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The emerging literature on the novel coronavirus pandemic has reported several cases of varied retinal findings in patients with COVID-19. We report the case of a 59-year-old male who presented with complaint of bilateral blurry vision following hospital discharge after prolonged hospitalization for severe COVID-19 illness. On ocular exam, the patient demonstrated bilateral cotton wool spots localized to the posterior pole of each eye. Multimodal imaging demonstrated findings consistent with retinal nerve fiber layer infarcts in the areas of the cotton wool spots. Exam and imaging of our patient were most consistent with a Purtscher-like retinopathy. We suggest that as ophthalmologists care for increasing numbers of patients recuperating from COVID-19, they monitor for microangiopathic changes similar to those in our patient.

Purpose: This work analyzes a series of eyes with brolucizumab-associated intraocular inflammation (IOI) without retinal vasculitis reported to the American Society of Retina Specialists. Methods: The American Society of Retina Specialists Research and Safety in Therapeutics Committee analyzed clinical characteristics from submitted reports of IOI after brolucizumab. Eyes with retinal vasculitis or that received intraocular antibiotics were excluded. Results: Forty-nine eyes of 45 patients were collected. Mean visual acuity (VA) at baseline was 20/49 (range, 20/20-5/200). Patients presented with IOI a mean of 24 days (range, 3-63 days) after their most recent brolucizumab injection; 61% presented for an unscheduled visit while 39% presented at routine follow-up. Mean VA at IOI presentation was 20/67 (range, 20/20-3/200). The most common symptoms were floaters (78%) and blurry vision (76%). Pain (20%) and redness (16%) were less common; 3 (6%) eyes were asymptomatic. IOI was anterior only in 18%, posterior only in 31%, and both anterior and posterior in 51% of eyes. Treatment included topical steroids alone in 67% of eyes, whereas 10% of eyes received no treatment. Mean VA at last follow-up was 20/56 (range, 20/20-1/200). Three (6%) eyes lost 3 or more lines and 1 (2%) eye lost 6 or more lines. Conclusions: Brolucizumab-associated IOI without retinal vasculitis typically presented with a delayed onset of a few weeks. Often, VA decline was relatively mild. Most symptoms resolved and nearly all had a return-to-baseline VA, but a small percentage of patients had a significant decrease in VA at last follow-up.

Purpose This study evaluates outcomes of comparable pseudophakic rhegmatogenous retinal detachment (RRD) treated with pars plana vitrectomy (PPV) or PPV with scleral buckle (PPV-SB). Design Multicenter, retrospective, interventional cohort study. Participants Data were gathered from patients from multiple retina practices in the United States with RRD in 2015. Methods A large detailed database was generated. Pseudophakic patients with RRD managed with PPV or PPV-SB were analyzed for anatomic and visual outcomes. Eyes with proliferative vitreoretinopathy, giant retinal tears, previous invasive glaucoma surgery, and ≤90 days of follow-up were excluded from outcomes analysis. Single surgery anatomic success (SSAS) was defined as retinal attachment without ongoing tamponade and with no other RRD surgery within 90 days. Main Outcome Measures Single surgery anatomic success and final Snellen visual acuity (VA). Results A total of 1158 of 2620 eyes (44%) with primary RRD were pseudophakic. A total of 1018 eyes had greater than 90 days of follow-up. Eyes with proliferative vitreoretinopathy, previous glaucoma surgery, and giant retinal tears were excluded, leaving 893 pseudophakic eyes eligible for outcome analysis. A total of 461 (52%) were right eyes. A total of 606 patients (67%) were male, with a mean age of 65±11 years. Pars plana vitrectomy and PPV-SB as the first procedure were performed on 684 eyes (77%) and 209 eyes (23%), respectively. The mean follow-up was 388±161 days, and overall SSAS was achieved in 770 eyes (86%). Single surgery anatomic success was 84% (577/684) for PPV and 92% (193/209) for PPV-SB. The difference in SSAS between types of treatment was significant (P = 0.009). In eyes with macula-on RRD, SSAS was 88% in eyes treated with PPV and 100% in eyes treated with PPV-SB (P = 0.0088). In eyes with macula-off RRD, SSAS was 81% in eyes treated with PPV and 89% in eyes treated with PPV-SB (P = 0.029). Single surgery anatomic success was greater for PPV-SB than PPV for inferior (96% vs. 82%) and superior (90% vs. 82%) detachments. Mean final VA was similar for PPV (20/47) and PPV-SB (20/46; P = 0.805). Conclusions In pseudophakic RRDs, SSAS was better in patients treated with PPV-SB compared with PPV alone, whereas visual outcomes were similar for both groups.

Purpose To detail the methodology for a large multicenter retrospective cohort study (RCS) of primary rhegmatogenous retinal detachment (RRD) with detailed data collection and to present overall anatomic outcomes. Design This study used an RCS method. Participants All patients undergoing pars plana vitrectomy (PPV), scleral buckling (SB), and combined PPV/SB for primary RRD in 2015 from 5 large retina groups were included in the database. Methods To ensure validity of the cohort method, a large and detailed database was generated. Double data entry validation was conducted, and data audits were conducted. Anatomic and visual outcomes for all the cases in the dataset will be described but not compared, because the cases were not matched. In future studies, comparable cases of moderate-complexity RRD will be chosen naive to surgeon, surgery, and outcome for subgroup analysis. Main Outcome Measures Precision of data entry was confirmed by inter-rater reliability (IRR). Main surgical outcome for each procedure type was single-surgery anatomic success (SSAS). Results Inter-rater reliability showed significant agreement among raters (P 90 days of follow-up. Of these, 320 eyes (13.7%) underwent SB, 1200 eyes (51.4%) underwent PPV, and 815 eyes (34.9%) underwent PPV/SB. The SSAS was 84.2% for PPV, 91.2% for SB, and 90.2% for PPV/SB. Conclusions We compiled a large, accurately documented database of primary RRD cases repaired by PPV, SB, and PPV/SB from which cohort studies of moderately complex RRDs can be carried out. All 3 approaches had a high SSAS rate. Procedures chosen and their outcomes are described, but the broad case mix makes comparisons not possible until future cohort studies are completed.

