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Purpose:This article describes the clinical and multimodal imaging characteristics of subthreshold exudative choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD).Methods:Among 3773 patients with AMD, 8 eyes (6 patients) were identified with the clinical phenotype of interest. Dilated fundus examinations, color fundus photography, fluorescein angiography (FA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), and OCT angiography (OCTA) were performed.Results:OCT typically showed a moderately reflective irregular pigment epithelial detachment with overlying subretinal fluid (SRF). Traditional FA did not show leakage and ICGA showed no definitive neovascular network or hot spots. However, OCTA clearly demonstrated a CNV within the pigment epithelial detachment. The majority of our cases (7 of 8) did not receive antivascular endothelial growth factor (anti-VEGF) injections, and visual acuity remained stable over the available follow-up period of 1 to 10 years.Conclusions:CNV is often associated with SRF and vision loss in AMD, usually requiring frequent anti-VEGF injections. OCTA allowed us to better identify CNV not readily detected on FA and ICGA. Although some have suggested early clinical intervention with anti-VEGF injections in any case with fluid and confirmed CNV on OCTA, we describe a subset of AMD patients with SRF who may be better managed by observation. These cases may represent a more indolent, mature, and stable vascular network.

Objective To examine early performance on an eye surgery simulator and its relationship to subsequent live surgical performance in a single large residency program. Design Retrospective study. Setting Massachusetts Eye and Ear, Harvard Medical School, Department of Ophthalmology. Methods In a retrospective study, we compared performance of 30 first-year ophthalmology residents on an eye surgery simulator to their surgical skills as third-year residents. Variables collected from the eye surgery simulator included scores on the following modules of the simulator (Eyesi, VRmagic, Mannheim, Germany): antitremor training level 1, bimanual training level 1, capsulorhexis level 1 (configured), forceps training level 1, and navigation training level 1. Subsequent surgical performance was assessed using the total number of phacoemulsification cataract surgery cases for each resident, as well as the number performed as surgeon during residency and scores on global rating assessment of skills in intraocular surgery (GRASIS) scales during the third year of residency. Spearman correlation coefficients were calculated between each of the simulator performance and subsequent surgical performance variables. We also compared variables in a small group of residents who needed extra help in learning cataract surgery to the other residents in the study. Main Outcome Measures Relationships between Eyesi scores early in residency and surgical performance measures in the final year of residency. Results A total of 30 residents had Eyesi data from their first year of residency and had already graduated so that all subsequent surgical performance data were available. There was a significant correlation between capsulorhexis task score on the simulator and total surgeries (r = 0.745, p = 0.008). There was a significant correlation between antitremor training level 1 (r = 0.554, p = 0.040), and forceps training level 1 (r = 0.622, p = 0.023) with primary surgery numbers. There was a significant correlation between forceps training level 1 (r = 0.811, p = 0.002), and navigation training level 1 (r = 0.692, p = 0.013) with total GRASIS score. There was a significant inverse correlation between total GRASIS score and residents in need of extra help (r = −0.358, p = 0.003). Conclusion Module scores on an eye surgery simulator early in residency may predict a resident׳s future performance in the operating room. These scores may allow early identification of residents in need of supplemental training in cataract surgery.

Objective To test the applicability of existing retinopathy of prematurity (ROP) guidelines on Iranian patients and to develop novel ROP screening criteria in Iran. Methods Both eyes of 1932 infants born ≤37 weeks of gestation and/or weighting ≤3000 g were included in this prospective cohort study that was conducted across nine neonatal intensive care units and a tertiary eye hospital ROP clinic. The patients were examined for ROP and the need for treatment (type 1 ROP or worse). All the patients were screened 4 weeks after birth or at 31 weeks of postmenstrual age, whichever was later. The patients were followed until retinal vascularisation was completed or the patients reached 50 weeks of gestational age (GA) without prethreshold ROP. A receiver operating characteristic curve was used to determine the best screening criteria for ROP. Screening criteria from other countries were applied to our patient data to determine their ability to appropriately detect ROP. Main outcome measure Patients with ROP requiring treatment. Results The mean GA±SD and birth weight (BW)±SD of the screened patients were 32±2.7 weeks and 1713±516 g, respectively. Using criteria of GA≤32 weeks or BW ≤2000 yielded sensitivity and specificity of 100% and 26.7%, respectively, for treatment requiring ROP regardless of clinical comorbidities. Using screening recommendations of American Academy of Pediatrics would miss 25.4% of ROP and 8.4%ROP requiring treatment in our cohort. Conclusions Other countries screening recommendations would result in a significant amount of missed cases of treatment requiring ROP when applied to Iran. As a result, we have proposed new guidelines for premature babies in Iran.

