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Objective: To characterize geographic atrophy (GA) and evaluate differences between Asians and non-Asians., Design: Multicenter, retrospective case series., Participants: Subjects aged ≥ 50 years with GA secondary to age-related macular degeneration in the absence of neovascularization in the study eye and follow-up of ≥ 2 years., Methods: The GA lesion characterized at baseline and last follow-up based on multimodal imaging (fundus autofluorescence [FAF], near infrared [NIR], and spectral domain-OCT). Patients were grouped as either Asian or non-Asian., Main Outcome Measures: Comparison of (1) phenotypes of GA lesions (size, foveal involvement, number of foci, drusen background, and choroid background) and (2) growth rates of GA., Results: A total of 144 patients (169 eyes) with distribution of 50.9% Asians and 49.1% non-Asians. The age and sex were similar between Asians and non-Asians (Asians: mean age, 77.2 ± 10.1 years, 47.9% female; non-Asians: mean age, 79.7 ± 8.4 years, 58.7% female). Asians exhibited thicker choroids (167 ± 74 versus [vs.] 134 ± 56 μm; P < 0.01) and lower prevalence of drusen (40.7% vs. 66.3%; P < 0.01). At baseline, the GA area was smaller in Asians vs. non-Asians (NIR, 3.7 ± 4.6 vs. 6.3 ± 6.8 mm 2 ; P = 0.01: FAF, 2.4 ± 3.4 vs. 8.4 ± 9.6 mm 2 ; P < 0.01). Asians had fewer GA foci (1.7 ± 1.3 vs. 2.7 ± 2.2; P < 0.01) compared to non-Asians. The proportion with diffused or banded FAF junctional zone pattern was similar between Asians and non-Asians (44.2% vs. 60.2%; P = 0.20). Asians had a slower GA lesion growth rate than non-Asians (NIR, 0.7 vs. 1.9 mm 2 /year; P < 0.01: FAF, 0.3 vs. 2.0 mm 2 /year; P < 0.01: NIR, 0.2 vs. 0.4 mm/year; P < 0.01 square root transformed: FAF, 0.1 vs. 0.3 mm/year; P < 0.01 square root transformed). The factors associated with GA lesion growth rate are (from the highest effect size) ethnicity, junctional zone FAF pattern, baseline GA area, and number of GA foci. Higher GA lesion growth rate was observed in both Asian and non-Asian subgroups, with drusen or lesion size and FAF patterns meeting inclusion criteria of recent therapeutic trials, but growth rate remained significantly slower in Asians. Eyes with baseline lesion ≥ 5 mm 2 showed the highest growth rate, and the difference between ethnicities was no longer significant (2.6 vs. 3.3 mm 2 /year; P = 0.14)., Conclusions: There are differences in GA lesion phenotype, associated features, and growth rate between Asians and non-Asian subjects., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright © 2022 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

There have been recent advances in basic research and clinical studies in polypoidal choroidal vasculopathy (PCV). A recent, large-scale, population-based study found systemic factors, such as male gender and smoking, were associated with PCV, and a recent systematic review reported plasma C-reactive protein, a systemic biomarker, was associated with PCV. Growing evidence points to an association between pachydrusen, recently proposed extracellular deposits associated with the thick choroid, and the risk of development of PCV. Many recent studies on diagnosis of PCV have focused on applying criteria from noninvasive multimodal retinal imaging without requirement of indocyanine green angiography. There have been attempts to develop deep learning models, a recent subset of artificial intelligence, for detecting PCV from different types of retinal imaging modality. Some of these deep learning models were found to have high performance when they were trained and tested on color retinal images with corresponding images from optical coherence tomography. The treatment of PCV is either a combination therapy using verteporfin photodynamic therapy and anti-vascular endothelial growth factor (VEGF), or anti-VEGF monotherapy, often used with a treat-and-extend regimen. New anti-VEGF agents may provide more durable treatment with similar efficacy, compared with existing anti-VEGF agents. It is not known if they can induce greater closure of polypoidal lesions, in which case, combination therapy may still be a mainstay. Recent evidence supports long-term follow-up of patients with PCV after treatment for early detection of recurrence, particularly in patients with incomplete closure of polypoidal lesions., (Copyright © 2023 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.)

