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Purpose: To compare the incidence and visual outcomes of endophthalmitis after injection of an intravitreal dexamethasone implant and injection of intravitreal ranibizumab. Methods: This retrospective cohort study assessed endophthalmitis in eyes receiving an intravitreal injection of a 0.7 mg dexamethasone implant (DEX group), 0.5 mg ranibizumab (R5 group), or 0.3 mg ranibizumab (R3 group) between January 1, 2016, and May 31, 2018, at 2 large retina practices in the United States. Results: Suspected endophthalmitis occurred in 5 eyes after 4973 DEX injections, 43 eyes after 163 974 R5 injections, and 6 eyes after 18 954 R3 injections. Suspected endophthalmitis was significantly more common in the DEX group (1/995) than in the R5 group (1/3813) ( P = .008) but not than in the R3 group (1/3159) ( P = .10). Visual acuity outcomes were similar in the 3 groups. Conclusions: Suspected endophthalmitis might be more common after 0.7 mg dexamethasone injections than after 0.5 mg ranibizumab injections. Culture-positive endophthalmitis rates were similar across all 3 medications.

To review how private equity entities generate profit for investors and ophthalmologists.There is a preponderance of private equity acquisitions and consolidation in ophthalmology. These private equity entities generate revenue by growth, profit improvement, and efficient use of capital structure. Physician partners sell their revenue and assets to a private equity entity while retaining a percentage of future profit. In general, a greater percentage going forward, will result in a smaller initial buyout. Partners typically receive payment in the form of cash and stock in the private equity entity, aligning incentives of both parties to grow and succeed. Junior associates and future partners typically do not benefit from the cash buyout but might have opportunity to buy shares in the private equity entity.The ophthalmology job market has changed significantly with the rise in private equity. Private equity investors profit from organic growth, economies of scale, and future revenue of ophthalmology practices. Ophthalmology partners benefit from often sizeable buyouts and potentially profitable shares in the private equity entity. Junior and future ophthalmologist may be less likely to succeed financially compared with their contemporaries. Some private equity entities will thrive and other may fail, particularly if they are unable to attract talented new ophthalmologists.

Background/Objective Investigate real-world patients receiving faricimab for the treatment of neovascular age-related macular degeneration (nAMD). Subjects/Methods Multicenter, retrospective chart review was conducted on patients treated with faricimab for nAMD from February 2022 to September 2022. Collected data includes background demographics, treatment history, best-corrected visual acuity (BCVA), anatomic changes, and adverse events as safety markers. The main outcome measures are changes in BCVA, changes in central subfield thickness (CST) and adverse events. Secondary outcome measures included treatment intervals and presence of retinal fluid. Results After one injection of faricimab, all eyes (n = 376), previously-treated (n = 337) and treatment-naïve (n = 39) eyes demonstrated a + 1.1 letter (p = 0.035), a + 0.7 letter (p = 0.196) and a + 4.9 letter (p = 0.076) improvement in BCVA, respectively, and a − 31.3 μM (p p p n = 94), previously-treated (n = 81) and treatment-naïve (n = 13) eyes demonstrated a + 3.4 letter (p = 0.03), a + 2.7 letter (p = 0.045) and a + 8.1 letter (p = 0.437) improvement in BCVA, and a − 43.4 μM (p p p Conclusions Faricimab has demonstrated improvement or maintenance of visual acuity for patients with nAMD, along with rapid improvement of anatomical parameters. It has been well-tolerated with low incidence of treatable intraocular inflammation. Future data will continue to investigate faricimab for real-world patients with nAMD.

To evaluate the visual outcomes and the affect of timing of surgical repair of fovea-splitting rhegmatogenous retinal detachments.A retrospective, consecutive cohort from multiple surgeons at a single center. Fovea status (fovea-on, fovea-splitting, or fovea-off) was classified by preoperative optical coherence tomography. The primary outcome measure was the visual acuity at the last follow-up that was further correlated with the timing of surgical repair.One hundred and ninety-five eyes were included with 62 fovea-on, 65 fovea-splitting, and 68 fovea-off detachments. The mean preoperative logarithm of the minimum angle of resolution visual acuity for fovea-on, fovea-splitting, and fovea-off groups was 0.16 ± 0.21, 0.70 ± 0.56, and 1.67 ± 0.87, respectively (P =0.001). Mean postoperative logarithm of the minimum angle of resolution visual acuity for fovea-on, fovea-splitting, and fovea-off groups were 0.07 ± 0.13, 0.10 ± 0.15, and 0.20 ± 0.22, respectively (P =0.001). A statistically significant difference in mean postoperative logMAR visual acuity was found between fovea-off and fovea-on groups (P = 0.003) and between fovea-off and fovea-splitting groups (P = 0.013), however not between fovea-on and fovea-splitting groups (P = 0.827). Visual acuity improved when repair was performed earlier after presentation for fovea-on (R = 0.378, P = 0.002) and fovea-off groups (R = 0.277, P = 0.022), but not for the fovea-splitting group (R = 0.089, P = 0.481).We described the favorable visual outcomes of surgery for fovea-splitting rhegmatogenous retinal detachment and correlated these with the timing of surgical repair, which may help guide the management of this urgent, vision-threatening condition.

To report a novel surgical technique for evacuating submacular hemorrhage using the infusion stream of a 25 gauge vitrectomy system.Surgical case and video.A 54 year old male was taken to the operating room for a total hyphema, non-clearing vitreous hemorrhage, and elevated intraocular pressure after multiple tractional retinal detachment repairs by an outside surgeon. Intraoperatively the hyphema and vitreous hemorrhage were cleared, and the source of bleeding was discovered to be an avulsed vessel through a pre-existing retinal break just superior to the optic nerve. A large submacular hemorrhage was also present that was unable to be drained through the break by aspiration alone. With the vitreous cavity under fluid, the infusion cannula was manipulated to guide the infusion stream onto the macula. The stream was directed in a distal to proximal manner towards the retinal break, and the submacular blood was successfully expressed out through the break. Postoperatively the retina remained attached with almost complete resolution of the submacular hemorrhage.Utilizing the mechanical pressure of the infusion stream can be an effective method for evacuating large subretinal hemorrhages.

Purpose: This work investigated interest in telehealth services for patients with chronic retinal conditions. Methods: A single-center, multi-office study was conducted of patients with chronic retinal conditions who were seen by 1 of 4 physicians during June 2020. Patients whose next appointment was 6 months or later were telephoned. Patients completed a phone interest survey about their interest in a hybrid telehealth evaluation instead of a complete office evaluation with their provider. Results: Of 2136 patients reviewed, 453 met eligibility to participate in the survey. A total of 159 patients (35.1%) participated, of whom 91 (57.2%) indicated an interest in telehealth at their next follow-up visit. Of the 68 (42.8%) patients without a current interest in telehealth, 13 (19.1%) expressed interest in pursuing telehealth in the future. Age ( P = .19), sex ( P = .22), race ( P = .79), office location ( P = .19), number of prior visits ( P = .58), and median household income by patient’s zip code ( P = .14) were not predictors of telehealth interest. Among diagnoses, dry age-related macular degeneration was associated ( P = .04) with increased interest in telehealth. An increased number of ocular diagnoses were also found to predict a decreased ( P = .04) interest in telehealth. multivariable analysis revealed healthcare provider as the only significant predictor for interest in telehealth ( P = .03). Conclusions: Most patients with chronic retinal conditions may be interested in incorporating telehealth into routine care. Considerations should be made to evaluate interest in telehealth to guide patients to clinical experiences that best suit their needs.