OBJECTIVES To evaluate the impact of a comprehensive cataract surgery curriculum on the incidence of intraoperative complications. DESIGN We retrospectively compared the total number of cataract surgeries that the residents performed in all of the teaching sites, and the incidences of intraoperative complications (anterior capsule tear, posterior capsule rent, vitreous loss, anterior vitrectomy, zonular dialysis, iris trauma, hemorrhage, dropped lens fragment, corneal wound burn, incorrect intraocular lens) for the surgeries performed at Massachusetts Eye & Ear by residents in the pre-intervention group (residents graduating in 2004 and 2005), before the implementation of a surgical curriculum, and the residents in the post-intervention group (residents graduating in 2014 and 2015). SETTING Ophthalmology residency program at a major academic institution. PARTICIPANTS Residents graduating in 2004, 2005, 2014, and 2015. RESULTS We reviewed 4373 charts. 2086 of those surgeries were performed at Massachusetts Eye & Ear. The incidence of posterior capsule rent/vitreous loss/anterior vitrectomy was lower in the post-intervention group (1.4% versus 7.7%, p CONCLUSIONS Implementation of a comprehensive cataract surgery curriculum focusing on pre-operative, intra-operative and post-operative interventions, with an emphasis on patient outcomes resulted in a decrease in the rate of intraoperative complications.

Objective To design and implement a teaching skills curriculum that addressed the needs of an ophthalmology residency training program, to assess the effect of the curriculum, and to present important lessons learned. Design A teaching skills curriculum was designed for the Harvard Medical School (HMS) Residency Training Program in Ophthalmology. Results of a needs assessment survey were used to guide curriculum objectives. Overall, 3 teaching workshops were conducted between October 2012 and March 2013 that addressed areas of need, including procedural teaching. A postcurriculum survey was used to assess the effect of the curriculum. Setting Massachusetts Eye and Ear Infirmary, a tertiary care institution in Boston, MA. Participants Overall, 24 residents in the HMS Residency Training Program in Ophthalmology were included. Results The needs assessment survey demonstrated that although most residents anticipated that teaching would be important in their future career, only one-third had prior formal training in teaching. All residents reported they found the teaching workshops to be either very or extremely useful. All residents reported they would like further training in teaching, with most residents requesting additional training in best procedural teaching practices for future sessions. Conclusions The pilot year of the resident-as-teacher curriculum for the HMS Residency Training Program in Ophthalmology demonstrated a need for this curriculum and was perceived as beneficial by the residents, who reported increased comfort in their teaching skills after attending the workshops.

Purpose: To report a well-characterized Waldenstrom's macroglobulinemia (WM) case that provides insight into the mechanisms of two paraneoplastic complications -- cancer-associated retinopathy (CAR) and small fiber polyneuropathy (SFPN).Methods: Retrospective medical chart review.Results: A 58-year old man with WM developed vision loss and bilateral lower extremity pain. CAR was diagnosed by history, a depressed electroretinogram (ERG) and positive anti-retinal antibodies. SFPN diagnosis was based on abnormal autonomic nerve function testing and a distal-leg skin biopsy that demonstrated absent epidermal small-fiber innervation, IgM and complement deposition and microvasculopathy. Plasma exchange (PLEX) led to dramatic pain relief and subjective improvement in eye symptoms along with improvement of some ERG parameters. Repeat skin biopsy after treatment showed less microvascular abnormalities and decreased complement deposition.Conclusions: The concurrence of CAR and SFPN in this patient suggest t...

Purpose To evaluate the effect of a computer-based training program—Massachusetts Eye & Ear ROP Trainer—on residents' knowledge of retinopathy of prematurity (ROP) management. Methods In this prospective, randomized study, ophthalmology residents from nine different training programs consented to participate. Those who completed the study were randomly assigned to either the Trainer or the control group. The ROP Trainer was created using clinical cases encompassing the stages of ROP in digital pictures and videos. It includes sections on screening decisions, examination techniques, and diagnosis, and a reference section with the expert video clips and a searchable image library. Subjects in the control group were asked to study standard print material on ROP. A pre- and post-test, consisting of theoretical and practical (diagnosis) questions, and a post-intervention satisfaction test were administered. Accuracy of ROP diagnosis was assessed. Results A total of 180 residents agreed to participate, of whom 60 completed the study. Residents in the Trainer group had statistically significant improvements (P = 0.003) in ROP knowledge and diagnostic ability (P = 0.005). Residents randomized to the Trainer group were more satisfied with the training materials than were those in the control group. There was no significant difference in improving knowledge by year of training, sex, or country. Considering all training levels, a statistically significant increase was observed in sensitivity for the diagnosis of preplus or worse, zone I or II, ROP stage, category, and aggressive posterior ROP in the Trainer group. Conclusions In this study, the Trainer was shown to significantly improve ROP knowledge and diagnostic skills of residents, regardless of sex, year, of training, or country.