Purpose: This study was designed to demonstrate the safety and feasibility of episcleral brachytherapy (ESB) for the treatment of anti-vascular endothelial growth factor (anti-VEGF) resistant neovascular age-related macular degeneration (nAMD) in a 6-subject cohort adjunct to anti-VEGF therapy., Methods: Six eyes of six subjects with anti-VEGF resistant nAMD (persistent fluid or hemorrhage despite frequent anti-VEGF treatment) were treated with ESB between May 2018 and July 2018 as part of a larger early feasibility trial. Baseline and follow-up exams with multi-modal imaging were conducted., Results: In this analysis, six eyes were included. The mean age was 74.7 years; 33% were female; 67% had polypoidal choroidal vasculopathy. The mean number of lifetime anti-VEGF injections received prior to the study enrollment was 33.9 injections and 10 injections in the year prior to the study enrollment. In the first and second years following ESB, the mean number of injections was 8.5 and 8, respectively. No evidence of radiation-induced toxicity through 2 years following ESB was observed. The mean baseline VA was 55.3 letters. At 1 year, the mean VA increased by 3.2 letters and 1.7 letters at year 2. At 2 years, the mean change in vascular complex on ICGA was - 18%, - 43% on OCTA, and - 5% on FA. The subjects also experienced a mean decrease in CRT on OCT of 21% after 2 years., Conclusions: The results from this six-subject cohort with 2-year data support additional investigations of ESB for nAMD, specifically those with persistent disease activity and treatment resistant nAMD., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular AMD (nAMD) that accounts for a significant proportion of nAMD cases worldwide, and particularly in Asia. Contemporary PCV treatment strategies have closely followed those used in typical nAMD, though there are significant gaps in knowledge on PCV management and it remains unclear if these strategies are appropriate. Current clinical trial data suggest intravitreal anti-vascular endothelial growth factor (VEGF) therapy alone or in combination with photodynamic therapy is effective in managing haemorrhage and exudation in PCV, although the optimal treatment interval, including as-needed and treat-and-extend approaches, is unclear. Newer imaging modalities, including OCT angiography and high-resolution spectral domain OCT have enabled characterisation of unique PCV biomarkers that may provide guidance on how and when treatment and re-treatment should be initiated. Treatment burden for PCV is a major focus of future therapeutic research and several newly developed anti-VEGF agents, including brolucizumab, faricimab, and new modes of drug delivery like the port delivery system, offer hope for dramatically reduced treatment burden for PCV patients. Beyond anti-VEGF therapy, recent developments in our understanding of PCV pathophysiology, in particular the role of choroidal anatomy and lipid mediators in PCV pathogenesis, offer new treatment avenues that may become clinically relevant in the future. This article explores the current management of PCV and more recent approaches to PCV treatment based on an improved understanding of this unique disease process., (© 2021. The Author(s).)