Purpose Anatomically similar rhegmatogenous retinal detachments (RRDs) can be treated with scleral buckle (SB), pars plana vitrectomy (PPV), or SB combined with PPV (PPV/SB). This study compares moderately complex phakic primary RRD treated with SB, PPV, or PPV/SB to review anatomic and visual outcomes. Design Multicenter, retrospective, interventional cohort study. Participants Data were gathered on all patients from multiple retina practices in the United States with RRD in 2015 and >90 days of follow-up. The cohort of phakic patients with moderately complex RRD was analyzed. Methods A large and detailed database was generated. Eyes with findings that would bias toward PPV (vitreous hemorrhage, dense cataract, proliferative vitreoretinopathy, giant retinal tear, among others) were excluded. Age Main Outcome Measures Single surgery anatomic success (SSAS), defined as retinal attachment with no other RRD surgery within 90 days, is the main outcome measure. Final visual acuity is the secondary outcome measure. Pearson’s chi-square and analysis of variance were used to test treatment effect of surgery type on SSAS and vision. Results Single surgery anatomic success was noted in 155 of 169 SB cases (91.7%), 207 of 249 PPV cases (83.1%), and 271 of 297 PPV/SB cases (91.2%). Scleral buckle and PPV/SB were superior to PPV for SSAS (P = 0.0041). For macula-on or split cases, SB had significantly better visual outcomes than PPV or PPV/SB even after controlling for cataract (cases with minimal cataract at final follow-up or after cataract surgery) (P Conclusions For phakic moderately complex primary RRDs in this study of PPV versus SB versus PPV/SB, SB had the best visual outcomes, and PPV had the worst SSAS outcomes.

Purpose To evaluate the outcomes of after-hour encounters concerning patients referred by eye physicians to on-call retina services for emergent evaluation not seen in or referred by an emergency department. Design Retrospective study. Participants Patients seeking treatment at 3 private practice institutions over a 2-year period between 2017 and 2018. Methods A retrospective chart review was conducted comprising all patients who sought treatment emergently and after clinic hours from 3 academic nonhospital-associated retina-only private practice institutions over a 2-year period. Main Outcome Measures Patient presenting symptoms, diagnosis given at time of after-hours appointment, duration of symptoms, source of after-hours consultation (patient or provider), procedure performed at appointment, and appointments that led to surgery. Results Nine hundred eighty-seven charts were reviewed. Provider referrals accounted for 49.13% (n = 485) and patient-derived referrals accounted for 50% (n = 493) of appointments. New patients accounted for 27.6% (n = 146) of patient-derived and 85.2% (n = 413) of provider-derived referrals. The most common presenting symptoms were flashes and floaters (42.5%; n = 420), decrease in visual acuity (32.1%; n = 317), generalized eye pain (7.4%; n = 73), visual field disturbance (4.3%; n = 42), and postoperative ocular pain (3.4%; n = 34). An in-office procedure was performed at the time of examination in 18% of encounters (n = 178), with most of these being laser retinopexy. Surgery was performed within 24 hours in 18% (n = 180), within 48 hours in 20.6% (n = 203), within 72 hours in 21.7% (n = 214), and within 96 hours in 22.6% (n = 223) of the appointment. When combined with procedures, 36.2% (n = 358) of encounters led to urgent intervention within 24 hours. If a provider called about an existing patient, 37.5% of these appointments (n = 27) led to surgery versus 12.8% (n = 49) if an existing patient self-referred. If a provider called about a new patient, 31.7% of these appointments (n = 131) led to surgery versus 10% (n = 14) if a new patient self-referred. Conclusions At these 3 private practice retinal specialty clinics, 41% of after-hours appointment requests resulted in an intervention within 96 hours, and 36% of these patients underwent an intervention within 24 hours.

Purpose: To analyze a case series of retinal vasculitis reported to the American Society of Retina Specialists (ASRS) following Food and Drug Administration approval of brolucizumab for treatment of neovascular age-related macular degeneration. Methods: The ASRS Research and Safety in Therapeutics Committee analyzed clinical and imaging characteristics from submitted reports of retinal vasculitis after brolucizumab. Results: Retinal vasculitis was reported in 26 eyes of 25 patients (22 [88%] female) after treatment with brolucizumab. Imaging studies were available for 24 of 26 eyes. Most cases (92%) were associated with intraocular inflammation, which presented at a mean of 25 days (range, 3-63 days) after the most recent brolucizumab injection. Mean visual acuity (VA) was 20/52 (range, 20/25-4/200) before the adverse event, 20/151 (range, 20/25-hand motion) at presentation of the adverse event, and 20/243 (range, 20/30-light perception) at last follow-up. Twelve eyes (46%) had a greater than 3-line decrease in VA at final follow-up, and 12 eyes (46%) had a final VA of 20/200 or worse. Analysis of retinal imaging identified vasculopathy that involved retinal arteries (91%), retinal veins (79%), and choroidal vessels (48%). Occlusive disease was apparent on imaging in 83% of eyes. Treatment approaches were varied. Conclusions: Retinal vasculitis has been identified in a series of eyes following brolucizumab. Although a few eyes in this series were asymptomatic or minimally symptomatic, some eyes had significant vision loss. A careful examination for signs of active inflammation prior to brolucizumab injection is recommended. Once vasculopathy is suspected, angiographic imaging may help define the spectrum of involvement. Optimal treatment strategies remain unknown.

Purpose: This work reports long-term outcomes in macular telangiectasia type 2 (MacTel) with subretinal neovascularization (SRNV). Methods: A retrospective, single-center review of medical records was performed on all patients with a diagnosis of MacTel presenting between May 2004 and October 2019. Medical and ocular history, best-corrected visual acuity (BCVA) at baseline and final visit, optical coherence tomography data, and treatment history of SRNV secondary to MacTel were recorded. Results: A total of 471 eyes were diagnosed with MacTel. SRNV was present in 44 eyes (9.3%), of which 38 eyes met inclusion criteria for SRNV. Average follow-up duration in the SRNV group was 78.4 months. All SRNV patients underwent antivascular endothelial growth factor (anti-VEGF) therapy. There was no significant change from mean baseline (0.59 ± 0.45) to final (0.70 ± 0.49) BCVA in the SRNV group as a whole ( P = .13). Subgroup analysis revealed 17 of 38 eyes had SRNV at diagnosis and received immediate anti-VEGF treatment. In this subgroup mean pretreatment BCVA was 0.89 ± 0.43 and the mean final BCVA was 0.87 ± 0.61 ( P = .84). The remainder (21 of 38 eyes) developed SRNV during follow-up. In this subgroup, final BCVA after initiation of treatment was 0.56 ± 0.32, an improvement in BCVA from SRNV onset ( P = .04) and a decrease from pre-SRNV onset baseline BCVA ( P = .008). Conclusions: Visual acuity is maintained, not improved, in long-term follow-up of MacTel with SRNV treated with anti-VEGF. Patients presenting with SRNV have a worse prognosis than those who develop SRNV during follow-up.

