suggests that early MHs originate from an intraretinal split of the macula that evolves into intraretinal cysts (Fig. 1). It has been hypothesized that MHs develop from tangential traction from prefoveal vitreous cortex and/or epiretinal membranes and anteroposterior traction at the vitreoretinal interface resulting in vitreomacular traction syndrome. MH was once considered an untreatable condition until 1991 when vitrectomy and intraocular gas tamponade was first introduced by Kelly and Wendel. In the original report of 52 eyes which included mostly stage 3 MHs, the authors reported a primary anatomic closure rate of 58%. Six months after surgery, the visual acuity (VA) had improved by Z2 lines in 73% of eyes with closed holes. Currently, surgical management can achieve anatomic closure rates better than 90%, depending on preoperative MH size, duration of symptoms, and surgical technique used. The primary goal of surgery is to close the MH by removal of tangential and anteroposterior vitreous traction, activation of marginal glial cells by vitrectomy and ERM peeling, and immobilization/apposition of hole edges by intraocular gas tamponade and face-down positioning. Repeat MH surgery has been associated with a significant reduction in anatomic closure rate and perhaps functional outcome, thus the primary focus of surgical technique should be to close the MH in 1 procedure.

To evaluate the safety and efficacy of combining intravitreal dexamethasone implantation (Ozurdex) with pars plana vitrectomy (PPV).A retrospective review was conducted on cases where Ozurdex injection was performed in the operating room in conjunction with pars plana vitrectomy. Our primary outcome measure was the presence of surgical complications in the perioperative and 3-month postoperative window. We also measured visual acuity, intraocular pressure (IOP), and macular edema at baseline, one, and 3 months after surgery.Fifteen eyes in 14 cases were reviewed. There were no complications intraoperatively or at 1-month postoperatively. Two patients (2 eyes) with prior retinal detachment developed proliferative vitreoretinopathy and redetachment at 3 months. Visual acuity improved in 7 of 15 eyes, and an average improvement of 2 lines was achieved for the entire cohort. There was no overall change in intraocular pressure although 1 patient developed an increase in intraocular pressure5 mmHg. Five of 9 patients with baseline macular edema experienced improvement or resolution at 3 months.Intraoperative Ozurdex in combination with PPV may be safe and effective in treating macular edema caused by many different underlying diseases.

This case report describes 4 male children (age, 9–16) who had laser-related retinal injury to the macula of 1 eye or both eyes due to the mishandling of the laser pointer devices at a single vitreoretinal clinical practice. The presenting symptoms associated with laser pointer injury include central vision loss, central scotoma, and metamorphopsia. Clinical findings of laser-related retinal injury include reduced visual acuity, disruption of the photoreceptor ellipsoid zone, retinal pigment epithelium atrophy, and choroidal neovascular membrane formation. Disruption of the foveal ellipsoid zone (photoreceptor inner segment/outer segment layer) is the most common finding on optical coherence tomography imaging. Three patients had potential irreversible vision loss. Laser pointers are readily available and appropriate use of laser pointers in the pediatric population must be emphasized due to the potential irreversible retinal injury. Health professionals, school teachers, and parents should raise public awareness of this emerging public health issue by educating children about the dangers of laser pointers. Laser pointer devices among children should be discouraged and limited due to the possibility of permanent harm to themselves and others. Legislation and laws may be required to better control the sale and use of these devices.

PURPOSE To describe a bimanual vitrectomy technique for the removal of a descemet-stripping automated endothelial keratoplasty donor graft dislocated into the vitreous cavity. METHODS The surgical technique requires the use of a temporary keratoprosthesis and external chandelier illumination to overcome corneal edema and visualization of the dislocated donor graft, respectively. A bimanual pars plana vitrectomy approach is then performed with intraocular forceps and the vitrectomy handpiece for segmentation and removal of the dislocated graft. Penetrating keratoplasty is then performed to restore corneal clarity. RESULTS This surgical technique allows for the dislocated descemet-stripping automated endothelial keratoplasty donor graft to be removed from the vitreous cavity safely in an efficient manner. CONCLUSION The technique of bimanual pars plana vitrectomy with a temporary keratoprosthesis and external chandelier illumination can successfully remove a descemet-stripping automated endothelial keratoplasty donor graft dislocated into the vitreous cavity without the need for a large wound for donor graft explantation.

