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Robert E Morris,1– 3 Ferenc Kuhn,2,4 Cole Richardson1– 3 1Retina Specialists of Alabama, LLC, Birmingham, AL, USA; 2Helen Keller Foundation for Research and Education, Birmingham, AL, USA; 3Department of Ophthalmology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; 4Department of Ophthalmology, University of Pécs Medical School, Pecs, HungaryCorrespondence: Robert E Morris, Helen Keller Foundation for Research and Education, 2208 University Boulevard, Suite 101, Birmingham, AL, 35233, USA, Tel +1 205 936 0704, Email rmorris@rmeyes.comAbstract: Encircling (360 degree) retinal detachment prophylaxis using indirect ophthalmoscope laser delivery recently achieved strong proof of safety and effectiveness by preventing the development of peripheral retinal tears and detachments in the eyes of patients with Stickler syndrome (syndromic eyes). Untreated, Stickler syndrome patients have a 65% lifetime risk of retinal detachment (half by age 20, 80% bilateral). This report describes an optimal technique of encircling laser retinopexy to also prevent the more common retinal detachments seen in aging (non-syndromic) eyes that share with Stickler syndrome the common pathogenesis of peripheral retinal tears caused by vitreous traction.Keywords: retinal tear, retinal detachment, retinal detachment prevention, 360-degree laser retinopexy, encircling laser prophylaxis, ora secunda cerclage, Stickler syndrome

Robert E Morris,1– 3 Ferenc Kuhn,2,4 Timothy Sipos1– 3 1Retina Specialists of Alabama, LLC, Birmingham, AL, USA; 2Helen Keller Foundation for Research and Education, Birmingham, AL, USA; 3Department of Ophthalmology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; 4Department of Ophthalmology, University of Pécs Medical School, Pécs, HungaryCorrespondence: Robert E Morris, Helen Keller Foundation for Research and Education, 2208 University Boulevard, Suite 101, Birmingham, AL, USA, 35233, Tel +1 205 936-0704, Email rmorris@rmeyes.comAbstract: Stickler syndrome, a rare inherited disease, carries a lifetime risk of rhegmatogenous retinal detachment (RRD) of up to 65%, higher than any other predisposing condition known. Both syndromic and non-syndromic eyes suffer RRD predominately from the same pathogenesis, vitreous tractional tears in the peripheral retina. Consequently, extraordinary publications in 2021– 2022, each reporting successful prevention of RRD in Stickler syndrome, using 360-degree (encircling) laser retinopexy, provide the first strong evidence upon which similar prophylaxis in non-syndromic eyes at high risk of RRD from peripheral retinal tears can confidently go forward.Keywords: retinal tear, retinal detachment, retinal detachment prevention, 360-degree laser retinopexy, stickler syndrome, encircling laser prophylaxis

Bernard Dib,1–4 Robert E Morris,1–4 Matthew H Oltmanns,1–4 Mathew R Sapp,1–4 Jay P Glover,5 Ferenc Kuhn2,6,7 1Retina Specialists of Alabama, Birmingham, AL, USA; 2Helen Keller Foundation for Research and Education, Birmingham, Al, USA; 3University of Alabama at Birmingham (UAB), Department of Ophthalmology, Birmingham, Al, USA; 4UAB Callahan Eye Hospital, Birmingham, Al, USA; 5Retina Consultants of Nashville, Nashville, TN, USA; 6Milos Eye Hospital, Belgrade, Serbia; 7Zagorskiego Eye Hospital, Krakow, PolandCorrespondence: Robert E MorrisRetina Specialists of Alabama, 2208 University Blvd, Ste. 101, Birmingham, Al, 35233, USAEmail rmorris@retinanetwork.com View the original paper by Dr Dib and colleagues This is in response to the Letter to the Editor