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

Loeys-Dietz syndrome is a heritable disorder of the connective tissue leading to multisystem involvement including craniofacial features, skeletal abnormalities, cutaneous findings and early-onset and aggressive disease of the aorta and its branches. There are multiple types of Loeys-Dietz syndrome related to pathogenic variants in TGFBR1, TGFBR2, SMAD3, TGFB2, and TGFB3. Individuals with Loeys-Dietz syndrome may be misdiagnosed as having Marfan syndrome due to shared phenotypic features and aortic root dilation. However, ectopia lentis has been an important discriminating feature, being unique to Marfan syndrome and not reported to be associated with Loeys-Dietz syndrome. We report the case of a 46-year-old woman with Loeys-Dietz syndrome type 4 due to a pathogenic variant in TGFB2 who was diagnosed with ectopia lentis at age 44. The patient underwent whole exome sequencing and no other pathogenic variants were found to explain the ectopia lentis. Our findings indicate that ectopia lentis may be an uncommon finding in Loeys-Dietz syndrome type 4 and emphasize the importance of genetic testing in familial thoracic aortic aneurysm disease.

Purpose:This study examines treatment-based outcomes of endophthalmitis due to antivascular endothelial growth factor (anti-VEGF) intravitreal injection and its effect on subsequent management of neovascular disease.Methods:A retrospective multicenter study was conducted of 157 patients with a diagnosis of endophthalmitis following anti-VEGF intravitreal injection at 10 major ophthalmic centers.Results:The median number of injections before endophthalmitis was 10 (range, 1 to 84 injections). Initial treatment with tap and inject with or without subsequent vitrectomy trended toward smaller visual acuity changes from baseline (4 ETDRS [Early Treatment Diabetic Retinopathy Study] letter difference vs 19 ETDRS letter difference) compared with initial vitrectomy, but the difference was not statistically significant. There was no significant change in medication choice among injections after endophthalmitis. There was a statistically significant shift away from regular interval (1- to 2-month) injections and a shift toward treat-and-extend and as-needed injection algorithms.Conclusions:The visual outcomes were not significantly different between patients who initially underwent tap and injection of antibiotics and those who underwent vitrectomy. There was no significant change in medication choice before and after endophthalmitis but there was a shift toward lower-frequency injection algorithms after postintravitreal injection endophthalmitis compared with prior.

Purpose of review To review the development of hypersonic vitrectomy and present the first case series in the United States. Recent findings From 27 September 2017 to 4 December 2017, 64 patients underwent hypersonic vitrectomy with 20 patients having conventional 23-ga vitrectomy for comparison. The preoperative diagnoses ranged from vitreous opacities to rhegmatogenous retinal detachments. The results will be presented, as well as a postoperative questionnaire on the utility of hypersonic vitrectomy in a 5-center 71-patient series. Summary With the first major innovation in vitrectomy technology since the early days of pneumatic guillotine cutters, hypersonic vitrectomy has been shown to be an efficient, effective and safe alternative.

Purpose To investigate the natural history and genetic associations of drusenoid pigment epithelial detachment (DPED) associated with age-related macular degeneration (AMD). Design Retrospective analysis of a prospective cohort study. Participants Of the 4203 Age-Related Eye Disease Study 2 (AREDS2) participants, 391 eyes (325 participants) had DPED without late AMD at the time of DPED detection. Genetic analyses included 120 white AREDS2 participants and 145 Age-Related Eye Disease Study (AREDS) participants with DPED. Methods Baseline and annual stereoscopic fundus photographs were graded centrally to detect DPED, a well-defined yellow elevated mound of confluent drusen ≥433 μm in diameter, and to evaluate progression rates to late AMD: geographic atrophy (GA) and neovascular (NV)-AMD. Five single nucleotide polymorphisms (CFH [rs10611670], C3 [rs2230199], CFI [rs10033900], C2/CFB [rs114254831], ARMS2 [rs10490924]) and genetic risk score (GRS) group were investigated for association with DPED development. Kaplan–Meier analyses and multivariable proportional hazard regressions were performed. Main Outcome Measures Progression rates to late AMD and decrease of ≥3 lines in visual acuity (VA) from the time of DPED detection; association of rate of DPED development with genotype. Results Mean (standard deviation [SD]) follow-up time from DPED detection was 4.7 (0.9) years. DPED was associated with increased risk of progression to late AMD (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.98–2.82; P Conclusions This study replicates the results of previous natural history studies of eyes with DPED including the high rates of progression to late AMD and vision loss (regardless of progression to late AMD). The genetic associations are consistent with genes associated with AMD progression.

Purpose To analyze the prevalence, incidence, and clinical characteristics of eyes with geographic atrophy (GA) in age-related macular degeneration (AMD), including clinical and genetic factors affecting enlargement. Design Prospective cohort study within a controlled clinical trial. Participants Age-Related Eye Disease Study 2 (AREDS2) participants, aged 50–85 years. Methods Baseline and annual stereoscopic color fundus photographs were evaluated for GA presence and area. Analyses included GA prevalence and incidence rates, Kaplan-Meier rates, mixed-model regression, and multivariable analysis of the square root of GA, area adjusted for covariates, including clinical/imaging characteristics and genotype. Main Outcome Measures (1) Presence or development of GA; (2) change in the square root of GA area over time. Results At baseline, 517 eyes (6.2%) of 411 participants (9.8%) had pre-existing GA (without neovascular AMD), with the following characteristics: 33% central, 67% noncentral; and the following configurations: 36% small, 26% solid/unifocal, 24% multifocal, 9% horseshoe/ring, and 6% indeterminate. Of the remaining 6530 eyes at risk, 1099 eyes (17.3%) of 883 participants developed incident GA without prior neovascular disease during mean follow-up of 4.4 years. The Kaplan-Meier rate of incident GA was 19% of eyes at 5 years. In eyes with incident GA, 4-year risk of subsequent neovascular AMD was 29%. In eyes with incident noncentral GA, 4-year risk of central involvement was 57%. GA enlargement rate (following square root transformation) was similar in eyes with pre-existing GA (0.29 mm/year; 95% confidence interval 0.27–0.30) and incident GA (0.28 mm/year; 0.27–0.30). In the combined group, GA enlargement was significantly faster with noncentrality, multifocality, intermediate baseline size, and bilateral GA (P Conclusions Analyses of AREDS2 data on natural history of GA provide representative data on GA evolution and enlargement. GA enlargement, which was influenced by lesion features, was relentless, resulting in rapid central vision loss. The genetic variants associated with faster enlargement were partially distinct from those associated with risk of incident GA. These findings are relevant to further investigations of GA pathogenesis and clinical trial planning.