PURPOSE To evaluate the refractive outcomes of sutureless intrascleral fixation of intraocular lens with pars plana vitrectomy. METHOD A retrospective, consecutive cohort from multiple surgeons of a single center. Primary outcomes included spherical equivalent (SEQ) and change in SEQ (ΔSEQ) from preoperative intraocular lens power calculations. Secondary outcomes included refractive outcomes of fixation at 1.5 mm, 2 mm, and 2.5 mm posterior to the limbus. RESULTS In total, 84 eyes of 80 patients were included. Preoperative logarithm of the minimum angle of resolution visual acuity was 1.21 ± 0.68 (20/320). The mean follow-up time was 2.33 ± 1.36 years. At 3 months, SEQ was -0.50 ± 1.59 D and ΔSEQ was 0.58 ± 1.49 D. At 1 year, SEQ was -0.55 ± 1.32 D and ΔSEQ was 0.39 ± 1.42 D. At the last follow-up, logarithm of the minimum angle of resolution visual acuity was 0.34 ± 0.34 (20/40), SEQ was -0.51 ± 1.44 D, and ΔSEQ was 0.57 ± 1.27 D. There was no difference between SEQ or ΔSEQ throughout follow-up (P = 0.97 and P = 0.96, respectively). At fixation distances more posterior to the limbus, mean ΔSEQ was more hyperopic at 3 months, 1-year, and the last follow-up (P = 0.02, P = 0.01, and P = 0.006, respectively). CONCLUSION Refractive outcomes for sutureless intrascleral fixation of intraocular lens with pars plana vitrectomy were favorable and showed stability postoperatively. These results may aid surgeons achieve better desired refractive outcomes for this technique.

Purpose To review evidence and provide guidelines on intracameral (ICM) injection techniques and monitoring. Materials and methods A review of published literature on ICM injection and intravitreal injections formed the basis for roundtable deliberations by an expert panel of ophthalmologists. Results ICM injection as a way to deliver medications is growing in popularity. However, there is limited published literature and no standard approach to best practices for ICM injections, particularly when not accompanying another surgical procedure. Fortunately, there is long clinical experience with ICM manipulation and a large body of evidence surrounding intravitreal injections that has provided important guidance. The expert panel formulates several concrete guidelines and many suggested techniques to help physicians safely and effectively employ ICM injections. Conclusions This committee addressed the many considerations surrounding ICM injection of drugs or implants and agree that it is a safe and effective surgical procedure when performed with appropriate training and according to established safe practices.

This is an observational case series of two patients who developed direct retinal damage following neodymium-doped yttrium-aluminum-garnet (YAG) laser treatment for symptomatic vitreous floaters. The first patient developed a vitreous hemorrhage and subsequent branch retinal vein occlusion from laser damage to a major retinal venule. The second patient developed a temporal scotoma from a full-thickness retinal break in the posterior pole requiring laser retinopexy. Direct YAG laser damage to the posterior pole can cause permanent visual deficits. [ Ophthalmic Surg Lasers Imaging Retina . 2021;52:610–613.]

Purpose: The relationship between poor hemoglobin A1c (HbA1c) control and risk of proliferative diabetic retinopathy (PDR) is well known. Nevertheless, some patients have discordant disease (controlled HbA1c and severe PDR or vice versa). One potential explanation for this discrepancy is the presence of underlying genetic mutations in the Wingless-related integration site (Wnt) signaling pathway. However, minimal clinical data exist on the presence of Wnt signaling mutations in patients with diabetes mellitus (DM) and the correlation with diabetic retinopathy. Methods: Retrospective, nonconsecutive case review of patients with type 1 or 2 DM who underwent genetic testing for at least 1 recognized Wnt signaling pathway mutation from 2011 to 2016. The clinical course and retinal images were reviewed for patients with identifiable mutations. Results: Thirty-six patients, ages 13 to 79 years, consented for genetic analysis. Three patients (8.3%) exhibited at least 1 recognized genetic mutation in the Wnt signaling pathway. Case 1 was a 65-year-old female with type 1 diabetes for > 20 years, HbA1c Conclusion: Wnt signaling pathway mutations exist in patients with DM. Further studies investigating the prevalence and clinical significance of these mutations in a larger diabetic population are warranted. Identification of these patients with genetic testing may enable earlier medical intervention.

BACKGROUND AND OBJECTIVE: To describe the ultra-widefield (UWF) imaging characteristics of patients with degenerative peripheral retinoschisis (DPR) using Optomap technology. PATIENTS AND METHODS: In this multicenter, retrospective, noncomparative, consecutive case series, eligible patients underwent detailed retinal examination including indirect ophthalmoscopy. UWF fundus imaging, including color fundus photography, autofluorescence, and angiography, was performed using standardized protocols and findings were recorded and reviewed and analyzed. RESULTS: A total of 35 patients (58 eyes) with DPR were identified who underwent 55 sessions of UWF imaging. Mean age was 65 years, and the inferotemporal quadrant was most commonly affected (74% of eyes). Of these patients, 31 underwent fluorescein angiography and 90% of these studies illustrated abnormalities in the area affected by the schisis. The most common finding was retinal vascular leakage originating from the deep capillary plexus observed in 29 eyes (93.5%). CONCLUSIONS: UWF imaging enables a more detailed identification of the clinical features associated with DPR and provides simple, practical, and noninvasive tools to monitor progression of disease. The breadth of retinal vascular complications identified with fluorescein angiography may suggest an important vascular component associated with the pathogenesis of this entity. [ Ophthalmic Surg Lasers Imaging Retina . 2019;50:557–564.]

PURPOSE: Epiretinal proliferation is a distinct clinical entity from epiretinal membrane that is classically associated with lamellar macular holes, but its prevalence and association with full-thickness macular holes (FTMH) have not been well described. We characterize MHEP macular hole associated epiretinal proliferation (MHEP) and its effects on long-term surgical outcomes. DESIGN: Multi-center, interventional, retrospective case control study. SUBJECTS: Consecutive eyes that underwent surgery for FTMH with a minimum of 12-months follow-up. METHODS: All eyes underwent pars plana vitrectomy, removal of any epiretinal membranes, and gas tamponade, with or without internal limiting membrane peeling. Spectral domain optical coherence tomography imaging was obtained pre- and post-operatively. MAIN OUTCOME MEASURES: Improvement in visual acuity and single surgery hole closure rates in eyes with, versus without, MHEP at 12 months. RESULTS: 725 charts were analyzed, and 113 patients met inclusion criteria. Of 113 eyes with FTMH, 30 (26.5%) had MHEP. Patients with FTMH and MHEP were older (P < 0.002), more often male (P = 0.001), and with more advanced macular hole stages than those without MHEP (P = 0.010). A full posterior vitreous detachment was more common in eyes with MHEP (P < 0.004). FTMH with MHEP had significantly less improvement in visual acuity 12-months postoperatively (P = 0.019) with higher rates of ellipsoid and external limiting membrane defects (P < 0.05) and with a higher rate of failure to close with one surgery compared to FTMH without MHEP (26.7% versus 4.8% [P = 0.002]). Peeling the internal limiting membrane was associated with improved rates of hole closure in FTMH with MHEP (P < 0.001). Multivariable testing confirmed that the presence of MHEP was an independent risk factor for less visual improvement (P = 0.031), single-surgery non-closure (P = 0.009), and that ILM peeling improved single-surgery closure rates (P = 0.026). CONCLUSIONS: We found that FTMH with MHEP has poorer anatomic and visual outcomes after vitrectomy compared to FTMH without MHEP. ILM peeling was associated with improved closure rates and should be considered when MHEP is detected preoperatively.

Purpose: The purpose of this article is to provide a data-driven set of best practices to consider in the management of diabetic macular edema (DME). Methods: The current discussion and recommendations represent the authors’ interpretations of data from selected references based on perceived relevance and study design. Results: DME is a common cause of visual impairment globally. The underlying progressive retinal microvascular damage is associated with upregulation of VEGF and a multitude of other inflammatory pathways. Three clinically relevant subcategories of DME can be identified: central-involved DME (CIDME) with preserved visual acuity, CIDME with associated visual loss, and non-CIDME. Management approaches may include observation, laser photocoagulation, intravitreal pharmacotherapy with anti-VEGF agents or corticosteroids, or a combination of these, and may vary depending on the specific type of DME and associated severity of diabetic retinopathy. Additional factors to consider in the management of patients with DME include the appropriate use of imaging and recognition of the chronic nature of the underlying disease process in many eyes. Conclusions: DME management is complex. Intravitreal pharmacotherapies are the current cornerstone of treatment for CIDME and appear poised to remain so for the foreseeable future.

