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To report a case of BRAF/MEK inhibitor-associated multifocal choroiditis that recurred after medication re-exposure and resolved after discontinuing BRAF/MEK inhibition and administering local steroid therapy.A 32-year-old woman with metastatic cutaneous melanoma on dabrafenib/trametinib presented with bilateral anterior uveitis and new bilateral multifocal chorioretinal scars. The anterior uveitis resolved after a course of topical steroids. She presented 18 months later with reactivation of bilateral multifocal choroiditis after starting encorafenib/binimetinib 1 month prior. The chorioretinal lesions appeared elevated with associated vitreous cell. Indocyanine angiography showed numerous foci of new choroiditis, more pronounced in the left eye. Encorafenib/binimetinib was discontinued and a subtenon triamcinolone injection was administered to the left eye. Her symptoms improved and the choroiditis resolved.BRAF/MEK inhibitors may be associated with ocular toxicity manifesting as multifocal choroiditis. The increasing use of these agents and risk of visual impairment warrants early detection and management.

To identify clinical factors associated with the need for future surgical intervention following closed globe ocular trauma.Retrospective cohort study.Patients in the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry with a diagnosis of closed globe ocular trauma occurring between 2013 and 2019, identified usingDiagnosis codes were used to identify multiple concomitant diagnoses present on the date of closed globe ocular trauma. Survival analyses were performed for each outcome of interest, and linear regression was used to identify clinical factors associated with the risk of surgical intervention.Outcomes included retinal break treatment, retinal detachment (RD) repair, retinal break treatmentOf the 206 807 patients with closed globe ocular trauma, 9648 underwent surgical intervention during the follow-up period (mean, 444 days): 1697 (0.8%) had RD repair, 1658 (0.8%) had retinal break treatment, 600 (0.3%) had glaucoma surgery, and 5693 (2.8%) had cataract surgery. Traumatic cataract was the strongest risk factor for cataract surgery (hazard ratio, 13.0; 95% confidence interval, 10.8-15.6), traumatic hyphema showed highest risk for glaucoma surgery (7.24; 4.60-11.4), and vitreous hemorrhage was the strongest risk factor for retinal break treatment and detachment repair (11.01; 9.18-13.2 and 14.2; 11.5-17.6, respectively) during the first 60 days after trauma date. Vitreous hemorrhage was a risk factor for cataract surgery at60 days after trauma date only. Iris-angle injury was the strongest risk factor for glaucoma surgery60 days after trauma, while vitreous hemorrhage remained the strongest factor for retinal break treatment and detachment repair at60 days. Traumatic hyphema was a risk factor for all surgical outcomes during all follow-up intervals.Diagnosis of concomitant traumatic cataract, vitreous hemorrhage, traumatic hyphema, and other risk factors may increase the likelihood of requiring surgical intervention after closed globe ocular trauma.

The objective grading of anterior chamber inflammation (ACI) has remained a challenge in the field of uveitis. While the grading criteria produced by the Standardization of Uveitis Nomenclature (SUN) International Workshop have been widely adopted, limitations exist including interobserver variability and grading confined to discrete categories rather than a continuous measurement. Since the earliest iterations of optical coherence tomography (OCT), ACI has been assessed using anterior segment OCT and shown to correlate with slit-lamp findings. However, widespread use of this approach has not been adopted. Barriers to standardization include variability in OCT devices across clinical settings, lack of standardization of image acquisition protocols, varying quantification methods, and the difficulty of distinguishing inflammatory cells from other cell types. Modern OCT devices and techniques in artificial intelligence show promise in expanding the clinical applicability of anterior segment OCT for the grading of ACI.