Acute retinal artery occlusion (RAO) is an urgent ophthalmic condition often indicative of future ischemic pathology. Patients diagnosed at an outpatient retina clinic must present to an emergency department (ED) or primary care clinic to obtain a systemic workup. We review the overall compliance and suspected delay in completing the required testing.Retrospective cohort study METHODS: Patients presenting with a symptomatic RAO from June 2009 to January 2019 at a vitreoretinal practice (The Retina Institute, St. Louis, MO) were included. Documentation of carotid vasculature and echocardiographic imaging was requested from the patient's primary care physician (PCP), cardiologist, or neurologist. Time to workup (TTW) from RAO diagnosis to receiving appropriate workup and site of workup (ED vs. outpatient setting) were recorded.One hundred forty-seven patients were included. A total of 132 (89.8%) patients were documented as having completed at least one type of cardiovascular or carotid imaging. Seventy-seven patients (52.3%) were documented to have completed both carotid and echocardiographic imaging. Following RAO diagnosis, 97 (66.0%) patients were referred to an outpatient facility while 35 (23.8%) were evaluated at an ED. Mean TTW through an ED setting vs. outpatient was 2.20 days (1.10 STDM, range 0-29) vs.13.6 days (2.23 STDM, range 0-149) respectively (p=0.003).Our study gives objective data to the delay suspected in referring patients with acute symptomatic RAO for outpatient workup. We recommend all outpatient ophthalmology and retina practices establish a relationship with a comprehensive or primary stroke center to facilitate urgent testing through an emergency department.

BACKGROUND AND OBJECTIVE: Posterior vitreous detachment (PVD) is a separation of the posterior hyaloid from the retina that manifests as photopsias and floaters. Optical coherence tomography (OCT) has demonstrated posterior vitreous opacities (PVOs) that may correlate with Shaffer's sign, which may correlate with retinal breaks. PATIENTS AND METHODS: Patients with symptomatic PVDs were retrospectively reviewed at a single institution by a single provider. Masked qualitative review of SD-OCTs by a single reviewer determined presence of PVOs. RESULTS: Among 78 patients, PVOs were found in 32 of the patients (41%), and 19 (59%) had retinal breaks. In those without PVOs, six (13%) had a break. Sensitivity and specificity were 76.0% and 75.5%, respectively. Removing patients with vitreous hemorrhages, sensitivity, and specificity of PVOs was 82.4% and 86.4%, respectively. CONCLUSION: In symptomatic PVDs, PVOs on OCT correlated with the presence of a retinal break, especially in the absence of a vitreous hemorrhage. [ Ophthalmic Surg Lasers Imaging Retina. 2020;51:628–632.]

This study evaluates outcomes of comparable pseudophakic rhegmatogenous retinal detachment (RRD) treated with pars plana vitrectomy (PPV) or PPV with scleral buckle (PPV-SB).Multicenter, retrospective, interventional cohort study.Data were gathered from patients from multiple retina practices in the United States with RRD in 2015.A large detailed database was generated. Pseudophakic patients with RRD managed with PPV or PPV-SB were analyzed for anatomic and visual outcomes. Eyes with proliferative vitreoretinopathy, giant retinal tears, previous invasive glaucoma surgery, and ≤90 days of follow-up were excluded from outcomes analysis. Single surgery anatomic success (SSAS) was defined as retinal attachment without ongoing tamponade and with no other RRD surgery within 90 days.Single surgery anatomic success and final Snellen visual acuity (VA).A total of 1158 of 2620 eyes (44%) with primary RRD were pseudophakic. A total of 1018 eyes had greater than 90 days of follow-up. Eyes with proliferative vitreoretinopathy, previous glaucoma surgery, and giant retinal tears were excluded, leaving 893 pseudophakic eyes eligible for outcome analysis. A total of 461 (52%) were right eyes. A total of 606 patients (67%) were male, with a mean age of 65±11 years. Pars plana vitrectomy and PPV-SB as the first procedure were performed on 684 eyes (77%) and 209 eyes (23%), respectively. The mean follow-up was 388±161 days, and overall SSAS was achieved in 770 eyes (86%). Single surgery anatomic success was 84% (577/684) for PPV and 92% (193/209) for PPV-SB. The difference in SSAS between types of treatment was significant (P = 0.009). In eyes with macula-on RRD, SSAS was 88% in eyes treated with PPV and 100% in eyes treated with PPV-SB (P = 0.0088). In eyes with macula-off RRD, SSAS was 81% in eyes treated with PPV and 89% in eyes treated with PPV-SB (P = 0.029). Single surgery anatomic success was greater for PPV-SB than PPV for inferior (96% vs. 82%) and superior (90% vs. 82%) detachments. Mean final VA was similar for PPV (20/47) and PPV-SB (20/46; P = 0.805).In pseudophakic RRDs, SSAS was better in patients treated with PPV-SB compared with PPV alone, whereas visual outcomes were similar for both groups.

Anatomically similar rhegmatogenous retinal detachments (RRDs) can be treated with scleral buckle (SB), pars plana vitrectomy (PPV), or SB combined with PPV (PPV/SB). This study compares moderately complex phakic primary RRD treated with SB, PPV, or PPV/SB to review anatomic and visual outcomes.Multicenter, retrospective, interventional cohort study.Data were gathered on all patients from multiple retina practices in the United States with RRD in 2015 and90 days of follow-up. The cohort of phakic patients with moderately complex RRD was analyzed.A large and detailed database was generated. Eyes with findings that would bias toward PPV (vitreous hemorrhage, dense cataract, proliferative vitreoretinopathy, giant retinal tear, among others) were excluded. Age40 years (bias toward SB) was excluded. Comparable cases of moderately complex RRD were then chosen naive to surgeon, surgery, and outcome for subgroup analysis.Single surgery anatomic success (SSAS), defined as retinal attachment with no other RRD surgery within 90 days, is the main outcome measure. Final visual acuity is the secondary outcome measure. Pearson's chi-square and analysis of variance were used to test treatment effect of surgery type on SSAS and vision.Single surgery anatomic success was noted in 155 of 169 SB cases (91.7%), 207 of 249 PPV cases (83.1%), and 271 of 297 PPV/SB cases (91.2%). Scleral buckle and PPV/SB were superior to PPV for SSAS (P = 0.0041). For macula-on or split cases, SB had significantly better visual outcomes than PPV or PPV/SB even after controlling for cataract (cases with minimal cataract at final follow-up or after cataract surgery) (P0.001).For phakic moderately complex primary RRDs in this study of PPV versus SB versus PPV/SB, SB had the best visual outcomes, and PPV had the worst SSAS outcomes.