Purpose To compare the rates of infectious endophthalmitis following intravitreal injection of ranibizumab using prefilled syringes vs conventional preparation. Design Multicenter retrospective cohort study. Methods All eyes receiving intravitreal injection of 0.5 mg ranibizumab for retinal vascular diseases at 10 retina practices across the United States (2016 to 2017) and Japan (2009 to 2017) were included. The total numbers of eyes and injections were determined from billing codes. Endophthalmitis cases were determined from billing records and evaluated with chart review. Primary outcome was the rate of postinjection acute endophthalmitis. Secondary outcomes were visual acuity and microbial spectrum. Results A total of 243 754 intravitreal 0.5 mg ranibizumab injections (165 347 conventional and 78 407 prefilled) were administered to 43 132 unique patients during the study period. In the conventional ranibizumab group, a total of 43 cases of suspected endophthalmitis occurred (0.026%; 1 in 3845 injections) and 22 cases of culture-positive endophthalmitis occurred (0.013%; 1 in 7516 injections). In the prefilled ranibizumab group, 12 cases of suspected endophthalmitis occurred (0.015%; 1 in 6534 injections) and 2 cases of culture-positive endophthalmitis occurred (0.0026%; 1 in 39 204 injections). Prefilled syringes were associated with a trend toward decreased risk of suspected endophthalmitis (odds ratio 0.59; 95% confidence interval 0.31-1.12; P = .10) and a statistically significant decreased risk of culture-positive endophthalmitis (odds ratio 0.19; 95% confidence interval 0.045-0.82; P = .025). Average logMAR vision loss at final follow-up was significantly worse for eyes that developed endophthalmitis from the conventional ranibizumab preparation compared to the prefilled syringe group (4.45 lines lost from baseline acuity vs 0.38 lines lost; P = .0062). Oral-associated flora was found in 27.3% (6/22) of conventional ranibizumab culture-positive endophthalmitis cases (3 cases of Streptococcus viridans, 3 cases of Enterococcus faecalis) compared to 0 cases in the prefilled ranibizumab group. Conclusion In a large, multicenter, retrospective study the use of prefilled syringes during intravitreal injection of ranibizumab was associated with a reduced rate of culture-positive endophthalmitis, including from oral flora, as well as with improved visual acuity outcomes.

Purpose To evaluate the outcomes of patients undergoing pneumatic retinopexy (PR) performed by vitreoretinal fellows at 6 academic centers in the United States. Design Retrospective, multicenter, consecutive case series. Participants Four hundred eighty-three patients with primary retinal detachments who underwent PR by 49 vitreoretinal fellows from 6 United States training sites between 2002 and 2016. Methods We reviewed medical records of patients and recorded baseline clinical characteristics (age, gender, baseline visual acuity, lens status, presence of lattice degeneration, presence of vitreous hemorrhage, location of retinal breaks, macular status, and size of detachment), visual and anatomic outcomes at 3 months after PR, as well as training level and PR experience of the fellow at the time of the procedure. Main Outcome Measures Single-procedure anatomic success and visual acuity at 3 months of follow-up and association with clinical and training-related factors. Results Vitreoretinal fellows performed a variable number of PR procedures, with a median of 7 per fellow (range, 1–24). Single-procedure anatomic success was 66.8%, and mean visual outcome was 0.43 logarithm of the minimum angle of resolution (Snellen equivalent, 20/54) at 3 months. Factors that were associated independently with single-procedure success included phakic lens status (P = 0.01), smaller size of retinal detachment (P = 0.02), and the fellow’s procedure experience (P = 0.01). The only factor associated with worse visual outcome was baseline visual acuity (P Conclusions Vitreoretinal fellows perform variably few PR procedures but have outcomes comparable with those reported by experienced specialists. Procedure experience of individual fellows may impact anatomic outcomes.

Purpose To determine the incidence of endophthalmitis after anti–vascular endothelial growth factor (VEGF) therapy at our institution and to identify potential risk factors for endophthalmitis occurring after injection. Design Retrospective, single-center cohort study. Participants All patients who received an intravitreal injection of an anti-VEGF medication between January 1, 2014, and March 31, 2017. Methods Current Procedural Terminology and International Classification of Diseases billing codes were used to identify instances of anti-VEGF administration and cases of endophthalmitis. Medical records and injection technique were reviewed carefully in each case. Multivariable logistic regression analysis was performed in a stepwise fashion to determine independent predictors of endophthalmitis based on injection protocol. Main Outcome Measures Incidence of endophthalmitis after injection and odds of endophthalmitis by injection technique with 95% confidence intervals (CIs). Results A total of 154 198 anti-VEGF injections were performed during the period of interest, resulting in 58 cases of endophthalmitis (0.038% [1:2659]). After adjustment for confounders, both 2% lidocaine jelly (odds ratio [OR], 11.28; 95% CI, 3.39–37.46; P Conclusions The incidence of endophthalmitis after anti-VEGF injections is low. Use of lidocaine jelly or Tetravisc may increase the risk of endophthalmitis after injection.

Purpose Routine use of face masks for patients and physicians during intravitreal anti–vascular endothelial growth factor (VEGF) injections has increased with the emergence of the coronavirus disease 2019 pandemic. This study evaluates the impact of universal face mask use on rates and outcomes of post-injection endophthalmitis (PIE). Design Retrospective, multicenter, comparative cohort study. Participants Eyes receiving intravitreal anti-VEGF injections from October 1, 2019, to July 31, 2020, at 12 centers. Methods Cases were divided into a “no face mask” group if no face masks were worn by the physician or patient during intravitreal injections or a “universal face mask” group if face masks were worn by the physician, ancillary staff, and patient during intravitreal injections. Main Outcome Measures Rate of endophthalmitis, microbial spectrum, and visual acuity (VA). Results Of 505 968 intravitreal injections administered in 110 547 eyes, 85 of 294 514 (0.0289%; 1 in 3464 injections) cases of presumed endophthalmitis occurred in the “no face mask” group, and 45 of 211 454 (0.0213%; 1 in 4699) cases occurred in the “universal face mask” group (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.51–1.18; P = 0.097). In the “no face mask” group, there were 27 cases (0.0092%; 1 in 10 908 injections) of culture-positive endophthalmitis compared with 9 cases (0.004%; 1 in 23 494) in the “universal face mask” group (OR, 0.46; 95% CI, 0.22–0.99; P = 0.041). Three cases of oral flora–associated endophthalmitis occurred in the “no face mask” group (0.001%; 1 in 98 171 injections) compared with 1 (0.0005%; 1 in 211 454) in the “universal face mask” group (P = 0.645). Patients presented a mean (range) 4.9 (1–30) days after the causative injection, and mean logarithm of the minimum angle of resolution (logMAR) VA at endophthalmitis presentation was 2.04 (~20/2200) for “no face mask” group compared with 1.65 (~20/900) for the “universal face mask” group (P = 0.022), although no difference was observed 3 months after treatment (P = 0.764). Conclusions In a large, multicenter, retrospective study, physician and patient face mask use during intravitreal anti-VEGF injections did not alter the risk of presumed acute-onset bacterial endophthalmitis, but there was a reduced rate of culture-positive endophthalmitis. Three months after presentation, there was no difference in VA between the groups.