355 We recently developed a prototype online program for training residents and fellows about retinopathy of prematurity (ROP). We were motivated by the lack of adequate training in this important area.[1‐5] Since ROP is a rapidly progressive disease that can result in blindness, adequate and efficient knowledge regarding ROP should be expected of retina and pediatric ophthalmology fellows and at least available to all ophthalmology residents.[1‐5] Although for teaching purposes it might be best for all training in ROP to take place in the NICU, this is not practical because of constraints in time and resources as well as the safety of affected infants. Fortunately, high quality wide‐angle images of the fundus can now be readily obtained for teaching and telemedicine. In the course of development of our program, it became clear that significant variability still exists among ROP practitioners in grading fundus photographs of infants with ROP. This has been previously discussed among experts.[6‐9] In addition, we realized that the most recent International Classification of ROP[10] does not fully reflect current thought, and that follow‐up schedules recommended in the latest consensus paper[11] do not fully take newly described features of the disease into account. Plus disease is defined as retinal vascular dilation and tortuosity. A standard photograph illustrating plus disease has been used for diagnosis since a consensus agreement for the CRYO‐ROP study in 1988.[12] Recognition of plus disease is critical because ROP diagnosis and treatment guidelines are now dependent on the presence or absence of this finding.[13] Thus, it has important implications for clinical care, development of computer‐based image analysis methods, and also telemedicine systems. Unfortunately, significant subjectivity in determination of plus disease remains a problem.[6,7,9,14,15] Using standard dilated ophthalmoscopy, disagreement was found in 12% of cases regarding a diagnosis of threshold disease in a report based on the CRYO‐ROP and LIGHT‐ROP studies.[14] Using image‐based diagnosis for identification Need for Refinement of International Retinopathy of Prematurity Guidelines and Classifications

Objective Evaluate the effectiveness of an interactive cognitive computer simulation for teaching the hydrodissection portion of cataract surgery compared with standard teaching and to assess the attitudes of residents about the teaching tools and their perceived confidence in the knowledge gained after using the tools. Design Case-control study. Participants and Controls Residents at academic institutions. Methods Prospective, multicenter, single-masked, controlled trial was performed in 7 academic departments of ophthalmology (Harvard Medical School/Massachusetts Eye and Ear Infirmary, University of Iowa, Emory University, University of Cincinnati, University of Pennsylvania/Scheie Eye Institute, Jefferson Medical College of Thomas Jefferson University/Wills Eye Institute, and the Aravind Eye Institute). All residents from these centers were asked to participate and were randomized into 2 groups. Group A (n = 30) served as the control and received traditional teaching materials; group B (n = 38) received a digital video disc of the Virtual Mentor program. This program is an interactive cognitive simulation, specifically designed to separate cognitive aspects (such as decision making and error recognition) from the motor aspects. Both groups took online anonymous pretests (n = 68) and posttests (n = 58), and answered satisfaction questionnaires (n = 53). Wilcoxon tests were completed to compare pretest and posttest scores between groups. Analysis of variance was performed to assess differences in mean scores between groups. Main Outcome Measures Scores on pretests, posttests, and satisfaction questionnaires. Results There was no difference in the pretest scores between the 2 groups ( P = 0.62). However, group B (Virtual Mentor [VM]) scored significantly higher on the posttest ( P = 0.01). Mean difference between pretest and posttest scores were significantly better in the VM group than in the traditional learning group ( P = 0.04). Questionnaire revealed that the VM program was "more fun" to use (24.1% vs 4.2%) and residents were more likely to use this type of program again compared with the likelihood of using the traditional tools (58.6% vs 4.2%). Conclusions The VM, a cognitive computer simulation, augmented teaching of the hydrodissection step of phacoemulsification surgery compared with traditional teaching alone. The program was more enjoyable and more likely to be used repetitively by ophthalmology residents. Financial Disclosure(s) Proprietary or commercial disclosures may be found after the references.

Purpose: To assess the feasibility of extraction of a chronically implanted subretinal electrode array. Methods: Inactive, polyimide strips (10 mm × 1.5 mm × 15 μm) were surgically implanted into the subretinal space of 8 rabbits using a mostly ab externo approach. Pre- and postoperative clinical examinations, electroretinography and in some cases optical coherence tomography were performed to follow the course of the eyes. Two months after implantation, the polyimide strips were extracted from 5 eyes; 2 animals kept the implants and served as controls. All animals were then sacrificed and eyes enucleated for histological examination. Results: All 8 surgeries yielded successful placement of the arrays into the subretinal space. All 5 extraction surgeries were performed without obvious complications. Clinical examinations and electroretinography did not reveal any significant abnormalities. The histological examinations showed alterations from normal anatomy in all animals; the anatomical changes in the explanted animals were relatively mild and confined to the area of the surgery. Conclusions: Successful extraction of electrode arrays from the subretinal space of rabbits can be reliably performed 2 months after implantation, which is beyond the time period when postoperative scarring would be most intense.