PURPOSE: Assess systemic vascular endothelial growth factor-A (VEGF) levels after treatment with intravitreous aflibercept, bevacizumab or ranibizumab. DESIGN: Comparative-effectiveness trial with participants randomly assigned to 2-mg aflibercept, 1.25-mg bevacizumab, or 0.3-mg ranibizumab following a retreatment algorithm. PARTICIPANTS: Participants with available plasma samples (N=436) METHODS: Plasma samples were collected before injections at baseline, 4-week, 52-week and 104-week visits. In a pre-planned secondary analysis, systemic free-VEGF levels from an ELISA immunoassay were compared across anti-VEGF agents and correlated with systemic side effects. MAIN OUTCOME MEASURES: Changes in the natural log (ln) of plasma VEGF levels. RESULTS: Baseline free-VEGF levels were similar across all 3 groups. At 4 weeks, mean ln(VEGF) changes were −0.30±0.61, −0.31±0.54, −0.02±0.44 pg/ml for the aflibercept, bevacizumab, and ranibizumab groups, respectively. The adjusted differences between treatment groups (adjusted CI; P-value) were −0.01 (−0.12, +0.10; P=0.89), −0.31 (−0.44, −0.18; P

J Michael Jumper,1 Pravin U Dugel,2,3 Sanford Chen,4 Kevin J Blinder,5 John G Walt6 On behalf of the ECHO Study Group 1West Coast Retina Medical Group, San Francisco, CA, USA; 2Retinal Consultants of Arizona, Phoenix, AZ, USA; 3USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; 4Orange County Retina, Santa Ana, CA, USA; 5The Retina Institute, St Louis, MO, USA; 6Allergan plc, Irvine, CA, USA Purpose: To evaluate the efficacy, safety, and injection frequency of vascular endothelial growth factor (VEGF) antagonists in the treatment of macular edema secondary to retinal vein occlusion (RVO) in clinical practice.Patients and methods: A multicenter retrospective study of the medical records of 165 patients (95 branch RVO, 70 central RVO) treated with at least three anti-VEGF injections in the study eye was conducted. Available data collected for at least 6 months after the first injection included Snellen best-corrected visual acuity (BCVA), central retinal thickness (CRT) by time-domain optical coherence tomography (TD-OCT) or spectral-domain optical coherence tomography (SD-OCT), anti-VEGF injections, other treatments/procedures for RVO, and adverse events.Results: At baseline prior to anti-VEGF treatment, mean BCVA was 20/80 Snellen equivalent and mean CRT was 499 µm. Mean number of anti-VEGF injections received was 7.1 during the first year, 5.4 during the second year, and 5.9 during the third year; 51.3% (842/1,641) of injections were ranibizumab, 44.1% (724/1,641) were bevacizumab, and 4.6% (75/1,641) were aflibercept. One in five patients received concomitant focal laser treatment. The percentage of patients achieving both BCVA of 20/40 or better and CRT ≤250 µm on TD-OCT or ≤300 µm on SD-OCT at the same visit (primary endpoint) was 26.1% (30/115) after the first anti-VEGF injection and ranged from 20.0% (7/35) to 36.7% (11/30) after the first 16 injections. After each anti-VEGF injection from the 1st to the 16th

Purpose: To analyze the surgical and visual outcomes in patients who underwent early versus delayed vitrectomy for dense nondiabetic, nonvascular vitreous hemorrhage from undetermined cause. Methods: A retrospective, consecutive series evaluating all patients with a preoperative diagnosis of nondiabetic vitreous hemorrhage treated surgically at The Retina Institute over the past 5 years. Vitreous hemorrhage had to be described as dense, with first-order vessels not visualized on funduscopic examination. Exclusion criteria included a diagnosis of diabetes mellitus, retinal vascular disease, any prior intraocular surgery other than cataract extraction, or any previously diagnosed ocular conditions. A total of 275 patients and 286 eyes were evaluated, with 52 patients and 52 eyes meeting inclusion criteria. Surgical treatment was with standard pars plana vitrectomy. Results: Of the 52 eyes that met inclusion criteria, 32 (61.5%) were found to have at least 1 retinal break. Sixteen eyes (30.1%) had a rhegmatogenous retinal detachment. Mean time from diagnosis of the vitreous hemorrhage to surgical intervention was 15 days (range, 0-78 days). Early vitrectomy was defined as surgical intervention within 10 days of diagnosis, while late vitrectomy was defined as surgical intervention following 10 days. Of eyes that were found to have a retinal detachment, 75% were phakic and 25% were pseudophakic. Final postoperative visual acuity in the early surgery cohort was 20/66, while in the late surgery cohort was 20/89, which did not achieve statistical significance ( P = .67). Conclusion: A significant percentage of patients with retinal detachment were phakic at the time of vitreous hemorrhage (75%) as compared to pseudophakic. Data from the largest series to date indicate that in phakic patients with dense hemorrhage, the risk of retinal detachment is high and should prompt consideration for more urgent surgical intervention.

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

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

Kevin J Blinder,1 Pravin U Dugel,2,3 Sanford Chen,4 J Michael Jumper,5 John G Walt,6 David A Hollander,6 Lanita C Scott6 On behalf of the ECHO Study Group 1The Retina Institute, St Louis, MO, 2Retinal Consultants of Arizona, Phoenix, AZ, 3USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, 4Orange County Retina, Santa Ana, 5West Coast Retina Medical Group, San Francisco, 6Allergan plc, Irvine, CA, USA Purpose: To evaluate the efficacy, safety, and injection frequency of vascular endothelial growth factor (VEGF) inhibitors as used in clinical practice for the treatment of diabetic macular edema.Methods: Multicenter (10 sites), retrospective chart review in patients (n=156) who received ≥3 anti-VEGF injections. Data collected for ≥6months after the first injection included Snellen best-corrected visual acuity (BCVA) and central retinal thickness (CRT) by time-domain or spectral-domain optical coherence tomography (TD-OCT or SD-OCT).Results: Mean number of anti-VEGF injections (627 bevacizumab, 594 ranibizumab, 1 aflibercept) was 5.8 (year 1), 5.0 (year 2), and 3.4 (year 3). Percentage of patients with BCVA of 20/40 or better and CRT ≤250µm on TD-OCT or ≤300µm on SD-OCT at the same visit (primary endpoint) ranged from 16.4% to 38.9% after the first 10 injections; 51.9%–62.3% achieved ≥20/40 BCVA and 26.2%–48.0% met CRT criteria. Therapy was well tolerated with 19 treatment-related adverse events (all ocular) reported.Conclusion: Anti-VEGF injections were administered less frequently and were less effective than those in the ranibizumab registration trials. After each of the first 9 injections