Purpose To assess the diagnostic usefulness of retinal nonperfusion to classify eyes based on diabetic retinopathy (DR) severity on OCT angiography (OCTA) and determine whether wider field of view (FOV) OCTA protocols enhance the diagnostic usefulness of retinal nonperfusion in the classification of DR severity. Design Retrospective cross-sectional study. Participants Diabetic patients undergoing ultra-widefield (UWF) OCTA imaging at 1 academic retina practice. Methods Ultra-widefield OCTA images with 100° FOV were obtained from 60 eyes. Eyes were grouped as those with diabetes without retinopathy (DWR), those with nonproliferative diabetic retinopathy (NPDR), or those with proliferative diabetic retinopathy (PDR). The ratio of nonperfusion (RNP) was expressed as the percent area of capillary nonperfusion within the FOV. The RNP was obtained in the FOV 100° image and concentric sectors encompassing 10°, 10° to 30°, 30° to 50°, and 50° to 100°. Main Outcome Measures Mean RNP among DR groups, mean RNP measured among FOV sectors, and area under the curve (AUC) of the receiver operating characteristics when using RNP as a cutoff value to distinguish between DR groups. Results Mean RNP from the FOV 50° to 100° sector was different among all groups: DWR, 14.6±5.1%; NPDR, 27.5±7.5%; and PDR, 41.5±19.1% (P Conclusions Ratio of nonperfusion on average is higher in more severe DR. The most peripheral sector of the widefield OCTA (FOV 50°–100°) showed on average higher RNP and showed more diagnostic usefulness in determining DR severity compared with more central sectors and the FOV 100 image as a whole.

To investigate the incidence, seasonal variation, and differences among age, sex, and race for rhegmatogenous retinal detachment (RRD) repair, retinal break (RB) treatment, and posterior vitreous detachment (PVD) in the Intelligent Research in Sight (IRIS) Registry.Retrospective database study.Patients in the IRIS Registry who underwent RRD repair, RB treatment, or cataract surgery (CS) based on Current Procedural Terminology codes and PVD diagnosis based on International Classification of Diseases, Ninth and Tenth Revision, codes.Daily incidence rates were defined as the ratio of patients who underwent RRD repair or RB treatment and patients with a diagnosis of PVD to the total number of patients followed on a given day within the IRIS Registry. The CS group was included as a comparison for seasonal variation. Rates were stratified by decade of life, sex, and race.Time series trends for incidence rates of RRD, RB, and PVD.A total of 7 115 774 patients received a diagnosis of incident PVD, 237 646 patients underwent RRD repair, and 359 022 patients underwent RB treatment. Also included were 5 940 448 patients who underwent CS. The mean daily incidence for RRD repair, RB treatment, PVD diagnosis, and CS were 0.46 per 100 000 patients, 0.70 per 100 000 patients, 13.90 per 100 000 patients, and 11.80 per 100 000 patients, respectively. Men showed higher incidence of RRD repair and RB treatment than women, whereas women showed higher incidence of PVD diagnosis. Rhegmatogenous retinal detachment incidence was higher in White people compared with other races. Seasonal decreases in PVD, RB treatment, RRD repair, and CS corresponded to national holidays, with larger decreases in winter months. Kaplan-Meier estimates showed that RRD repair and RB treatment typically occurred within 60 days of PVD diagnosis.Within the IRIS Registry, the highest incidence of RRD was in the 6th and 7th decade of life. There was a higher incidence of RRD repair and RB treatment in men compared with women. The seasonal variation associated with national holidays was less pronounced for RRD repair and RB treatment.

Purpose To describe two cases of medium-sized uveal melanoma presenting with hemorrhagic choroidal detachments. Observations The first case is a 39-year-old man who presented with choroidal hemorrhage and angle closure glaucoma. The second case is a 42-year-old man who presented with choroidal hemorrhage and posterior scleritis. Vitrectomy with transvitreous fine needle aspiration biopsy was ultimately required to diagnose malignant uveal melanoma in each case. Conclusions and importance Intraocular hemorrhage is a rare presenting sign of uveal melanoma. When it does occur, it is typically associated with large tumors. Hemorrhagic choroidal detachments are particularly rare in uveal melanoma, and can limit the diagnostic utility of clinical exam, B-scan ultrasonography, and magnetic resonance imaging. Although it is uncommon, it is important to maintain a high index of suspicion for choroidal melanoma in any patient with unexplained choroidal hemorrhage.