Purpose: To develop and validate OCT and color fundus photography (CFP) criteria in differentiating polypoidal choroidal vasculopathy (PCV) from typical neovascular age-related macular degeneration (nAMD) in eyes with suboptimal response to anti-vascular endothelial growth factor (VEGF) monotherapy and to determine whether OCT alone can be used to guide photodynamic therapy (PDT) treatment., Design: Clinical study evaluating diagnostic accuracy., Participants: Patients with nAMD who received 3-month anti-VEGF monotherapy but had persistent activity defined as subretinal fluid or intraretinal fluid at month 3 assessments., Methods: In phase 1, international retina experts evaluated OCT and CFP of eyes with nAMD to identify the presence or absence of features due to PCV. The performance of individual and combinations of these features were compared with ICGA. In phase 2, these criteria were applied to an independent image set to assess generalizability. In a separate exercise, retinal experts drew proposed PDT treatment spots using only OCT and near-infrared (NIR) images in eyes with PCV and persistent activity. The location and size of proposed spot were compared with ICGA to determine the extent of coverage of polypoidal lesions (PLs) and branching neovascular network (BNN)., Main Outcome Measures: Sensitivity and specificity of CFP and OCT criteria to differentiate PCV from nAMD and accuracy of coverage of OCT-guided PDT compared with ICGA., Results: In eyes with persistent activity, the combination of 3 non-ICGA-based criteria (sharp-peaked pigment epithelial detachment [PED], subretinal pigment epithelium [RPE] ring-like lesion, and orange nodule) to detect PCV showed good agreement compared with ICGA, with an area under the receiver operating characteristic curve of 0.85. Validation using both an independent image set and assessors achieved an accuracy of 0.77. Compared with ICGA, the OCT-guided PDT treatment spot covered 100% of PL and 90% of the BNN., Conclusions: In nAMD eyes with persistent activity, OCT and CFP can differentiate PCV from typical nAMD, which may allow the option of adjunct PDT treatment. Furthermore, OCT alone can be used to plan adjunct PDT treatment without the need for ICGA, with consistent and complete coverage of PL., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To develop consensus terminology in the setting of polypoidal choroidal vasculopathy (PCV) and to develop and validate a set of diagnostic criteria not requiring indocyanine green angiography (ICGA) for differentiating PCV from typical neovascular age-related macular degeneration (nAMD) based on a combination of OCT and color fundus photography findings., Design: Evaluation of diagnostic test results., Participants: Panel of retina specialists., Methods: As part of the Asia-Pacific Ocular Imaging Society, an international group of experts surveyed and discussed the published literature regarding the current nomenclature and lesion components for PCV, and proposed an updated consensus nomenclature that reflects our latest understanding based on imaging and histologic reports. The workgroup evaluated a set of diagnostic features based on OCT images and color fundus photographs for PCV that may distinguish it from typical nAMD and assessed the performance of individual and combinations of these non-ICGA features, aiming to propose a new set of diagnostic criteria that does not require the use of ICGA. The final recommendation was validated in 80 eyes from 2 additional cohorts., Main Outcome Measures: Consensus nomenclature system for PCV lesion components and non-ICGA-based criteria to differentiate PCV from typical nAMD., Results: The workgroup recommended the terms polypoidal lesion and branching neovascular network for the 2 key lesion components in PCV. For the diagnosis of PCV, the combination of 3 OCT-based major criteria (sub-retinal pigment epithelium [RPE] ring-like lesion, en face OCT complex RPE elevation, and sharp-peaked PED) achieved an area under the receiver operating characteristic curve of 0.90. Validation of this new scheme in a separate subset 80 eyes achieved an accuracy of 82%., Conclusions: We propose updated terminology for PCV lesion components that better reflects the nature of these lesions and is based on international consensus. A set of practical diagnostic criteria applied easily to spectral-domain OCT results can be used for diagnosing PCV with high accuracy in clinical settings in which ICGA is not performed routinely., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the effectiveness of three consecutive intravitreal injections of bevacizumab (Avastin) and ranibizumab (Lucentis) in patients with treatment-naïve neovascular age-related macular degeneration., Methods: This is a retrospective comparative study of qualifying consecutively treated patients (n = 176) with new-onset subfoveal choroidal neovascularization presenting at 6 retina referral centers. Patients were treated with 3 consecutive monthly injections of ranibizumab (0.5 mg) or 3 injections of bevacizumab every 6 weeks (1.25 mg) as determined by physician and patient preference. Ophthalmologic evaluations included monthly visual acuity measurements, ocular examinations, and optical coherence tomography imaging at each visit., Results: A 29.2% reduction in the mean central foveal thickness measurement through optical coherence tomography was found in the ranibizumab-treated patients versus a 20.9% reduction in the bevacizumab-treated patients (P

Purpose: To describe a modified technique of haptic externalization during repositioning of dislocated posterior chamber lens implants, which facilitates placement of scleral fixation sutures around the haptic for implant stabilization., Methods: We describe a technique of repositioning a dislocated posterior chamber implant with scleral fixation sutures, which uses a small, clear corneal incision for externalization of the haptic. After a loop of 10-0 Prolene suture (Ethicon, Inc., Somerville, New Jersey) is placed around the externalized haptic, the sutures are retrieved through a sclerotomy 1.0 mm posterior to the limbus. The haptic is reimplanted into the ciliary sulcus. A separate scleral fixation bite closes the sclerotomy, and it is tied to the 10-0 Prolene sutures looped around the haptic., Results: The dislocated implant was stable and fixated in good position 5 months after surgery using this technique., Conclusion: This externalization technique minimizes the extensive intraocular manipulations necessary to create a suture loop around a haptic of a dislocated implant. The clear corneal incision allows for clear visualization during externalization of the haptic.