To evaluate the clinical course of patients with neovascular age-related macular degeneration (nAMD) after developing endophthalmitis during their treatment with intravitreal injections.Multicenter, retrospective series.From April 2013 to October 2018, 196,598 intravitreal anti-vascular endothelial growth factor (VEGF) injections were performed, with 75 cases of endophthalmitis (incidence 0.0381%). There was no association between intravitreal anti-VEGF drug (P = 0.29), anesthetic method (P = 0.26), povidone concentration (P = 0.22), or any intraprocedure variable and endophthalmitis incidence. Seventy-two patients (96%) were treated with intravitreal tap and inject , while 3 underwent immediate pars plana vitrectomy. After endophthalmitis resolution, 17 patients (22.7%) were not re-treated for nAMD (in 10 cases due to inactive disease; follow-up, 115 ± 8.4 weeks). Patients required less frequent anti-VEGF injections after infection (7.4 ± 0.61 weeks vs. 11.5 ± 1.8 weeks; P = 0.004). Preinfection logarithm of the minimum angle of resolution visual acuity was 0.585 ± 0.053 (∼20/77). It worsened with endophthalmitis (1.67 ± 0.08, ∼20/935; P0.001) and again on postendophthalmitis treatment day 1 (1.94 ± 0.064; count fingers; P0.001), but improved after reinitiating nAMD therapy (1.02 ± 0.11; ∼20/209; P0.001). Better visual acuity on postendophthalmitis week 1 (P = 0.002) and reinitiation of nAMD treatment (P = 0.008) were associated with better final visual acuity, and streptococcal culture with worse visual acuity (P = 0.028). The postendophthalmitis treatment interval was associated with the anti-VEGF drug used (aflibercept = ranibizumabbevacizumab; P0.001).Patients with nAMD required fewer injections after endophthalmitis, suggesting a biological change in disease activity. Neovascular age-related macular degeneration became quiescent in 13.3% of eyes. Most achieved better outcomes with anti-VEGF reinitiation.

Purpose To evaluate the retinal periphery in patients with idiopathic juxtafoveal telangiectasis or macular telangiectasis type 2 (MacTel2), using widefield fluorescein angiography (WFA). Methods Single-center, retrospective, observational case series of 50 eyes of 50 patients with MacTel2 and 50 eyes of 50 age-matched controls. Results Thirty-seven eyes in the MacTel2 group (74%) showed peripheral capillary nonperfusion or dropout, compared to 37 eyes in the control group (74%, p=1.0). Morphologically, the MacTel2 group trended towards having a higher proportion of pruning-type capillary dropout (44%) compared to controls (28%), but this was not statistically significant (p=0.12). Patients with MacTel2 had a higher incidence of microaneurysms compared to controls (MacTel2 56%; Controls 42%; p=0.048), independent of age or systemic risk factors. There was no difference in the incidence of venous-venous shunts (MacTel2 10%; Controls 10%; p=1.0), arteriovenous shunts (MacTel2 14%; Controls 18%; p=0.60), venous tortuosity (MacTel2 60%; Controls 66%; p=0.58), or arterial tortuosity (MacTel2 54%; Controls 68%; p=0.20), which was mild in the majority of cases. Conclusions We note a high incidence of peripheral vascular and retinal findings in both patients with MacTel2 and age-matched controls, using WFA. Patients with MacTel2 had significantly more microaneurysms, independent of age or other systemic risk factors.Summary SUMMARY:: We note a high incidence of peripheral retinal vascular findings in both patients with macular telangiectasis type 2 and age-matched controls. Patients with MacTel2 had significantly more microaneurysms compared to controls, independent of age or other systemic risk factors.

Importance Some eyes with neovascular age-related macular degeneration (AMD) have persistent exudation despite frequent intravitreal anti–vascular endothelial growth factor (VEGF) injections. Adjuvant therapies that further reduce edema may improve vision outcomes. Objective To compare the short-term effect of topical dorzolamide-timolol vs placebo in eyes with neovascular AMD that have persistent exudation following intravitreal anti-VEGF injections. Design, Setting, and Participants Randomized placebo-controlled clinical trial with enrollment from March 1, 2017, through October 30, 2018. Multicenter trial at 4 clinical sites in the United States. Sixty-three patients with neovascular AMD who had persistent exudation despite intravitreal anti-VEGF injections at 4-week, 5-week, or 6-week intervals. Interventions Patients were randomized to use dorzolamide-timolol or artificial tears for the study duration. They continued to receive the same anti-VEGF drug at the same interval as the 2 visits before enrollment for 3 additional study visits. Main Outcomes and Measures The primary outcome measure was change in mean central subfield thickness on optical coherence tomography from baseline to visit 3 (approximately 3 months). Secondary measures included change in mean maximum subretinal fluid height, mean maximum pigment epithelial detachment height, and mean visual acuity (VA). Results This trial included 52 patients. All 27 patients (100%) assigned to dorzolamide-timolol and 23 of 25 (92%) assigned to placebo were analyzed for the primary outcome. Mean (SD) age was 78.4 (7) years, and 34 of 50 patients (68%) were women. Mean (SD) injections were 20.5 (14) (range, 4-58) before enrollment. Mean (SD) baseline logMAR VA was 0.361 (0.26) (approximate Snellen equivalent, 20/50). Comparing the dorzolamide-timolol with placebo group from baseline to visit 3, mean (SD) change in central subfield thickness (primary outcome) was −36.6 (54) μm vs 1.7 (52.3) μm (difference, 30.8; 95% CI, 0.3-61.3;P = .04); secondary outcomes: maximum PED height was −39.1 (65) μm vs 1.1 (16) μm (difference, 39.6; 95% CI, 9.6-69.6;P = .01) and change in VA from baseline to visit 3 was −2.3 (5) vs 0.3 (1) letters (difference, 2.6 letters; 95% CI, −1.9 to 7.1 letters;P = .78). Conclusions and Relevance These findings suggest use of dorzolamide-timolol in patients with neovascular AMD with persistent exudation resulted in anatomic but not visual acuity improvements compared with placebo at approximately 3 months. Additional clinical trials with longer follow-up and larger sample sizes presumably would be needed to determine the role, if any, of dorzolamide-timolol in neovascular AMD. Trial Registration ClinicalTrials.gov Identifier:NCT03034772

Purpose: The purpose of this article is to report the characteristics of patients with retinoschisis-related retinal detachments and to summarize their clinical outcomes after surgical repair. Methods: A single-center interventional case series of 37 eyes from 35 patients who underwent surgery to repair a retinoschisis-related retinal detachment between January 1, 2009 and January 1, 2017 was conducted. Results: The mean ± SD age at the time of the first retinal detachment repair was 63 ± 13 years. As the initial surgery, scleral buckle was performed in 14 eyes, scleral buckle + vitrectomy in 14 eyes, and vitrectomy in 9 eyes. The single-operation success rate for the entire cohort was 65% (24/37), and the final anatomic success rate was 97% (36/37). Among eyes requiring more than 1 surgery, 46% (6/13) developed proliferative vitreoretinopathy. Best-corrected visual acuity improved or remained stable after 1 year of follow-up in the majority (n = 27, 73%) of eyes. The mean (SD) number of surgeries required to achieve the final anatomic and visual result was 1.8 (1.2) for all eyes (range, 1-5 surgeries). Conclusion: The single-surgery success rate for retinoschisis-related retinal detachments was lower than that reported for typical rhegmatogenous retinal detachments, and the incidence of proliferative vitreoretinopathy was higher. When counseling patients with retinoschisis-related retinal detachments, it is important to caution them that they may require more than 1 surgery to achieve anatomic success.