Robert E Morris,1– 4 Edward Scott Parma,5 Nathaniel H Robin,6 Mathew R Sapp,1– 4 Matthew H Oltmanns,1– 4 Matthew R West,1– 4 Donald C Fletcher,7,8 Ronald A Schuchard,9 Ferenc Kuhn2,10,11 1Retina Specialists of Alabama, Birmingham, AL, USA; 2Helen Keller Foundation for Research and Education, Birmingham, AL, USA; 3University of Alabama at Birmingham (UAB), Department of Ophthalmology, Birmingham, AL, USA; 4UAB Callahan Eye Hospital, Birmingham, AL, USA; 5Retina Specialists of Alabama Montgomery, Montgomery, AL, USA; 6UAB Department of Genetics, Birmingham, AL, USA; 7University of Kansas Medical Center, Department of Ophthalmology and KU Eye Center, Kansas City, KS, USA; 8Retina Consultants of Southwest Florida, Ft. Myers, FL, USA; 9Envision Research Institute, Wichita, KS, USA; 10Milos Eye Hospital, Belgrade, Serbia; 11University of Pécs, Department of Ophthalmology, Pécs, HungaryCorrespondence: Robert E MorrisRetina Specialists of Alabama, 2208 University Blvd, Birmingham, AL 35233, USATel +1 (205) 558-2598Fax +1 (205) 558-2596Email rmorris@retinanetwork.comPurpose: To introduce a novel technique of encircling laser prophylaxis (ora secunda cerclage Stickler syndrome, OSC/SS) to prevent rhegmatogenous retinal detachment (RRD) in Stickler syndrome eyes.Patients and Methods: After first eye RRD at age 50 and at age 18, respectively, a 53-year-old father and his 22-year-old son with type 2 SS (STL2) gave informed consent and underwent OSC/SS prophylaxis, performed in each fellow eye. A 26-year-old STL2 daughter then suffered first eye retinal detachment and similarly chose fellow eye OSC/SS prophylaxis. A second son, 28 years of age with STL2, chose OSC/SS prophylaxis in both eyes.Results: The three OSC/SS treated fellow eyes have gone 12 years, 11 years, and 8 years without RRD. STL1 and less common STL2 eyes are known to have a similar rate of RRD, and 80% of STL1 fellow eyes develop RRD at a median of 4 years in the absence of prophylaxis. Moreover, five of six (83%) known STL2 family members suffered RRD, only the STL2 son with bilateral OSC/SS remaining bilaterally attached. All five OSC/SS treated eyes (average 8.7 years post-prophylaxis) retained preoperative visual acuity of 20/20 to 20/30, with an average, asymptomatic reduction of meridional field in each eye to 50 degrees. In contrast, in the three eyes having suffered RRD prior to presentation, visual acuity ranged from 20/125 to 8/200 and average meridional field was 29 degrees.Conclusion: Encircling grid laser (OSC) modified in Stickler eyes to encompass the ora serrata and extend posteriorly to and between the vortex vein ampullae (OSC/SS) is a reasonable RRD prophylaxis option to offer STL1 and STL2 patients as an alternative to no treatment or less effective prophylaxis. Because of rarity and severity, the ultimate proof of safety and efficacy will likely come not from randomized trials, but from a non-randomized, prospective, cohort comparison study of such individual efforts.Keywords: Stickler syndrome, SS, STL1, STL2, retinal detachment prevention, giant retinal tear, encircling laser prophylaxis, Ora Secunda Cerclage, OSC, OSC/SS