Two patients who developed decreased visual acuity after several months of ethambutol treatment for Mycobacterium avium-intracellulare infection had bitemporal visual field defects that suggested optic chiasm damage. Multifocal electroretinography (mfERG) disclosed markedly low-amplitude responses at fixation and in the regions corresponding to the visual field defects. These results suggested that the visual dysfunction might be entirely attributable to retinal rather than optic nerve toxicity. These are the first reported patients to show mfERG abnormalities that correspond to bitemporal visual field defects and add to the growing evidence that ethambutol damages the retina.

Purpose To review presenting characteristics, clinical course, and long-term visual and anatomic outcomes of patients with traumatic macular holes at a tertiary referral center. Design Retrospective case series. Methods Twenty-eight consecutive patients with traumatic macular holes at a single tertiary referral center were reviewed. In addition to visual acuities and treatments throughout the clinical course, specific dimensions of the macular hole, including diameters, height, configuration, shape, and the presence of a cuff of fluid, were examined using spectral-domain optical coherence tomography (OCT). Results Twenty-eight patients were identified with a mean initial visual acuity (VA) of logMAR 1.3 (20/400) and a mean follow-up of 2.2 years. Eleven holes (39.3%) closed spontaneously in median 5.7 weeks. Eleven underwent vitrectomy with a median time to intervention of 35.1 weeks. Median time to surgery for the 5 eyes with successful hole closure was 11.0 weeks vs 56.3 weeks for the 6 eyes that failed to close ( P = .02). VA improved in closed holes ( P P P = .04), but VA did not improve in holes that did not close ( P = .22). There was no relation between initial OCT dimensions and final hole closure status, although there was a trend, which did not reach statistical significance, toward small dimensions for those that closed spontaneously. Conclusions A fairly high spontaneous closure rate was observed, with a trend toward smaller OCT dimensions. We found no relationship between hole closure and the OCT characteristics of the hole. Surgical intervention was less successful at hole closure when elected after 3 months.

Purpose To report successful treatment of exogenous Fusarium and Aspergillus endophthalmitis with new antifungal agents. Design Interventional case report. Methods Treatment of two cases is reviewed. Results A 64-year-old man developed post-cataract Fusarium moniliforme endophthalmitis. Infection persisted despite removal of the intraocular lens, three vitrectomies, and five intravitreal injections of amphotericin. Inflammation resolved and vision improved from 20/80 to 20/40 on 6 months of oral voriconazole. A 55-year-old man developed post-cataract intraocular inflammation. After three vitrectomies and removal of the intraocular lens, Aspergillus fumigatus endophthalmitis was diagnosed. Intravitreal amphotericin and systemic voriconazole were given, but one week later there were early signs of recurrence. Intravenous caspofungin was added and the eye improved. Caspofungin was continued for 6 weeks and voriconazole for 6 months. Vision improved from counting fingers to 20/80 at 6 months and 20/25 at 23 months. Conclusion Voriconazole is a promising new therapy for Fusarium and Aspergillus endophthalmitis. Caspofungin may act synergistically with voriconazole in treating Aspergillus endophthalmitis.

Objective Although cataract surgery is one of the most commonly performed surgeries in the country, it is a microsurgical procedure that is difficult to learn and to teach. This study aims to assess the effectiveness of a new method for introducing postgraduate year (PGY)-3 ophthalmology residents to cataract surgery. Setting Hospital-based ophthalmology residency program. Design Retrospective cohort study. Participants PGY-3 and PGY-4 residents of the Harvard Medical School Ophthalmology Residency from graduating years 2010 to 2012. Results In July 2009, a new method of teaching PGY-3 ophthalmology residents cataract surgery was introduced, which was termed "the stepwise introduction to cataract surgery." This curriculum aimed to train residents to perform steps of cataract surgery by deliberately practicing each of the steps of surgery under a structured curriculum with faculty feedback. Assessment methods included surveys administered to the PGY-4 residents who graduated before the implementation of these measures ( n = 7), the residents who participated in the first and second years of the new curriculum ( n = 16), faculty who teach PGY-4 residents cataract surgery ( n = 8), and review of resident Accreditation Council for Graduate Medical Education surgical logs. Resident survey response rate was 100%. Residents who participated in the new curriculum performed more of each step of cataract surgery in the operating room, spent more time practicing each step of cataract surgery on a cataract surgery simulator during the PGY-3 year, and performed more primary cataract surgeries during the PGY-3 year than those who did not. Faculty survey response rate was 63%. Faculty noted an increase in resident preparedness following implementation of the new curriculum. There was no statistical difference between the precurriculum and postcurriculum groups in the percentage turnover of cataracts for the first 2 cataract surgery rotations of the PGY-4 year of training. Conclusions The introduction of cataract surgery to PGY-3 residents in an organized, stepwise manner improved resident preparedness for the PGY-4 year of residency. This surgical teaching method can be easily applied to other surgical specialties.