Purpose To describe surgical outcomes and structural characteristics of intraocular lenses (IOLs) implanted with transconjunctival sutureless intrascleral (SIS) fixation in human eyes. Design Retrospective interventional surgical case series involving live and cadaveric human eyes. Methods In this study, we investigated the surgical outcomes and structural anatomy of secondary IOLs implanted with the SIS technique in human eyes. All cases involving SIS IOL fixation performed at a single academic center from January 1, 2012, through July 30, 2016, were reviewed to describe the surgical technique, common indications, clinical outcomes, and the rate of common operative complications. To investigate the structure of SIS-fixated IOLs in vivo, slit-lamp biomicroscopy, ultrasound biomicroscopy, and intraoperative endoscopy were analyzed to describe anatomical outcomes. The primary anatomical outcomes were the optic pupillary centration and location of haptic externalization. Results were correlated with cadaveric human eyes that underwent the SIS-IOL technique. Cadaveric eyes were imaged and analyzed using high-resolution photography for centration, stress measurements at the haptic-optic junction, and qualitative descriptors of IOL optic and haptic position. Results A total of 122 consecutive patients who underwent IOL placement using SIS technique were included in the study with mean follow-up of 1.52 years (range, 0.4-4.5 years). The majority (75%) of patients received a new 3-piece IOL for primary aphakia or after IOL exchange. The other patients (25%) had a dislocated 3-piece IOL that was rescued using the SIS technique. Preoperative mean Snellen visual acuity was 20/633 (logarithm of the minimum angle of resolution = 1.501). At the final visit, the mean best-corrected visual acuity was 20/83 (logarithm of the minimum angle of resolution = 0.6243) and final mean spherical equivalent was -0.57 diopters. The most common complications were vitreous hemorrhage (22% of eyes), which resolved spontaneously in most cases, and cystoid macular edema. The rates of IOL dislocation, IOL decentration, haptic erosion, IOL tilting, iris capture, and endophthalmitis were low. Intraoperative endoscopy and ultrasound biomicroscopy demonstrated a securely fixated IOL and well-centered optic without iris or ciliary body touch. Structural study of cadaveric eyes confirmed IOL optic and haptic anatomy observed during live human surgery. The ab interno haptic insertion was the anterior pars plana, away from the iris, ciliary processes and ora serrata. The degree of haptic externalization was correlated with the degree of strain on the haptic-optic junction. The angle of the haptic-optic junction in SIS-fixated IOLs (33.97°) was not significantly different compared with overlaid native nonfixated IOL (32.93°) but increased slightly with degree of haptic tip externalization (36.26 and 39.16 for 2 and 3 mm haptic externalizations, respectively). Conclusion In this comprehensive study, we demonstrate the surgical outcomes achieved with SIS fixation of IOLs. Surgical and postoperative complications do occur, albeit at a low rate, and can effectively be managed with excellent anatomical and visual outcomes. The structural and anatomical data in this study may help guide SIS placement and optimize long-term surgical results.

To investigate the efficacy of the intravitreal dexamethasone implant as the treatment for recalcitrant macular edema after successful rhegmatogenous retinal detachment repair.A retrospective review of the medical records was performed on 17 consecutive patients (17 eyes) with recalcitrant macular edema associated with rhegmatogenous retinal detachment repair who were treated with a single or multiple injections of an intravitreal dexamethasone 0.7-mg implant (Ozurdex; Allergan Inc) at two centers. Main outcomes of the study were change in logarithm of the minimum angle of resolution visual acuity, measurement of central foveal thickness, and macular cube volume as measured by spectral domain optical coherence tomography and frequency of complications.The mean age was 67 years (range, 51-78 years). All 17 patients received previous topical therapy and 12 of them had previous administration of intravitreal triamcinolone with persistence of macular edema. Baseline mean best-corrected visual acuity was 20/100 (logarithm of the minimum angle of resolution 0.75; range, 0.18-1.3 ±0.37) in the affected eyes. There was a statistically significant improvement in best-corrected visual acuity at 1 month (P0.001) and 3 months (P = 0.01). Mean baseline central foveal thickness was 505 μm, and mean macular cube volume was 10.62 mm. There was a statistically significant decrease in central foveal thickness and macular cube volume at 1 month (505-290 μm, P = 0.013 and 10.62-9.13 mm, P0.0001) and 3 months (P = 0.01). All patients developed recurrence of macular edema at 3 months, which required retreatment. The average number of implants was 4 (range, 1-14). No adverse effects such as retinal detachment or endophthalmitis occurred. Two patients experienced an increase in intraocular pressure that was controlled with topical therapy.Macular edema that occurs in eyes after successful repair of rhegmatogenous retinal detachment can be chronic and recalcitrant, and may be successfully and safely treated with the dexamethasone intravitreal implant.

Intraocular lenses (IOLs) can have inadequate support for placement in the capsular bag as a result of ocular trauma, metabolic or inherited conditions such as Marfan syndrome or pseudoexfoliation, or complicated cataract surgery. Surgical options for patients with inadequate capsular support include alternative placement of the IOL in the anterior chamber, fixation to the iris, or fixation to the sclera. The surgical techniques for each of these approaches have improved considerably over the last several decades resulting in improved visual and ocular outcomes. If no capsular or iris support exists, the surgeon can fixate an IOL to the sclera or the patient can remain aphakic. IOLs can be fixated to the sclera using sutures or by tunneling the IOL haptics into the sclera without sutures. This review summarizes the preoperative considerations, surgical techniques, outcomes, and unique complications associated with implantation of scleral-fixated IOLs.

Purpose To report the prevalence and surgical outcomes of macular holes (MHs) in eyes with age-related macular degeneration (AMD). Design Interventional, retrospective, consecutive case series. Participants Patients with MH and concurrent non-neovascular (NNV) or neovascular (NV) AMD. Methods The records of 27 912 patients diagnosed with AMD between 2009 and 2014 at Associated Retinal Consultants were reviewed. Demographic data, visual acuity (VA), funduscopic examination, and optical coherence tomography were reviewed in those with a concurrent diagnosis of MH. Main Outcome Measures The VA and MH closure status. Results A total of 15 196 patients with NNV and 12 716 patients with NV AMD were identified. A total of 199 eyes (0.7%) had MHs (160 NNV [1.1%]; 39 NV [0.3%]). Mean time to diagnosis of MH after the initial visit was 11.2 months (7.1 NNV; 24.8 NV). A total of 127 eyes underwent surgical repair (106 NNV; 21 NV). The final closure rate in those who underwent vitrectomy was 89.8% (91.5% NNV; 81.0% NV) and 25.0% in those who were observed (18.5% NNV, P P = 0.02). Preoperative logarithm of the minimum angle of resolution VAs in NNV and NV AMD was 0.8±0.4 and 0.8±0.5, respectively, and final VA was 0.6±0.5 ( P P = 0.52), respectively. Mean follow-up time was 5.0 years. Conclusions The prevalence of MH was higher in eyes with NNV AMD than in those with NV AMD. The surgical closure rate was comparable in both groups, but VA improvement reached statistical significance only in the NNV AMD group.

Purpose:With multiple anti–vascular endothelial growth factor (VEGF) and steroid therapies available for diabetic macular edema (DME), there is a need for early determination of the best treatment for a particular patient to prevent irreversible vision loss from chronic DME. In this study, we classify patients as responders or nonresponders to anti-VEGF monotherapy in the treatment of DME after a single anti-VEGF injection.Methods:The study was designed as a single-center, retrospective, interventional case series. We included patients who received 3 consecutive monthly injections with the same anti-VEGF agent. We excluded patients who were treated for DME in the preceding 3 months with any form of anti-VEGF therapy. Visual acuity and central retinal thickness (CRT) data were followed for 1 year. Receiver operating characteristic (ROC) curve analysis was performed in order to identify the cutoff values for identifying responders.Results:One hundred seven eyes were reviewed, with 40 eyes of 34 patients meeting all inclusion criteria. Based on ROC curve analysis, a reduction in CRT by >15% at 1 month identified eyes that responded to treatment and had a >25% reduction in CRT at 3 months (sensitivity, 0.75; specificity, 0.92).Conclusion:Diabetic macular edema eyes that have early response to anti-VEGF treatment by reduction in CRT will have significant response to treatment by 3 months.