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

To describe fluocinolone acetonide implant dissociations in the Multicenter Uveitis Steroid Treatment (MUST) Trial.Randomized clinical trial with extended follow-up.Review of data collected on the first implant in the eye(s) of participants. Dissociation was defined as the drug pellet no longer being affixed to the strut and categorized as spontaneous or surgically related.A total of 250 eyes (146 patients) had at least 1 implant placed. Median follow-up time after implant placement was 6 years (range 0.5-9.2 years). Thirty-four dissociations were reported in 30 participants. There were 22 spontaneous events in 22 participants; 6-year cumulative risk of a spontaneous dissociation was 4.8% (95% confidence interval [CI]: 2.4%-9.1%). The earliest event occurred 4.8 years after placement. Nine of 22 eyes with data had a decline in visual acuity ≥5 letters temporally related to the dissociation. Thirty-nine implant removal surgeries were performed, 33 with replacement. Twelve dissociations were noted during implant removal surgeries in 10 participants (26%, 95% CI 15%-48%); 5 of these eyes had a decline in visual acuity ≥5 letters after surgery. The time from implant placement to removal surgery was longer for the surgeries at which dissociated implants were identified than for those without one (5.7 vs 3.7 years, P.001). Overall, visual acuity declined 15 or more letters from pre-implant values in 22% of affected eyes; declines were frequently associated with complications of uveitis or its treatment.There is an increasing risk of dissociation of Retisert implants during follow-up; the risk is greater with removal/exchange surgeries, but the risk of both spontaneous and surgically related events increases with longevity of the implants. In 22% of affected eyes visual acuity declined by 15 letters. In the context of eyes with moderate to severe uveitis for years, this rate is not unexpected.

Purpose To review the wide variety of treatment modalities available for choroidal neovascularization secondary to the presumed ocular histoplasmosis syndrome. Methods A literature search was performed to review the multitude of studies conducted to investigate the efficacy and safety of treatment modalities available for choroidal neovascularization secondary to the presumed ocular histoplasmosis syndrome. Results Each treatment modality is reviewed, with the studies summarized and presented to support or refute the method of treatment. Two case reports are presented to demonstrate the treatment regimens. Conclusion This is a comprehensive review of the treatment modalities available to address choroidal neovascularization secondary to the presumed ocular histoplasmosis syndrome. Investigators will continue to strive toward higher efficacy and safety with future innovations in the field.

PURPOSE: Assess associations of 2-year visual acuity (VA) outcomes with VA and optical coherence tomography central subfield thickness (CST) after 12 weeks of anti-vascular endothelial growth factor treatment for diabetic macular edema in DRCR.net Protocol T. DESIGN: Randomized clinical trial. METHODS: Setting: Multicenter (89 U.S. sites). Patient Population: Eyes with VA and CST data from baseline and 12-week visits (616 of 660 eyes randomized [93.3%]). Intervention: Six monthly injections of 2.0-mg aflibercept, 1.25-mg bevacizumab, or 0.3-mg ranibizumab; subsequent injections and focal/grid laser as needed for stability. Main Outcome Measures: Change in VA from baseline and VA letter score at 2 years. RESULTS: Twelve-week VA response was associated with 2-year change in VA and 2-year VA letter score for each drug (P

Fundus autofluorescence (FAF) and widefield angiography (WFA) are relatively new imaging modalities becoming ubiquitous in many clinical practices. FAF uses the properties and distribution of retinal pigment to improve understanding of the pathophysiology of retinal diseases. Clinical applications of FAF continue to expand. It is noninvasive, and available on multiple platforms for clinicians. From monitoring progression of common diseases such as macular degeneration to evaluating drug toxicities, it has become a clinically important imaging modality in evaluating retinal disease. Similarly, fluorescein angiography has been useful in elucidating retinal vascular diseases not clearly evident by funduscopic examination alone. However, visualization of the peripheral retina with WFA has drastically improved ophthalmic providers' abilities to screen, diagnose, monitor, and treat various retinal vascular diseases. The aim of this review is to provide an overview of the role of FAF and WFA in common clinical practice, as well as limitations providers should be aware.

Purpose. To describe the clinical response of refractory macular edema associated with Coats’ disease following treatment with aflibercept and laser photocoagulation. Methods. Case report. Results. A 17-year-old female presented with decreased vision of the left eye. Ophthalmic exam demonstrated intraretinal hemorrhages and exudation with associated edema centrally. Angiographic evaluation revealed central leaking microaneurysms and peripheral capillary dropout. These findings and a systemic work-up that yielded an incidental Factor V Leiden mutation lead to a diagnosis of Coats’ disease. Initial treatment consisted of laser photocoagulation and intravitreal bevacizumab but with poor response. Switching to intravitreal aflibercept resulted in resolution of the refractory macular edema and improvement of visual acuity to 20/25 in the left eye. Conclusion. We describe a case of refractory macular edema which responded more favorably to intravitreal aflibercept compared with bevacizumab when combined with laser photocoagulation in a patient with Coats’ disease.

BACKGROUND AND OBJECTIVE: While copious data exist regarding the incidence, treatment, and prognosis of rhegmatogenous retinal detachment (RRD), fewer data exist regarding bilateral RRD. PATIENTS AND METHODS: The authors performed a retrospective review of patients with sequential bilateral rhegmatogenous retinal detachments over a 5-year period from January 1, 2009, through December 31, 2014, that were repaired at a single institution. Data were reviewed for 80 eyes of 40 patients, which is the largest series of sequential RRD reported. RESULTS: In patients with sequential RRD, the subsequently affected eyes were more likely to present with better initial visual acuity, shorter duration of symptoms, less macula-off status, and less concurrent proliferative vitreoretinopathy. The subsequent eye had better final visual acuity and was less likely to re-detach. Subsequent eyes tended to progress to RRD despite prophylactic retinopexy. CONCLUSION: The constellation of baseline characteristics in which subsequent eyes presented with better initial visual acuity, shorter duration of symptoms, less macula-detached status, and less concurrent proliferative vitreoretinopathy when compared to the initial eye correspond with the findings that subsequent eyes had more successful anatomical and better visual outcomes. [ Ophthalmic Surg Lasers Imaging Retina . 2015;46:445–449.]