To explore the visual and anatomic outcomes of patients with refractory or recurrent neovascular age-related macular degeneration (AMD) who were converted from bevacizumab and/or ranibizumab to aflibercept.Two-center, retrospective chart review.Treatment history, visual acuity (VA), and central macular thickness (CMT) on spectral-domain optical coherence tomography were collected. Patients were divided into "refractory" (persistent exudation despite monthly injections) or "recurrent" (exudation suppressed, but requiring frequent injections).One hundred and two eyes of 94 patients were included; 68 were refractory and 34 were recurrent. Eyes received a mean of 20.4 prior bevacizumab/ranibizumab injections and a mean of 3.8 aflibercept injections. Mean follow-up was 18 weeks. Mean VA was 20/50-1 before conversion, 20/50-2 after 1 aflibercept injection (P = .723), and 20/50+2 after the final injection (P = .253). Subgroup analysis of refractory and recurrent cases also showed stable VA. Of the refractory cases, mean CMT had improved after 1 injection (P.001) and the final injection (P.001). Intraretinal (P .001) and subretinal (P.001) fluid decreased after 1 injection, and the mean injection interval was extended from 5.2 to 6.2 weeks (P = .003). Of the recurrent cases, mean CMT improved after 1 injection (P .001) and the final injection (P.001). Intraretinal (P = .003) and subretinal (P = .046) fluid decreased after 1 injection, and the mean injection interval was extended from 7.2 to 9.5 weeks (P = .001).Converting patients with chronic neovascular AMD to aflibercept results in stabilized vision and improved anatomic outcomes, while allowing injection intervals to be extended.

Birdshot chorioretinopathy (BSCR) is a rare form of posterior uveitis in which hypopigmented choroidal lesions are scattered throughout the posterior pole. In order to avoid the poor natural history of BSCR, many practitioners would argue that it is critical to diagnose and carefully monitor the often subtle activity of this disease; BSCR can progress insidiously in a white and painless eye, and treatment algorithms based on visual acuity, vitreous inflammation, and retinal vascular leakage of fluorescein alone have been ineffective. This article reviews the various modalities that can be used to diagnose and monitor BSCR, including the clinical and ophthalmoscopic features, diagnostic criteria, electroretinography (ERG--full field, multifocal, and pattern), fluorescein angiography (FA), indocyanine green (ICG) angiography, optical coherence tomography (OCT), fundus autofluorescence (AF), visual fields, HLA A29 testing, and other laboratory testing. HLA-A29 testing can be useful in diagnostically borderline cases, but a positive test is not as useful as one might think in cases where the clinical suspicion for BSCR is low. Out of all the testing modalities, the ERG has been studied most extensively in its relationship to successful treatment. The key parameter is the 30 Hz flicker implicit time, which is abnormal in 70% of patients at baseline. A normal implicit time is correlated with the chance that a patient can be successfully tapered from systemic immunomodulatory therapy without recurrence. Alternatively, some practitioners use ICG angiography or visual field testing for adjunctive monitoring. OCT is used most commonly to follow macular edema. While there is no consensus on how to best monitor disease activity, our institution uses serial ERGs as an adjunct to the normal exam.

The Virtual Mentor Cataract Surgery Trainer is a computer based, cognitive simulation of phacoemulsification cataract surgery. It is designed to teach the steps of the surgery, common errors, and ways to rectify these errors. We interviewed phaco experts, and edited video of the interviews into brief clips for use as just in time feedback to learners, and as answers to Help and Reference questions. Our database includes over 100 edited expert video clips. Combining information from expert interviews with our own observations, we created the overall architecture for the simulation, including action options, questions, and appropriate expert stories for each step of the procedure. We wrote pathways and scenarios for the capsulorhexis and nucleus removal modules. We wrote questions and answers for Help and Reference sections for these modules. We created over 400 3D animations for steps and complications of the capsulorhexis and nucleus removal modules. Although not part of our statement of work, we were able to leverage our funding with additional resources. We were therefore able to complete a clear corneal incision module and revise the capsulorhexis module to include new material. We created new animations for the capsulorhexis moduel in order to have a consistent style for all animations. The value of this teaching method has been validated in a study that has been accepted in a peer reviewed journal.

Leber congenital amaurosis (LCA) is a congenital retinal dystrophy that was first described almost 150 years ago. LCA still remains an important cause of blindness with about 20% of children in schools for the blind being affected by it. LCA has genetic heterogeneity and the study of this disease is elucidating the genetics and molecular interactions involved in the development of the retina. This paper reviews the clinical history of the disease since it was first described. We further discuss the differential diagnosis of the disease and the difficulties encountered in making the diagnosis. We also review the genetics of the disease and the role of future therapies.