Purpose: To evaluate the efficacy of a dexamethasone intravitreal implant in combination with intravitreal anti-vascular endothelial growth factor (VEGF) agents for treatment-resistant neovascular age-related macular degeneration (nvAMD). Methods: This study was designed as a single-center, retrospective interventional case series. Consecutive patients with treatment-resistant nvAMD underwent simultaneous combined injection of anti-VEGF agent and dexamethasone intravitreal implant. Eighteen patients with mean age of 81.5 years were included. Patients received an average of 26.3 anti-VEGF injections before dual therapy, with a mean follow-up of 8.2 months after dual therapy. Results: Dual therapy produced a significant mean decrease in central foveal thickness (126.3 μm), compared to a mean increase in 29.9 μm when treated with anti-VEGF monotherapy ( P = .0017). Patients also had a mean decrease in macular cube volume of −0.85 mm3 with dual therapy compared to anti-VEGF monotherapy ( P = .0014). There was a moderate correlation between the number of prior anti-VEGF injections and the magnitude of anatomic response, suggesting that shorter disease duration may positively influence response to combined treatment. Although there was a slight trend toward improved mean visual acuity after dual therapy, these differences did not reach statistical significance. Nevertheless, with combination treatment, 33% of patients gained 1 or more lines of vision. Dual therapy resulted in a significantly lower number of required anti-VEGF injections (4.25 vs 5.33) and an increase in the anti-VEGF injection-free interval to 1.41 months from 1.12 months during the 6 months following dual therapy compared to the same interval before dual therapy. Dual therapy was well tolerated; 2 eyes developed mild intraocular pressure elevation effectively managed with topical therapy and 1 patient developed worsening cataract. Conclusions: Combined treatment of anti-VEGF with dexamethasone intravitreal implant is a viable alternative for treatment-resistant nvAMD and may reduce treatment burden. Earlier treatment with dual therapy may be beneficial to maximize anatomic and visual outcomes in these patients.

Benjamin J Thomas, Yoshihiro Yonekawa, Jeremy D Wolfe, Tarek S Hassan Department of Vitreoretinal Surgery, William Beaumont Hospital, Royal Oak, MI, USA Objective: To compare the effects of intravitreal ranibizumab (RZB) or dexamethasone (DEX) intravitreal implant in cases of recalcitrant diabetic macular edema (DME).Methods: Retrospective, interventional study examining patients with symmetric bilateral, center-involved DME recalcitrant to treatment with RZB, who received DEX in one eye while the contralateral eye continued to receive RZB every 4–5 weeks for a study period of 3 months.Results: Eleven patients (22 eyes) were included: mean logarithm of the minimal angle of resolution (logMAR) visual acuity (VA) for the DEX arm improved from 0.415 (standard deviation [SD] ±0.16) to 0.261 (SD ±0.18) at final evaluation, and mean central macular thickness (CMT) improved from 461 µm (SD ±156) to 356 µm (SD ±110; net decrease: 105µm, P=0.01). Mean logMAR VA for the RZB arm improved from 0.394 (SD ±0.31) to 0.269 (SD±0.19) at final evaluation. Mean CMT improved from 421 µm (SD ±147) to 373 µm (SD ±129; net decrease: 48 µm, P=0.26).Conclusion: A subset of recalcitrant DME patients demonstrated significant CMT reduction and VA improvement after a single DEX injection. Keywords: aflibercept, bevacizumab, central macular thickness, macular edema, dexamethasone implant, diabetic macular edema, diabetic retinopathy, ranibizumab

Eric Nudleman,1 Jeremy D Wolfe,2,3 Maria A Woodward,4 Yoshihiro Yonekawa,2,3 George A Williams,2,3 Tarek S Hassan2,3 1Department of Ophthalmology, Shiley Eye Center, University of California, San Diego, La Jolla, CA, 2Beaumont Eye Institute, Oakland University William Beaumont School of Medicine, 3Associated Retinal Consultants, Royal Oak, 4Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA Purpose: Antivascular endothelial growth factor injection is the mainstay of treating neovascular age-related macular degeneration (AMD). Previous studies have shown that switching treatment from ranibizumab to aflibercept led to an improvement in eyes with recalcitrant activity. Herein, we identify a unique subset of patients whose eyes with neovascular AMD were previously well controlled with ranibizumab injections were then worsened after being switched to aflibercept. Methods: This is a retrospective interventional case series. Eyes with neovascular AMD, previously well controlled with monthly injections of ranibizumab, which then developed worsening of subretinal fluid after being switched to aflibercept were included. Results: A total of 17 eyes were included. All eyes developed increased subretinal fluid when switched from ranibizumab to aflibercept. Fourteen patients were switched back to ranibizumab after a single injection of aflibercept and had subsequent rapid resolution of subretinal fluid. Three patients continued with monthly aflibercept injections for two subsequent months and demonstrated the persistence of the increased subretinal fluid until they were switched back to treatment with ranibizumab at which time the fluid resolved. No eye had persistent decline in visual acuity. Conclusion: Switching from intravitreal ranibizumab to aflibercept in eyes with well-controlled neovascular AMD may result in worsening in a subset of patients and resolves when therapy is switched back to ranibizumab. Keywords: anti-VEGF; intravitreal injection; macula; optical coherence tomography; retina

Purpose To compare the incidence and clinical outcomes of endophthalmitis following intravitreal injections of bevacizumab, ranibizumab, and aflibercept. Design Multicenter, retrospective cohort study. Methods All included patients had received intravitreal injections of bevacizumab, ranibizumab, or aflibercept between January 1, 2009 and September 30, 2013 at 5 retina practices. Billing records were used to identify the total number of anti–vascular endothelial growth factor (VEGF) injections administered. Patients who developed endophthalmitis were ascertained from endophthalmitis logs and billing records. Chart review of these patients was performed to confirm that the endophthalmitis was related to the antecedent anti-VEGF injection. Visual outcomes, causative organisms, and clinical course were also recorded. Results A total of 503 890 anti-VEGF injections were included, from which 183 cases of presumed endophthalmitis were identified. The rate of endophthalmitis for bevacizumab was 0.039% (60/153 812), which was similar to ranibizumab 0.035% (109/309 722; P = .522) and aflibercept 0.035% (14/40 356; P = .693). Similarly, there was no difference in the rates between ranibizumab and aflibercept ( P = .960). The culture-positive rate of the vitreous/aqueous tap was 38% for both bevacizumab and ranibizumab and was 43% for aflibercept. Furthermore, visual acuity remained decreased at 3 months follow-up for bevacizumab ( P = .005), ranibizumab ( P P = .07) compared to vision at causative injection. Conclusions Endophthalmitis following intravitreal bevacizumab, ranibizumab, and aflibercept injection appears to occur at similar rates and have comparable visual outcomes. This study suggests that the choice of anti-VEGF agent should be primarily based on efficacy and patient response rather than concern for risk of infection.

BACKGROUND AND OBJECTIVE: The authors report the technique of using the 27-gauge (G) vitreous cutter through 25-G valved cannulas to allow hybrid instrumentation of both gauges. PATIENTS AND METHODS: Vitrectomy is initiated with standard placement of 25-G valved cannulas, followed by insertion of a 27-G vitreous cutter through the 25-G cannulas. RESULTS: The hybrid procedure emphasizes the advantages of both platforms: The 25-G cutter is more efficient for core vitrectomy and is more rigid to facilitate peripheral vitrectomy; the 25-G platform enjoys a wider armamentarium of instrumentation options; and the smaller profile of the 27-G cutter can be maneuvered more easily into tight surgical planes to act analogous to vertical scissors, with the added benefits of aspiration and spatula-like features. The authors illustrate this technique in three cases: diabetic tractional retinal detachment with dense plaques, posterior stage 4B retinopathy of prematurity, and sutureless scleral fixation of an intraocular lens. CONCLUSIONS: Hybrid use of the 25-G and 27-G platforms offers greater versatility for the management of complex vitreoretinal conditions. [ Ophthalmic Surg Lasers Imaging Retina . 2016;47:352–355.]