Purpose: To report two patients in their seventh decade who exhibited findings consistent with multiple evanescent white dot syndrome., Methods: Case reports of two patients referred for evaluation of decreased vision, visual field loss, and retinal white spots., Results: A 60-year-old man and a 67-year-old woman had photopsia, visual field loss, and decreased central visual acuity. Examination disclosed numerous white retinal spots, ranging from 50 to 400 microm, with eventual foveal granularity. Visual field testing showed an enlarged blind spot and peripheral field defects. Fluorescein angiography, electroretinography, and electrooculography results were consistent with multiple evanescent white dot syndrome. Eventually, the retinal lesions resolved in both patients and baseline visual acuity was recovered., Conclusion: A diagnosis of multiple evanescent white dot syndrome should be considered in patients with retinal findings typical of multiple evanescent white dot syndrome, regardless of age.

Background: Serous retinal and retinal pigment epithelial detachments resembling central serous chorioretinopathy developed in three patients who had paraproteinemias., Methods: The patients in this study were examined at two institutions, and their charts, photographs, and fluorescein angiograms were reviewed by the authors. Two patients had cryoglobulinemia and one had lgA, lgM benign gammopathy., Results: These patients had decreased central visual acuity and metamorphopsia at the initial examination. All three patients were women. Two patients were taking systemic corticosteroids in tapering doses at the time of the initial examination. The multiple serous retinal pigment epithelial and retinal detachments were unilateral in one patient and bilateral in two patients. Two patients were treated with laser photocoagulation because of chronic visual loss and foveal detachments. At the most recent examination, each patient had visual acuity of 20/30 or better in both eyes and complete resolution of subretinal fluid., Conclusions: Patients with paraproteinemia may develop multiple serous detachments of the retinal pigment epithelium and of the neurosensory retina. The chorioretinopathy in these patients may have been related to their paraproteinemia, type A personality, corticosteroid use, or a combination of these factors. The final visual acuity in these three patients was good.

Purpose/methods: To evaluate the role of initial visual acuity as a factor for progressive loss of vision or progression to a full-thickness macular hole in eyes with stage I macular holes (tractional foveal detachment without dehiscence). The study population included 35 patients with stage I macular holes with best-corrected visual acuity of 20/25 to 20/80 in one eye, and a full-thickness macular hole in the fellow eye., Results/conclusions: Eyes with stage I macular holes with best corrected visual acuity between 20/50 and 20/80 had a 66% (ten of 15 eyes) rate of progression to full-thickness macular hole, whereas eyes with best-corrected visual acuity of between 20/25 and 20/40 had a 30% (six of 20 eyes) risk of progression to full-thickness macular hole. The risk of progression to macular hole is significantly higher in eyes with stage I macular holes with best-corrected visual acuity of 20/50 or worse (P = .03).

Purpose: Theoretically, idiopathic macular holes develop because of tangential vitreous traction on the fovea. The purpose of this study was to demonstrate ultrasonographically the vitreomacular relationships in a series of 44 consecutive patients with macular holes and to correlate the ultrasonographic findings with the clinical and intraoperative findings of these patients., Methods: I examined 47 eyes with a macular holes by using contact lens biomicroscopy and clinically staged the macular hole and the status of the vitreous. A kinetic B-scan ultrasonographic examination of the vitreomacular relationships was performed in each study eye and in the fellow eye by using a contact method, with topical anesthesia., Results: The clinical stage of macular hole in 47 eyes of 44 patients included eight holes in stage 1, five in stage 2, 22 in stage 3, and 12 in stage 4. The vitreous was attached to the macular region by ultrasound interpretation in seven of eight stage 1 holes, two of five stage 2 holes, 21 of 22 stage 3 holes, and zero of 12 stage 4 holes. The correlation between the clinical status of the vitreous and the ultrasonographic findings was high (94%). The status of the vitreous by ultrasound was confirmed intraoperatively in all 14 patients undergoing subsequent surgery., Conclusions: Ultrasonographic examination of the vitreomacular relationships provides an accurate assessment of vitreomacular attachment or detachment. The ultrasonographic findings in these 47 eyes with macular holes support the vitreomacular traction theory of macular holes.

Purpose/methods: A progressive early stage of macular hole developed in a severely myopic eye of a 37-year-old woman., Results/conclusions: The patient improved after pars plana vitrectomy, peeling of the posterior hyaloid, and gas-fluid exchange. Biomicroscopic, ultrasonographic, and intraoperative findings support the theory of cortical vitreous traction as the cause of macular hole in severely myopic eyes.