Diseases of the retina and optic nerve are common causes of irreversible blind- ness. Given the lack of effective treatments, several laboratories are utilizing micro- electronic technology to develop either a cortical or retinal prosthesis. Each strategy offers certain advantages, but both face numerous and formidable challenges. Conse- quently, a clinically useful device of either type is still conceptual. The technological means to build prostheses are available but the ultimate obstacle is the integration of the technology with the brain. This review primarily focuses on our efforts to develop a retinal prosthesis. In particular we address the two problems that we believe to be most challenging: 1) need to demonstrate that retinal stimulation can produce “useful” vision in a blind patient, and 2) need to demonstrate long-term biocomopatibility of an implanted device in an animal.

Objectives: To describe the clinical, perimetric, and electroretinographic (ERG) results of 4 patients with cone dysfunction following irofulven treatment including the histopathologic and immunocytochemical features of one patient’s retinas. Design: Observational case series. Methods: The patients were examined clinically, including perimetric and ERG evaluations. Eyes from patient 1 and healthy postmortem eyes were processed for histopathologic and immunocytochemistry studies with antibodies specific for cones, rods, and reactive Muller cells. Main Outcome Measures: Clinical signs and symptoms, perimetry, ERG, retinal histopathologic and immunocytochemistry study results. Results: All 4 patients had ERG changes consistent with abnormal cone responses and relatively normal rod responses. Compared with control eyes, the retina of patient 1 had approximately half the normal numbers of macular cones and fewer peripheral cones. The number of rods were normal but all rod and cone outer segments were shortened. Conclusion: High-dose irofulven treatment causes conespecific damage with relative sparing of rods. Arch Ophthalmol. 2005;123:29-34

Purpose To investigate the incidence of and reasons for voluntary resident attrition from ophthalmology training programs. Design Retrospective survey. Methods A survey was mailed to residency program directors of the 121 Accreditation Council for Graduate Medical Education–accredited ophthalmology residency programs asking them to report the number of residents who withdrew from training during 2001 to 2002 and the reasons for withdrawal. Results Of 102 responding programs, 13 (12.7%) had one resident withdraw from training in the academic year 2001 to 2002. These 13 residents represented 1.1% of all ophthalmology residents in training at the responding institutions during that academic year. The most frequent reason for withdrawing was to enter another medical specialty. Conclusions Voluntary resident attrition from ophthalmology training programs is uncommon. The 1.1% attrition rate in this study is the lowest among published reports of attrition from other specialties.

PURPOSE This work is part of a feasibility assessment of a retinal prosthesis as a means to restore vision to patients with blindness caused by retinitis pigmentosa. The primary goal was to assess the concordance of the form of induced perception and the pattern of electrical stimulation of the retina, and the reproducibility of the responses. METHODS Five volunteers with severe retinitis pigmentosa and one with normal vision were studied. A companion paper in this issue provides details on demographics, visual function, surgical methods, general stimulation strategy, and data analysis. Volunteers were awake during surgery while a 10-microm-thick, microfabricated electrode array was placed on the retina. The array was connected to extraocular current sources that delivered charges to 50-, 100-, and 400-microm-diameter electrodes. Negative control trials were randomly included. Perceptual quality was judged by the similarity between the form of stimulation and perception (i.e., accuracy) and the reproducibility of responses. RESULTS Only 1 of 40 control tests yielded a false-positive result. On average, volunteers 3, 5, and 6 reported percepts that matched the stimulation pattern 48% and 32% of the time for single- and multiple-electrode trials, respectively. Two-point discrimination in the best cases may have been achieved in two blind subjects using (center-to-center) electrode separation of 600 and 1960 microm. Reproducibility was achieved 66% of the time in the blind subjects. By comparison, in the normal-sighted subject, perceptual form was reported accurately 57% of the time, with 82% reproducibility, and two-point discrimination may have been achieved in one trial with 620-microm electrode spacing and in two trials each with 1860- and 2480-microm electrode spacing. In subjects 5 and 6, perceptual size was inconsistently related to the charge, although relatively large differences in charge (median: 0.55 microcoulombs [microC]) between two trials produced differently sized percepts. Longer stimuli did not produce rounder percepts. CONCLUSIONS Single percepts induced by single-electrode stimulation were relatively small, but the form of percepts, especially after multielectrode stimulation, often did not match the stimulation pattern, even in a normal-sighted volunteer. Reproducible percepts were more easily generated than those that matched the stimulation pattern.