Transconjunctival sutureless intrascleral fixation is an important surgical option for secondary intraocular lens (IOL) implantation. In this report, the authors describe the technique of using a 27-gauge platform to perform pars plana vitrectomy, lensectomy, and sutureless scleral IOL fixation in a patient with crystalline lens dislocation secondary to Marfan's syndrome. Case report and detailed description of the surgical technique are discussed. [ Ophthalmic Surg Lasers Imaging Retina . 2016;47:376–379.]

BACKGROUND AND OBJECTIVE: Intravitreal corticosteroids may accelerate the normalization of macular morphology after vitrectomy and epiretinal membrane (ERM) peeling. The authors compared the visual and anatomic outcomes of eyes undergoing this procedure with the intraoperative use of the dexamethasone intravitreal implant (DEX) (Ozurdex; Allergan, Irvine, CA) versus triamcinolone acetonide (IVTA) (Triesence; Alcon, Fort Worth, TX). PATIENTS AND METHODS: Interventional, retrospective, consecutive, case-control study. RESULTS: Fifty-five participants were included (DEX = 19; IVTA = 36). Best-corrected visual acuity (BCVA) improved at 1, 2, 3, and 6 months in both the DEX ( P = .40, .45, .02, .08, respectively) and IVTA ( P < .01, = .10, < .01, < .01) arms. Similarly, central macular thickness (CMT) improved at 1, 2, 3, and 6 months in both the DEX ( P < .01, = .03, < .01, < .01) and IVTA ( P < .01, < .01, < .01, < .01) arms. There were no statistical differences between DEX and IVTA regarding BCVA and CMT. CONCLUSION: Both intraoperative DEX and IVTA, used at the completion of vitrectomy and at membrane peeling for epiretinal membrane, were effective in improving visual and anatomic outcomes, though there was a trend toward greater significance with IVTA. [ Ophthalmic Surg Lasers Imaging Retina . 2016;47:232–237.]

Purpose: To describe a technique to reduce intraocular lens (IOL) tilt after sutureless intrascleral (SIS) fixation. Methods: Case report with review of surgical technique. Results: We report a technique that can be used to correct IOL tilt that may rarely accompany SIS IOL fixation. The procedure involves placing pupil-spanning polypropylene sutures on either side of the IOL optic to keep the optic parallel to the plane of the iris. Conclusion: Sutureless intrascleral IOL tilt correction can be achieved using polypropylene suture, thus obviating the need for more invasive surgical maneuvers, such as IOL exchange.

To determine whether haptic flanging during 27-gauge sutureless intrascleral fixation of intraocular lenses (IOLs) increases IOL stability and to report the short-term clinical outcomes of sutureless intrascleral surgery using 27-gauge trocar cannulas with haptic flanging.Retrospective surgical case series using live and cadaveric human eyes.In the cadaveric experiment using five eyes, flanged haptics required more force to dislocate the IOL compared with unflanged haptics (14 ± 4 vs. 3 ± 1 g, P = 0.03). The clinical series included 52 eyes from 52 patients. The average age at the time of surgery was 73 ± 14 years, with a mean follow-up of 27 ± 19 weeks. The most common indication for surgery was IOL dislocation/subluxation (n = 43, 83%). Mean visual acuity improved from 20/140 preoperatively to 20/50 at postoperative Month 1 (P0.001). The most common postoperative issue was intraocular pressure elevation (n = 12, 23%). Two patients (4%) needed a reoperation for IOL dislocation.Haptic flanging during 27-gauge sutureless intrascleral surgery creates a more stable scleral-fixated IOL compared with the traditional unflanged technique based on a cadaveric human eye study. In addition, this variation of sutureless intrascleral surgery seems safe and effective for patients who require secondary IOLs.

Background/aims To describe the results of pars plana vitrectomy (PPV) for persistent symptomatic vitreomacular traction (VMT) with or without macular hole (MH) after intravitreal ocriplasmin injection. Methods Multicentre retrospective study of eyes that received intravitreal ocriplasmin between January 2013 and January 2014 for symptomatic VMT with or without MH, and then went on to PPV (ocriplasmin-treated group) for persistent pathology, compared with a control group of patients with symptomatic VMT with or without MH who were offered ocriplasmin injection but proceeded directly to PPV (PPV-only group). Intraoperative characteristics, visual acuity (VA) outcomes and spectral-domain optical coherence tomography images were reviewed for the two groups. Primary outcome measure was VA after PPV. Results 51 eyes of 51 patients underwent PPV after receiving ocriplasmin, and 22 eyes of 22 patients proceeded directly to PPV. Although VA was significantly better at all time points in the PPV-only compared with the ocriplasmin-treated group, at 3 and 6 months after PPV both groups had similar amount of visual improvement. Both groups had similar rates of pathology resolution; 50/51 (98%) eyes in the ocriplasmin group and 22/22 (100%) eyes in the PPV-only group had release of VMT and/or MH closure after PPV. The two groups had similar PPV-related complication rates. Conclusions Eyes with persistent symptomatic VMT and/or MH have similarly high rates of pathology resolution as well as similar VA gains regardless of whether they received ocriplasmin prior to PPV.

Purpose Induction of focal retinal detachment (RD) for subretinal delivery of stem cells and gene therapy is increasingly common. In order to determine if this procedure has an adverse impact on the retina, we use spectral-domain optical coherence tomography (SD-OCT) to evaluate the pre- and postoperative retinal anatomy of the incidentally detached normal retina surrounding large submacular hemorrhages (SMH) during surgical displacement procedures. Methods Retrospective, observational study of human subjects with monocular SMH evaluated before and after surgical displacement using clinical exam, fundus photography, and SD-OCT. Manual measurements of the inner retinal thickness (IRT), outer retinal thickness (ORT), and full retinal thickness (FRT) were made in regions involving the SMH and surrounding normal retina. Comparison of retinal thickness measurements was made using the Wilcoxon signed-rank test. Results Seven eyes were included in this study. All eyes successfully underwent surgical displacement of SMH. Visual acuity improved in 6/7 subjects and was unchanged in the remaining subject. Incidental RD of the normal retinal regions surrounding the SMH did not cause any significant change in IRT, ORT, or FRT that was detectable by SD-OCT. In contrast, mean FRT overlying regions with SMH was significantly greater before surgery compared to after displacement of SMH or normal adjacent retina. Conclusions Surgically induced focal RD does not cause detectable retinal changes in the incidentally detached normal retina surrounding large SMH. Therefore, surgical induction of focal RD should not be considered to have the same adverse impact on the retina as pathologic RD.

Purpose To derive novel insights into the pathophysiology of vancomycin-related hemorrhagic occlusive retinal vasculopathy (HORV) through a careful clinicopathologic correlation. Methods We retrospectively reviewed the clinical and pathologic course of 2 consecutive patients who developed HORV. The clinical history, multimodal imaging, ultrasound biomicroscopy (UBM), and intraoperative and histologic findings are reported. Results Both patients presented with decreased vision and eye pain within 1 week following otherwise uncomplicated cataract extraction and were diagnosed with HORV after endophthalmitis was ruled out. Both patients presented with significant ocular discomfort that progressively worsened, and both experienced a dismal visual outcome despite early aggressive medical and surgical therapy. One patient requested enucleation for a blind and painful eye. Upon histologic examination of this eye, the iris and ciliary body appeared to be infarcted with separation of the iris and ciliary epithelia from their adjacent stromal components. These findings were corroborated by UBM of the second patient. Histologic examination of the posterior segment demonstrated severe hemorrhagic necrosis of the neurosensory retina and an occlusive nonarteritic vasculopathy of the retina and choroid. The choroid was thickened by prominent nongranulomatous chronic inflammation accompanied by a glomeruloid proliferation of small vessels. The inflammatory infiltrate was almost exclusively confined to the choroid and consisted of predominantly T cells. There was conspicuous absence of inflammatory cells in the retina and no histologic evidence of leukocytoclastic vasculitis. Conclusions HORV is a rare condition that can lead to profound vision loss. Significant ocular pain can be a presenting sign of HORV in cases with severe iris and ciliary body ischemia. Although it has been suggested that HORV is a form of leukocytoclastic retinal vasculitis, the histologic findings herein indicate that the pathophysiology is more complex. It is grounded in a necrotizing retinal vasculopathy in the absence of retinal vasculitis, chronic nongranulomatous choroiditis, and an unusual glomeruloid proliferation of endothelial cells in the choroid and elsewhere in the eye.