An immunocompetentwoman in her 80s underwent uncomplicated cataract surgery in her righteye4monthspriorwithbest-correctedvisualacuity (BCVA)of20/25OD.Twoweeks prior topresentation, shereportedagradual increase inblurredvisionwith intermittent floaters in the right eyebut deniedpain or inciting events.HerBCVAwas20/50OD. Therewere large keratic precipitates, 1+ anterior chamber cell and flare, and no hypopyon. Numerous white precipitates were noted on the anterior and posterior surface of a 3-piece posterior chamber intraocular lens (Figure, A). Therewere 2+ to 3+ anterior vitreous cells and a 2–disc area chorioretinal scar along the superior retinal arcadeswith extramacular drusen, but no areasof chorioretinitis (Figure, B). B-scanultrasonography showedaposterior vitreousdetachmentandmoderatevitreousopacities.Thecontralateralphakiceyeshowedsimilardrusen but was otherwise unremarkable. The patient underwent a vitreous tap,whichwas negative for organisms, aswell as injection of intravitreal vancomycin hydrochloride and ceftazidime in the right eye. Topical prednisolone acetate and ofloxacin were started 4 times daily, and steroids were increased toevery2hourswhile awakeat follow-up.HerBCVA improved to20/30OD4days later. TheBCVAremainedexcellent andkeraticprecipitatesdissipatedby 1monthof followup, with stable findings in the posterior pole. Topical antibiotics were stopped and topical steroidswere gradually tapered. At 2months’ follow-up, however, she had recurrent anterior chamber and vitreous inflammation with mild cystoid macular edema. Quiz at jamaophthalmology.com Fundus photograph B Slitlamp photograph A

Creutzfeldt-Jakob disease is a rare degenerative disease of the brain characterized by rapid irreversible neurological decline. The Heidenhain variant describes any case of Creutzfeldt-Jakob disease in which visual symptoms predominate in the early stages. The authors report a 63-year-old female who had rapidly progressive bilateral visual field loss since 2 months prior to evaluation. Over the following 2 weeks, the patient developed rapidly progressive visual changes and eventually died. Her case has several unusual features: (1) lack of neurological deficits classically seen with Creutzfeldt-Jakob disease such as myoclonus and ataxia; (2) rapid progression of a clearly documented consecutive homonymous hemianopia over less than 2.5 months from onset of symptoms to death; (3) early symmetric temporal atrophy of the optic nerves and paracentral retinal thinning with optical coherence tomography imaging; (4) negative single-photon emission computed tomography imaging; and (5) negative magnetic resonance i...

Purpose Conjunctival adherence of a tick is an uncommon event with few reports previously cited in the literature. We report a unique case of tick penetration, specifically a black-legged deer tick ( Ixodes scapularis ), into the conjunctiva. Observations This patient experienced a 3-week history of unilateral mild ocular pain, decreased vision, and pigmented lesion of her right eye. Slit lamp examination demonstrated a tick attached to the conjunctiva. Pathology confirmed the insect exoskeleton. Visual appreciation of the tick demonstrated probable deer tick larval stage given the shape, size, pigmentation pattern and geographic location of the specimen. Polymyxin-trimethoprim eye drops were prescribed for use three times daily and loteprednol twice daily. Conclusions and importance Despite the low risk for Lyme disease, which is endemic to the Adirondack region where the patient was affected, doxycycline was prescribed for prophylaxis. In any case of suspected tick penetration to the ocular surface, immediate ophthalmologic consultation and prompt removal via the method mentioned above is recommended, as well as attention paid to the Infectious Diseases Society of America guidelines regarding prophylaxis.