PURPOSE. To report methods for performing epiretinal electrical stimulation with microfabricated electrode arrays and determining perceptual thresholds on awake human volunteers during acute surgical trials. METHODS. Four hypotheses were tested: (1) epiretinal stimulation can be performed during acute experiments without obviously damaging the retina or degrading vision or the health of the eye; (2) perception can be obtained 50% of the time in blind patients with charge densities below published safety limits; (3) the minimal charge needed to induce perception would be higher in patients with more severe retinal degeneration; and (4) threshold charge would be lower at shorter stimulus durations. Five subjects with severe blindness from retinitis pigmentosa and one with normal vision (who underwent enucleation of the eye because of orbital cancer) were studied. Electrical stimulation of the retina was performed on awake volunteers by placing a single 250-m diameter handheld needle electrode or a 10-m thick microfabricated array of iridium oxide electrodes (400-, 100-, or 50-m diameter) on the retina. Current sources outside the eye delivered charge to the electrodes. Assessment of damage was made by observing the clinical appearance of the eyes, comparing pre- and postoperative visual acuity, obtaining retinal histology in one case, and comparing perceptual thresholds with published safety limits. RESULTS. No clinically visible damage to the eye or loss of vision occurred. Even at sites removed from stimulation, histology revealed swollen photoreceptor inner and outer segments, which were believed to be nonspecific findings. Percepts could not be reliably elicited with 50-m diameter electrodes using safe charges in one blind patient. With the two larger electrodes, only the normal-sighted patient had thresholds at charge densities below 0.25 and 1.0 millicoulombs (mC)/cm 2 for 400- and 100-m diameter electrodes, respectively, which is one seemingly reasonable estimate of safety derived from the product of charge per phase and charge density per phase. In blind patients, thresholds always exceeded these levels, although most were close to these limits in patient 6. The range of charge density thresholds with the 400-m electrode in blind patients was 0.28 to 2.8 mC/cm 2 . The normal-sighted patient had a threshold of 0.08 mC/cm 2 with a 400-m electrode, roughly one quarter of the lowest threshold in the blind patients. Strength‐ duration curves obtained in two blind patients revealed the lowest threshold charge at the 0.25- or 1.0-ms stimulus duration. CONCLUSIONS. Threshold charge densities in severely blind patients were substantially higher than that in a normal-sighted patient. Charge densities in blind patients always exceeded one seemingly reasonable estimate of safe stimulation. The potential adversity of long-term stimulation of the retina by a prosthesis has yet to be determined. (Invest Ophthalmol Vis Sci. 2003;44:5355‐5361) DOI:10.1167/iovs.02-0819

Purpose. To determine whether electroretinogram results can help predict the success in tapering of immunosuppressive medication in patients with birdshot retinochoroidopathy. Methods. Fifteen patients with birdshot retinochoroidopathy who had at least three serial electroretinograms (ERG) during the course of their disease were included in the study. Charts of patients seen at the Immunology and Uveitis Service at the Massachusetts Eye and Ear Infirmary, Boston, Massachusetts were retrospectively reviewed. Seven parameters of the ERGs were examined: dim scotopic amplitude, bright scotopic amplitude, bright scotopic implicit time, single-flash photopic amplitude, single-flash photopic implicit time, 30 Hz flicker amplitudes, and 30 Hz flicker implicit times. For each parameter the patients were divided into two groups, those with normal and those with abnormal responses at the time their immunosuppressive medication taper was initiated. The percentage of patients in each group who were able to successfully taper their immunosuppressive medication was calculated. A successful taper of medication was defined as no recurrence of disease signs or symptoms for at least 1 year after the medication was terminated. Results. Abnormalities in the bright scotopic response amplitudes and 30 Hz flicker implicit times were associated with recurrence of inflammation as immunosuppressive therapy was tapered. Conclusion. ERG can serve as a useful adjunct in helping determine when to initiate tapering of immunosuppressive therapy in patients with birdshot retinochoroidopathy.

Purpose To characterize the morphology of outer retinal holes caused by solar maculopathy, using spectral-domain optical coherence tomography (SD-OCT). Design This study is an observational case series. Methods The SD-OCT findings of 3 patients (6 eyes) with chronic solar maculopathy are presented. Results SD-OCT demonstrates a characteristic appearance of partial-thickness hole(s) in the outer retina at the fovea. In 3 of 6 eyes, there is 1 hole directly beneath the umbo. In the remaining 3 eyes, there are multifocal holes spread across the fovea. Holes in more restricted layers, as had been previously reported with time-domain OCT, were not seen. In addition, advanced visualization of SD-OCT data demonstrates a hyperreflective ring around the outer retinal hole. Conclusions SD-OCT can be used diagnose solar maculopathy. In patients with central scotomas, characteristic outer retinal hole(s) without inner retinal cystic changes may prompt the clinician to uncover an undisclosed history of sungazing. Similar OCT findings can be caused by welder's maculopathy, tamoxifen retinopathy, juxtafoveal macular telangiectasia, foveolar vitreomacular traction, or, rarely, a closed macular hole, achromatopsia, alkyl nitrite abuse, acute retinal pigment epitheliitis, or Stargardt disease.