PURPOSE To report the visual acuity outcomes after pars plana vitrectomy for delayed vitreoretinal sequelae of infectious endophthalmitis. All eyes were initially treated with intravitreal antibiotics (Abx). METHODS Multicenter, retrospective, consecutive case series. RESULTS Forty-two eyes met the study criteria. The mean follow-up was 48 weeks (SD ± 61.8). Mean interval from Abx to pars plana vitrectomy was 13 weeks (SD ± 14.3, range 2-70). Indications for pars plana vitrectomy included vitreous opacities (VO) (n = 22), epiretinal membrane (n = 9), and retinal detachment (n = 11). LogMAR visual acuity improved from 1.87 (Snellen equivalent: 20/1,482) preoperatively to 1.35 (Snellen equivalent: 20/447) at final evaluation (P < 0.001). LogMAR visual acuity improved significantly for patients with vitreous opacities (P < 0.01) and retinal detachment (P = 0.02) but not for patients with epiretinal membranes (P = 0.08). CONCLUSION Patients with infectious endophthalmitis can gain vision if they have a pars plana vitrectomy for delayed sequelae such as vitreous opacities or for retinal detachment.

Antivascular endothelial growth factor injection is the mainstay of treating neovascular age-related macular degeneration (AMD). Previous studies have shown that switching treatment from ranibizumab to aflibercept led to an improvement in eyes with recalcitrant activity. Herein, we identify a unique subset of patients whose eyes with neovascular AMD were previously well controlled with ranibizumab injections were then worsened after being switched to aflibercept.This is a retrospective interventional case series. Eyes with neovascular AMD, previously well controlled with monthly injections of ranibizumab, which then developed worsening of subretinal fluid after being switched to aflibercept were included.A total of 17 eyes were included. All eyes developed increased subretinal fluid when switched from ranibizumab to aflibercept. Fourteen patients were switched back to ranibizumab after a single injection of aflibercept and had subsequent rapid resolution of subretinal fluid. Three patients continued with monthly aflibercept injections for two subsequent months and demonstrated the persistence of the increased subretinal fluid until they were switched back to treatment with ranibizumab at which time the fluid resolved. No eye had persistent decline in visual acuity.Switching from intravitreal ranibizumab to aflibercept in eyes with well-controlled neovascular AMD may result in worsening in a subset of patients and resolves when therapy is switched back to ranibizumab.

BACKGROUND AND OBJECTIVE: Punctate inner choroidopathy (PIC) is an inflammatory chorioretinopathy characterized by multiple punctate, hypopigmented fundus lesions. Optical coherence tomography angiography (OCTA) is an emerging imaging modality that enables high-resolution visualization of the retinal and choroidal vasculature. The objective of this study is to examine the OCTA findings in PIC. PATIENTS AND METHODS: Observational, retrospective review of five patients with PIC. RESULTS: OCTA revealed several features in PIC lesions: distinctly visible choroidal neovascular membranes when present, as well as flow voids within the choroid and choriocapillaris layers that correspond with hypocyanescent lesions on indocyanine green angiography. CONCLUSION: OCTA may serve as a useful adjunctive imaging modality in diagnosing and monitoring patients with PIC. [ Ophthalmic Surg Lasers Imaging Retina . 2017;48:786–792.]

Purpose To report the clinical presentation, microbiologic spectrum, and visual outcomes associated with acute-onset infectious endophthalmitis undergoing therapeutic pars plana vitrectomy. Methods Multicenter interventional retrospective noncomparative consecutive case series. Billing records were reviewed to identify all charts for patients undergoing pars plana vitrectomy within 14 days of diagnosis of acute-onset infectious endophthalmitis over a 4-year period at 5 large tertiary referral retina practices. Statistical analysis was performed to assess for factors associated with visual outcomes. Results Seventy patients were identified. The most common clinical setting was postcataract surgery (n = 20). Only 3 patients (4.3%) presented with 20/400 or better visual acuity (VA). Although most of the patients initially underwent vitreous tap and intravitreal antibiotic injection (n = 47, 67.1%), all patients eventually underwent pars plana vitrectomy within 14 days of presentation with 68.5% (48/70) of patients undergoing pars plana vitrectomy within 48 hours of presentation. Positive intraocular cultures were obtained in 56 patients (80%). The most common identified organism was Streptococcus sp (n = 19). Visual acuity at last follow-up was 20/400 or better in 19 patients (27.1%). Three patients underwent evisceration or enucleation (4.3%). Last recorded postoperative VA (mean LogMAR 1.99 ± 0.94, Snellen VA equivalent finger count) improved from presenting VA (mean LogMAR 2.37 ± 0.38, Snellen VA hand motions) (P ≤ 0.001). There was no statistically significant correlation between the underlying etiology or the timing of surgery with this VA outcome. Conclusion Although less than one-third of patients achieved 20/400 or better VA, this VA often improved significantly from presenting VA.

Widefield photography and angiography provide access up to 200-degrees of the retinal periphery. The range of normal peripheral findings has not been characterized, yet is relevant to studies addressing putative peripheral retinal vascular pathology.This study was an observational retrospective cohort study. Adult patients with epiretinal membrane or choroidal nevi who underwent imaging with Optos 200 MA/200Tx were included. Dye transit times, peripheral arteriovenous shunting, presence of vessels crossing the horizontal raphe, right angle vessels, terminal networks, absence of capillary detail, ground glass hyperfluorescence, peripheral drusen, and microaneurysms were evaluated.Fifty-eight eyes of 31 patients met inclusion criteria. Mean peripheral arterial filling time was 8.65 ± 2.54 seconds (range 3-15 seconds). One or more peripheral anomalies were noted in all patients (P0.01). The prevalences of findings were: arteriovenous shunting (0.00%), vessels crossing the horizontal raphe (44.83%), right angle vessels (70.69%), terminal networks (77.59%), absence of capillary detail (98.28%), ground glass hyperfluorescence (87.93%), drusen (34.48%), and microaneurysms (41.38%).There was a high prevalence of peripheral vascular anatomic variations in eyes expected to have normal peripheral retinal vasculature. These findings may provide a reference for future studies addressing putative pathologic peripheral angiographic findings.

PURPOSE To evaluate the aftermarket efficacy of ocriplasmin for vitreomacular adhesion (VMA) and identify the frequency and duration of structural changes on optical coherence tomography. METHODS The authors conducted a retrospective case series of 36 eyes treated with ocriplasmin for symptomatic VMA at a single center between February 2013 and September 2013. Eyes were evaluated for release of VMA at 1 month postinjection, preinjection adhesion size, postinjection closure of macular hole, presence of subretinal fluid after release of adhesion, size of subretinal fluid, outer retinal structural change, and visual acuity at 1 month, 6 months, and 1 year. RESULTS Fifteen eyes (42%) had complete release of VMA at 1 month postinjection, and 78% of eyes had closure of the macular hole. Eyes that did not have an epiretinal membrane that had a smaller initial adhesion size and a smaller macular hole size were more likely to have complete release of VMA. Subretinal fluid was present after release in 73.3% of treated eyes, and ellipsoid zone changes were present in 66.7% of treated eyes. At the end of 1 year, complete resolution of subretinal fluid occurred in 87% of treated eyes with only trace subretinal fluid remaining in 2 eyes. Complete resolution of ellipsoid zone changes was found in all eyes. Best-corrected visual acuity improved throughout the first year after treatment. CONCLUSION Ocriplasmin is effective in the treatment of patients with symptomatic VMA. Results can be improved with patient selection based on specific criteria. Subretinal fluid and ellipsoid zone changes are common after treatment but mostly resolve over 1 year.