Background: Air travel has been contraindicated for patients with intraocular gas on the basis of experimental studies, because of the risk of elevated intraocular pressure during atmospheric depressurization., Methods: A clinical study of gas bubble volume and intraocular pressure rise during a low-altitude air flight was performed on a patient with a gas bubble volume of 65% after retinal detachment surgery., Results: The flight was well tolerated, and the patient did not experience pain or decreased vision. The maximum altitude of the flight was 3,000. Maximum intraocular pressure was 49 mmHg, with a baseline of 16 mmHg. Increases in intraocular pressure and bubble volume were instantaneous with changes in altitude. Implications for pressurized flight situations are discussed., Conclusion: Low-altitude air flight can be well tolerated by patients with intraocular gas, even with a relatively large vitreous cavity gas fill. Decisions about when to let patients with intraocular gas fly should be made on an case-to-case basis, depending on ocular factors and the planned flight characteristics.

Because survival of low birth-weight infants requiring intensive care has improved recently, particularly since the advent of exogenous surfactant therapy, we reviewed our experience at Kapiolani Medical Center for Women and Children (KMCWC) from 1989 to 1991 to determine if the incidence of retinopathy of prematurity (ROP), a serious long-term complication, had also increased. During this 3-year period, threshold disease, the ROP stage in which cryosurgery is recommended, occurred only in infants < or = 1000 grams. Seventy-four infants < or = 1000 grams were diagnosed with ROP of any stage. Sixteen eyes (9 infants) reached threshold; 14 were treated with cryosurgery. Six of these eyes have useful vision on follow up; 8 do not. Exogenous surfactant therapy had no significant effect on ROP incidence or severity in our series. Although ROP incidence did not increase during this review period, it remains a serious problem in high-risk premature infants in our Newborn Intensive Care Unit.

Combined cataract removal, posterior chamber intraocular lens (PC IOL) implantation, and pars plana vitrectomy were performed in 15 diabetic patients who presented with coexisting cataract and vitreoretinal complications from proliferative diabetic retinopathy (PDR). Posterior chamber IOLs were placed anterior to the anterior lens capsule after pars plana lensectomy and vitrectomy in nine eyes, whereas extracapsular cataract extraction (ECCE) with PC IOL placement was performed before vitrectomy in six eyes. Panretinal laser endophotocoagulation was applied in 13 of the 15 eyes as an important part of the operative procedure. Because of inactive diabetic retinopathy or satisfactory preoperative panretinal photocoagulation, 2 of the 15 eyes did not receive laser endophotocoagulation. Visual acuity was improved in 12 eyes and was similar to preoperative vision in 3 eyes. After a minimum of 6 months and a maximum of 28 months of follow-up, the visual results are the following: 20/40 or better (4 eyes), 20/50 to 20/200 (5 eyes), 20/400 to 5/200 (5 eyes), and hand motions (1 eye). Although 5 of the 15 eyes required secondary vitreoretinal procedures, neovascular glaucoma and complications attributable to the IOL did not occur. A recurrent postoperative retinal detachment (RD) developed with subsequent hypotony and rubeosis iridis in 1 of the 15 eyes.

We inserted posterior chamber lenses into 21 eyes with complications of diabetic retinopathy upon completion of pars plana lensectomy and vitrectomy in a single session. After the original surgery, two eyes developed retinal detachments and underwent vitrectomy revisions with scleral buckling, one eye had a fluid-gas exchange for residual vitreous cavity blood, one eye had supplemental laser treatment, and one eye had intraocular antibiotics for endophthalmitis. Six months later, postoperative vision was better in 16 of the 21 eyes (76%), the same in four eyes (19%), and worse in one eye (5%). In 16 eyes visual acuity was 20/200 or better, and in six eyes it was 20/40 or better postoperatively. Decreased vision was caused by preexisting macular disease; two eyes had corneal edema with iris neovascularization associated with residual retinal detachment. The procedure and lenses were well tolerated and provided good pseudophakic vision.

The authors have isolated herpes simplex virus type 1 (HSV-1) from the vitreous of two patients with acute retinal necrosis. Clinical and laboratory data suggest that one case represented a primary HSV-1 infection, whereas the other case appeared to be a recurrent HSV-1 infection. In the primary case, changes on magnetic resonance imaging (MRI) suggest spread of the virus posteriorly to both optic tracts and the lateral geniculate ganglia. This case shares many features with the "von Szily" experimental model for HSV retinitis in the mouse.