BACKGROUND AND OBJECTIVE: To determine early evolution of the vitreomacular interface and clinical efficacy and safety profile after ocriplasmin treatment. PATIENTS AND METHODS: Retrospective, multicenter, observational case series. Patients with vitreomacular adhesion (VMA) confirmed on optical coherence tomography (OCT) received a single intravitreal ocriplasmin injection. Changes in the vitreomacular interface were evaluated by spectral-domain OCT. Adverse events were monitored at all visits. RESULTS: Of 22 patients treated with ocriplasmin, 14 (64%) had VMA resolution, with six (43%) achieving VMA release within the first week. Eight patients (36%) showed improvement in visual acuity (VA) of at least two Snellen lines. Rate of VMA resolution was 79% for VA less than 20/40 and 38% for VA of 20/40 or greater. Safety findings include changes in the ellipsoid layer (n = 3) and transient increases in subretinal fluid (n = 6). CONCLUSION: Ocriplasmin was effective for VMA resolution, with a rapid onset of action. Patients with worse baseline VA showed a higher VMA resolution rate. [ Ophthalmic Surg Lasers Imaging Retina. 2015;46:209–216.]

The optimal management approach to retinal arterial macroaneurysms (RAM) is unknown. This paper compares long-term outcomes in RAM treated with laser therapy versus observation. This is an IRB-approved retrospective study of patients with symptomatic RAM. Charts of patients with a diagnosis of RAM causing symptomatic visual loss were reviewed. Patients with less than 6 months follow up, other confounding diagnoses, or additional therapy beyond thermal laser were excluded. Statistical analysis was done using χ2 or Student’s t test as appropriate. Forty-eight patients with RAM were identified and 27 were included in the study (13 treated, 14 observed). Mean visual acuity in the observation group improved from 20/120 to 20/96 (p = 0.53) compared to 20/280 to 20/54 (p = 0.0003) in the treated group. Subgroup analysis showed that visual acuity in primarily hemorrhagic lesions treated with laser therapy improved by 1.21 logMAR compared to a loss of 0.11 logMAR (p = 0.002) in those that were observed. In primarily exudative lesions, both treated and observed lesions showed an improvement of 0.32 logMAR. No patients in the treatment group had a final visual acuity below 20/200 compared to four in the observation group. Treatment with direct laser photocoagulation was associated in this study with greater improvement in visual acuity and may decrease the risk of severe visual loss especially in primarily hemorrhagic RAM lesions. Compared to observation alone.

BACKGROUND AND OBJECTIVE: To evaluate the efficacy of ranibizumab in the treatment of choroidal neovascularization secondary to presumed ocular histoplasmosis syndrome. PATIENTS AND METHODS: Patients enrolled in the ranibizumab group received a monthly intravitreal injection of 0.5 mg of ranibizumab. Patients in the photodynamic therapy (PDT) group received a quarterly dosing of intravenous verteporfin coupled with PDT. RESULTS: Mean change in ETDRS visual acuity at 1 year was 19.6 letters in the ranibizumab group versus 21 letters in the PDT group. All patients in the PDT group required rescue ranibizumab therapy. Four of five patients (80%) in the ranibizumab group and one of two patients (50%) in the PDT group showed a greater than 15 letter gain at 1 year. CONCLUSION: Ranibizumab appears to be a safe and effective treatment option for choroidal neovascularization secondary to the presumed ocular histoplasmosis syndrome.

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

Purpose To assess anatomic and visual outcomes of ocriplasmin use for symptomatic vitreomacular adhesion (VMA). Design Retrospective chart review. Methods Macula Society members were surveyed online to collect data on ocriplasmin for symptomatic VMA. Clinical and optical coherence tomography data were collected using standardized data entry forms. Results There were 208 patients (208 eyes) with symptomatic VMA followed at least 3 weeks after receiving ocriplasmin. At baseline, VMA was focal (

The internal limiting membrane represents the structural interface between the retina and the vitreous and has been postulated to serve several essential functions. Recently, internal limiting membrane peeling has been used in the treatment of a variety of retinal disorders. We review the history, techniques, rationale, and outcomes of internal limiting membrane peeling.A review of the literature.Internal limiting membrane peeling has been used to successfully treat a variety of retinal disorders including macular hole, epiretinal membrane, diabetic macular edema, retinal vein occlusion, and others.Internal limiting membrane peeling may serve as an important component in the armamentarium of retinal surgery.

Objective To compare pars plana vitrectomy (PPV) with PPV and scleral buckle (PPV/SB) for repair of rhegmatogenous retinal detachment (RRD). Design A retrospective chart review. Participants Patients who underwent PPV or PPV/SB for RRD repair at a single institution. Methods A retrospective chart review of patients in two different treatment groups and analysis of the anatomic and functional results. Results Single-surgery anatomic success was achieved in 31 of 37 (83.8%) phakic eyes that underwent PPV and in 66 of 68 (97.1%) phakic eyes that underwent PPV/SB ( p = 0.0216). Among pseudophakic eyes, 42 of 48 (87.5%) in the PPV group and 62 of 66 (93.9%) in the PPV/SB group achieved single-surgery reattachment ( p = 0.3175). Visual acuity improvement was marginally greater in the PPV group among phakic ( p = 0.4898) and pseudophakic ( p = 0.2465) eyes. Conclusions PPV/SB may be associated with a decreased risk for retinal redetachment when compared to PPV for repair of phakic RRD. In pseudophakic eyes, the anatomic success rate between the two techniques appears to be similar.

BACKGROUND AND OBJECTIVE: To report the effect of intravitreal bevacizumab on visual acuity and central retinal thickness (CRT) in refractory diabetic macular edema. PATIENTS AND METHODS: Records of 60 eyes of 54 consecutive patients who underwent intravitreal bevacizumab therapy for refractory diabetic macular edema were reviewed. All eyes received intravitreal bevacizumab 1.25 mg/0.05 mL, and 36 eyes underwent pretreatment and post-treatment optical coherence tomography. Mean follow-up was 7.4 months. RESULTS: Pretreatment mean visual acuity plus or minus standard deviation was 0.71 ± 0.28 logarithm of the minimum angle of resolution (LogMAR) Snellen letters. At final follow-up, mean visual acuity had improved to 0.66 ± 0.30 LogMAR ( P = .0543). Mean baseline CRT was 440 ± 106 µm, and follow-up mean CRT was 386 ± 129 µm ( P = .008). Vitrectomized eyes had worse visual acuity and CRT outcomes ( P = .002 and P = .028, respectively) compared with nonvitrectomized eyes. CONCLUSION: Intravitreal bevacizumab may provide a functional and anatomic benefit in eyes with persistent diabetic macular edema despite previous treatments. [Ophthalmic Surg Lasers Imaging 2010;41:323–329.]