Bernard Dib,1– 4 Robert E Morris,1– 4 Matthew H Oltmanns,1– 4 Mathew R Sapp,1– 4 Jay P Glover,5 Ferenc Kuhn2,6,7 1Retina Specialists of Alabama, Birmingham, AL, USA; 2Helen Keller Foundation for Research and Education, Birmingham, AL, USA; 3University of Alabama at Birmingham (UAB), Department of Ophthalmology, Birmingham, AL, USA; 4UAB Callahan Eye Hospital, Birmingham, AL, USA; 5Retina Consultants of Nashville, Nashville, TN, USA; 6Milos Eye Hospital, Belgrade, Serbia; 7Zagorskiego Eye Hospital, Krakow, PolandCorrespondence: Robert E MorrisRetina Specialists of Alabama, 2208 University Blvd, Ste. 101, Birmingham, AL 35233, USAEmail rmorris@retinanetwork.comPurpose: In this study, we report the treatment outcomes of complete and early vitrectomy for endophthalmitis (CEVE) after cataract surgery as the predominate initial treatment, accompanied by systemic antibiotics and retreatment of persistent or recurrent purulence (CEVE+).Patients and Methods: Clinical features and microbiological factors were retrospectively reviewed in 62 eyes of 62 patients who were treated for acute postcataract endophthalmitis (APCE) occurring within three weeks of cataract surgery at Retina Specialists of Alabama, between 2007 and 2017.Results: Visual acuity on presentation included light perception (LP) in 18 eyes (29%) and hand motion (HM) in 23 eyes (37%). Initial treatment was maximum possible vitrectomy in 48 eyes (77%) and tap-and-inject in 14 eyes (23%), with 38 eyes (61%) receiving two or more treatments. Cultures for the first intervention were positive in 49 eyes (79%) and virulent in 18 eyes (29%). At a median follow-up time of five months, final visual acuity was ≥ 20/40 in 49 eyes (79%), between 20/50 and 5/200 in seven eyes (11%), and < 5/200 in six eyes (10%). Virulence was the strongest predictor of poor visual outcome. Retinal detachment occurred in four eyes (6%), likely from necrotic retinal defects in each case.Conclusion: Complete and early vitrectomy is a safe and effective initial treatment for APCE. When accompanied by systemic antibiotics and retreatment (CEVE+) of recurrent media opacification, it improves recovery of 20/40 or better visual acuity by approximately 50% compared to a predominantly tap-and-inject treatment paradigm. We recommend CEVE for fundus-obscuring APCE (∼ 75% of all cases) whenever the view is inadequate to rule out macular distress.Keywords: endophthalmitis, postcataract endophthalmitis, vitrectomy, tap and inject, TAP, VIT, EVS, APCE

Robert E Morris,1–3 Hannah Hashimi,4 Andrew J McFarland,1,2,5 Ferenc Kuhn,2,6–7 Mathew Sapp,1–3 Matthew Oltmanns1–3 1Retina Specialists of Alabama, Birmingham, AL, USA; 2Helen Keller Foundation for Research and Education, Birmingham, AL, USA; 3Department of Ophthalmology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; 4School of Medicine, UAB, Birmingham, AL, USA; 5Retina Associates, Winchester, VA, USA; 6Milos Eye Hospital, Belgrade, Serbia; 7Zagorskeigo Eye Hospital, Krakow, PolandCorrespondence: Robert E MorrisRetina Specialists of Alabama, 2208 University Blvd, Birmingham, AL 35233, USATel +1 205 558 2598Fax +1 205 558 2596Email rmorris@retinanetwork.comPurpose: To present rapid and safe closure of the pit-macula communication (PMC) by core vitrectomy and adequate duration gas tamponade as our preferred method of resolving optic disc pit (ODP) maculopathy and to define the term “maculoschisis” in ODP maculopathy as an alternative to the term “schisis-like.&#x201DPatient and methods: A twenty-four-year-old female presented with an optical coherence tomography (OCT) confirmed ODP and a “giant” communicating maculoschisis cavity. Central macular thickness (CMT) measured 906 microns, and macular volume was twice normal, at 20.8 mm3. Snellen corrected visual acuity was 20/70. Two months after initial vitrectomy performed elsewhere with short-term gas tamponade (SF6 20%), CMT and visual acuity were not significantly improved. Combined lens extraction/intraocular lens placement and repeat vitrectomy with C3F8 15% gas tamponade were performed, with one supplemental (office) gas injection.Results: OCT imaging six weeks postoperatively showed definitive closure of the PMC with CMT reduced by 405 microns. Sequestered from its ODP source, foveal schisis fluid then resolved by 12 weeks postoperatively. At final follow-up 3.4 years postoperatively, the macula remained dry with a CMT of 322 microns and a concave foveal contour. Macular volume was reduced to (a normal) 10.2 mm3 and visual acuity had improved to 20/25.Conclusion: No report heretofore has documented rapid, sustained closure of the PMC by gas tamponade as the preferred method of expeditiously resolving ODP maculopathy. However, tamponade PMC closure sequesters ODP fluid and uniquely provides early assurance of ultimate maculopathy resolution. In all other techniques, PMC closure is a trailing phenomenon and success remains uncertain during months to a year or more of (unsequestered) fluid resolution. We suggest that more invasive techniques (laser barrier application to the peripapillary choroid, vitreoretinal interface maneuvers, and pit-plugging) be withheld unless a recurrence is detected during subsequent examinations.Keywords: optic disc pit, ODP, schisis, maculoschisis, ODP maculopathy, vitrectomy, tamponade, optical coherence tomography, OCT