PURPOSE. To assess the application of optical frequency domain imaging (OFDI) at 1050 nm for the detection of choroidal neovascularization (CNV) in age-related macular degeneration (AMD) and its response to treatment. Three patients presenting with blurred vision and exudative AMD were imaged before and after anti-VEGF treatment with ranibizumab. METHODS. The patients were imaged with OFDI, a swept-source-based, high-speed optical coherence tomography (OCT) system developed at the Wellman Center for Photomedicine. A center wavelength of 1050 nm was used that has been demonstrated to provide better imaging of the deeper structures of the retina below the RPE, such as the choroidal vasculature. Three-dimensional data sets were acquired in 2 to 4 seconds. RESULTS. En face images were compiled from cross-sectional OFDI data and correlated with color fundus photography (CF) and fluorescein angiograms (FAs). Cross-sectional images were coregistered with CF and FA to obtain depth-resolved information about CNV, CNV volume, retinal thickness, subretinal fluid volume and height of neurosensory detachment before and after treatment with ranibizumab. A band of reduced reflectivity below the RPE was identified in all three subjects that corresponded to areas of confirmed and suspected occult CNV on FA. After treatment, this band was reduced in volume in all patients. CONCLUSIONS. High-speed 3-D OFDI at 1050 nm is a promising technology for imaging the retina and choroid in neovascular AMD. The developed system at 1050 nm provides good contrast for occult (type 1) CNV and may have advantages compared with time domain and current state of the art spectral domain OCT systems (SD-OCT) at 850 nm. Copyright © Association for Research in Vision and Ophthalmology.

PURPOSE. To assess the biocompatibility of materials for possible use in subretinal prostheses. METHODS. Strips (0.5 5 mm; 10-m thick) of either plain poly(imide) or poly(imide) coated with amorphous aluminum oxide (AAO), amorphous carbon (AC), parylene, poly(vinyl pyrrolidone) (PVP), or poly(ethylene glycol) (PEG) were each implanted into the subretinal space of four Yucatan miniature pigs. Two types of control surgery without implantation were performed in four other animals. Electroretinograms (ERGs) were performed before and after surgery. All animals were euthanatized 3 months after surgery, and histologic slides of the retina were assessed for 15 criteria. Paired, two-tailed Student’s t-tests were used for statistical analyses. RESULTS. Across all animals, the mean amplitude of the ERG b-wave did not differ from baseline after 3 months. In implanted animals, the histologic analyses revealed that (1) all the implanted materials produced abnormalities that were significantly greater than in the control subjects; (2) overall, PEG, parylene, and PVP produced less histologic disruption than the other three materials; (3) parylene and PEG did not differ significantly from the control in disturbing retinal anatomy; (4) only PI and AAO produced RPE alterations that were significantly greater than in control subjects; and (5) AAO and PI produced a significantly greater degree of peri-implant cellular responses than did the other materials. CONCLUSIONS. All implants produced some alteration of the retina, but there were clear differences among the materials in the degree to which their presence disturbed the normal anatomy of the retina or RPE or incited tissue reactions around the implant. (Invest Ophthalmol Vis Sci. 2006;47:3514 –3522)

To determine predictors of choroidal neovascularization (CNV) and visual outcome after traumatic choroidal rupture.A retrospective review of patients with traumatic choroidal rupture diagnosed in the Retina Service, Massachusetts Eye and Ear Infirmary, Boston, between January 1993 and August 2001 was performed. Parametric and nonparametric statistical methods were used to evaluate visual prognosis, CNV, and retinal detachment after traumatic choroidal rupture.One hundred eleven cases were identified and reviewed. Visual acuity (VA) changes were recorded in all of the cases. Thirty-eight (34%) of the 111 patients recovered driving vision (VAor =20/40). Rupture location was recorded in 107 cases. Recovery of driving vision was seen in 20 (59%) of 34 eyes with peripheral choroidal ruptures, 17 (22%) of 73 eyes with macular choroidal ruptures, 38 (38%) of 99 eyes without CNV, 1 (8%) of 12 eyes with CNV, 38 (40%) of 96 eyes without retinal detachment, and 1 (7%) of 15 eyes with retinal detachment. Older age and location of rupture within the arcades were positively associated with CNV formation (P = .04 and .03, respectively). Foveal location of rupture, multiple ruptures, and poor baseline VA were associated with failure to recover driving vision in univariate regression analyses. In multivariate analysis, rupture location and baseline VA were independently associated with visual outcome. Of 12 patients diagnosed with CNV, 5 were not treated, 4 were treated with argon laser photocoagulation, 1 was treated with surgery, 1 was treated with argon laser photocoagulation followed by surgery, and 1 was treated with verteporfin photodynamic therapy.Most patients with traumatic choroidal rupture do not achieve final VA of 20/40 or better. Poor visual outcome was most highly associated with a macular rupture and baseline VA of less than 20/40. The formation of CNV was most strongly associated with older age and macular choroidal rupture.