Importance Prevalence of persistent central-involved diabetic macular edema (DME) through 24 weeks of anti–vascular endothelial growth factor therapy and its longer-term outcomes may be relevant to treatment. Objective To assess outcomes of DME persisting at least 24 weeks after randomization to treatment with 2.0-mg aflibercept, 1.25-mg bevacizumab, or 0.3-mg ranibizumab. Design, Setting, and Participants Post hoc analyses of a clinical trial, the DRCR.net Protocol T among 546 of 660 participants (82.7%) meeting inclusion criteria for this investigation. Interventions Six monthly intravitreous anti–vascular endothelial growth factor injections (unless success after 3 to 5 injections); subsequent injections or focal/grid laser as needed per protocol to achieve stability. Main Outcomes and Measures Persistent DME through 24 weeks, probability of chronic persistent DME through 2 years, and at least 10-letter (≥ 2-line) gain or loss of visual acuity. Results The mean age of participants was 60 years, 363 (66.5%) were white, and 251 (46.0%) were women. Persistent DME through 24 weeks was more frequent with bevacizumab (118 of 180 [65.6%]) than aflibercept (60 of 190 [31.6%]) or ranibizumab (73 of 176 [41.5%]) (aflibercept vs bevacizumab,P Conclusions and Relevance Persistent DME was more likely with bevacizumab than with aflibercept or ranibizumab. Among eyes with persistent DME, eyes assigned to bevacizumab were more likely to have chronic persistent DME than eyes assigned to aflibercept. These results suggest meaningful gains in vision with little risk of vision loss, regardless of anti–vascular endothelial growth factor agent given or persistence of DME through 2 years. Caution is warranted when considering switching therapies for persistent DME following 3 or more injections; improvements could be owing to continued treatment rather than switching therapies. Trial Registration clinicaltrials.gov Identifier:NCT01627249

Neovascular age-related macular degeneration is responsible for the overwhelming majority of vision loss in age-related macular degeneration. Not too long ago, the disease was poorly controlled with few treatment options. Today, angiogenesis is the central focus in the pathogenesis of this disease, with VEGF identified as a major mediator of this process. These advances have opened the door for targeted anti-VEGF therapy, leading to significant improvements in visual outcomes for a majority of patients. There is, however, a portion of the population that responds poorly to initial treatment with little explanation as to why this occurs. Combination therapies are now being investigated to tackle anti-VEGF monotherapy nonresponders.

Purpose: To report the outcome for eyes treated with intravitreal injection of bevacizumab combined with verteporfin photodynamic therapy (PDT) for choroidal neovascularization (CNV) in age-related macular degeneration (AMD). Study Design and Participants: Interventional, consecutive, retrospective case series including 40 eyes of 40 patients with newly diagnosed juxtafoveal or subfoveal CNV secondary to AMD. Methods: The charts of patients treated with a 1.25-mg intravitreal injection of bevacizumab followed by PDT within a 2-week period were reviewed. Main outcome measures were visual acuity stabilization (defined as no change or a gain in visual acuity) and need for retreatment. Results: Thirty-three (83%) of 40 eyes had stabilization of visual acuity. Mean improvement in visual acuity was 1.73 lines. Twenty-six eyes (65%) required only a single intravitreal injection of bevacizumab combined with PDT. Of the 23 eyes with 12 months of follow-up, 17 (74%) had stabilization of visual acuity, while 9 (40%) had improvement in visual acuity (mean, 1.22 Snellen lines). Eleven eyes (48%) required only a single combined treatment for CNV resolution at the 12-month follow-up. Fifteen (88%) of 17 eyes with only 6 months of follow-up required only a single combined treatment. There were no complications such as endophthalmitis, uveitis, or ocular hypertension. Conclusion: These findings suggest that eyes treated with both intravitreal injection of bevacizumab and PDT require none to a minimal number of re-treatments to have stabilization of vision, even at 12 months of follow-up. Further investigation with large controlled trials is warranted to outline the appropriate treatment paradigm for combination therapy.

Objective To assess the efficacy and safety of intravitreal aflibercept injection in the treatment of CNV secondary to presumed ocular histoplasmosis syndrome (POHS). Purpose To assess safety of intravitreal aflibercept for the treatment of CNV secondary to presumed ocular histoplasmosis syndrome. Methods Masked, open-label, prospective study. Five subjects will receive 2.0 mg aflibercept injection every 8 weeks with 3 initial monthly doses over a 12 month period. Results No adverse systemic or ocular were reported. At month six, the mean visual acuity improved by 7.8 ETDRS letters, mean central subfoveal thickness decreased by 38.8 microns and mean OCT volume decreased by 0.076 mm3 . At month twelve, the mean visual acuity improved by12.4 ETDRS letters, mean central subfoveal thickness decreased by 34.6 microns and mean OCT volume decreased by 0.576 mm3. Conclusion The use of intravitreal 2.0 mg aflibercept injection for the treatment of CNV secondary to presumed ocular histoplasmosis syndrome yielded no systemic or ocular adverse events and produced improvement in visual acuity and reduction of OCT thickness and volume.

BACKGROUND AND OBJECTIVE: To study the relationship between early response to intravitreal aflibercept injection (IAI) for neovascular age-related macular degeneration (nAMD) and long-term visual outcomes PATIENTS AND METHODS: Seventeen patients with nAMD participated in this prospective clinical trial. All patients received three initial monthly IAIs, followed by IAIs at 8-week intervals. Study visits were scheduled at 1 week, followed by every 2 weeks for the first 3 months and then every 4 weeks until the conclusion of the study at 48 weeks. RESULTS: Eight eyes (47%) were dry on spectral-domain optical coherence tomography by week 2 (early responders), and the remaining nine eyes took an average of 7.5 weeks for fluid resolution (late responders). The mean change in best-corrected visual acuity (BCVA) at the final visit was +11.9 letters from baseline ( P = .002). Average BCVA gain in early responders was +11.6 letters compared to +12.2 letters in late responders ( P = .7). CONCLUSIONS: Although there was not a statistically significant correlation between early response to IAI and better long-term outcomes, both early and late responders maintained excellent visual outcomes at 48 weeks. [ Ophthalmic Surg Lasers Imaging Retina . 2015;46:1021–1027.]