Purpose: Familial retinal arteriolar tortuosity (FRAT) is a rare autosomal dominant disorder that is characterized by tortuosity of the second and higher order retinal arterioles. We implement swept-source optical coherence tomography angiography (SS-OCTA) to quantify vessel tortuosity in patients with FRAT. We hypothesize that patients with FRAT will have higher retinal arteriole tortuosity when compared to controls. Methods: Patients were scanned with a SS-OCTA device (Plex Elite 9000, Carl Zeiss Meditec, Dublin, CA). Images of a 12 × 12 mm2 area centered on the fovea were processed, and retinal vessels >23.5 μm in diameter were identified. An automatic tortuosity measurement program written in MATLAB was used to assess vessel tortuosity. Branch points in the vessels were detected and used to separate the vasculature into individual segments. The tortuosity was measured by calculating the arc-chord ratio of each vessel segment, where a minimum value of 1 indicated a straight vessel and higher values corresponded to increasing tortuosity. Results: Two patients (4 eyes) with a known history of FRAT and six controls (12 eyes) were enrolled in the study. The mean tortuosity of all vessel segments (MTVS) in scans of FRAT eyes was on average 1.1244 [range: 1.1044–1.1438] while for control eyes it was 1.0818 [range: 1.0746–1.0872]. Average MTVS of FRAT eyes was significantly higher compared to control eyes (p = 0.03). Conclusions and Importance: Our results are consistent with the hypothesis that patients with FRAT have higher objective measurements of tortuosity compared to controls. Broader applications of this method may be of benefit in other retinal diseases with changes in retinal vessel configuration. Keywords: Familial retinal arteriolar tortuosity, Vascular tortuosity, OCT angiography

The most common microvascular complication of diabetes is diabetic retinopathy, the leading cause of blindness in adults of working age. Our understanding of the vascular changes in diabetic retinopathy was enhanced by the demonstration of fluorescein angiography (FA) in the human retina for the first time in 1961. It was subsequently integrated with digital fundoscopic imaging to become an invaluable technique in evaluation of the retinal vasculature. The recent development of OCT-angiography (OCT-A) has revolutionized the clinician’s ability to examine the retinal vasculature without the need for injection of a contrast dye. By coupling OCT, which can provide noninvasive cross-sectional imaging of the central retina, with angiography in OCT-A, one can reveal retinal perfusion by allowing visualization of the depth-resolved retinal capillary plexus. OCT-A has allowed for more precise delineation of changes in the retinal microvasculature, specifically the alterations of retinal vasculature and loss of capillary perfusion from chronic microvascular occlusion in diabetic retinopathy.

Purpose To report two cases of idiopathic intraocular cilia presenting as sectoral scleritis with progressive intraocular inflammation. Methods Both patients were treated with intravitreal antibiotics and underwent pars plana vitrectomy where the cilia were removed and identified on histopathology. Results One patient developed a retinal detachment while being treated for presumed endophthalmitis. The intraocular cilium was discovered during pars plana vitrectomy. In the second case, the cilium was detected on dilated fundus exam and was believed to be the cause of the patient's scleritis and vitritis. Therapeutic vitrectomy was performed. In both cases, the cilia were positively identified on histopathology. Conclusion Idiopathic intraocular penetration of cilia should be considered in the differential diagnosis of sectoral scleritis with progressive intraocular inflammation.

Background. Diabetic retinopathy and kidney disease share underlying mechanisms of microvascular damage and are often comorbid in people with diabetes. We evaluated whether there is a relationship between retinal capillary perfusion as measured by swept-source optical coherence tomography angiography and estimated glomerular filtration rate (eGFR) and albuminuria in patients with diabetes and chronic kidney disease (CKD). Method. A cross-sectional pilot study was conducted at the University of Washington among a subset of participants with diabetes and CKD participating in a larger cohort study. Participants were excluded if they were known to have kidney disease from conditions other than diabetes. Ten participants (11 eyes) were included. Retinal nonperfusion (RNP) and vessel density (VD) were measured by swept-source optical coherence tomography angiography in 30° and 60° field of view (FOV) regions centered at the fovea. Correlations of RNP and VD with eGFR and albuminuria were analyzed. Results. Participants had a mean age of 72 years, hemoglobin A1c of 8.1%, eGFR of 45 mL/min/1.73 m2, and urine albumin-to-creatinine ratio of 162 mg/g. Mean (SD) RNP was 6.6% (4.2%) and 16.9% (7.7%) in 30° and 60° FOV regions, respectively. eGFR was negatively correlated to RNP in both the 30° and 60° FOV regions (R = −0.69, p = 0.004 , and R = −0.46, p = 0.057 , respectively), and correlations were stronger among a subset of 7 participants with evidence of diabetic retinopathy on exam and fundus photos. The estimated GFR was not significantly correlated with vessel density. Urine albumin-to-creatinine ratio was not significantly correlated with RNP or VD. Conclusions. Our proof-of-concept study showed that lower eGFR was significantly correlated with retinal nonperfusion in participants with diabetes and CKD. Advanced retinal imaging may enhance the noninvasive evaluation of kidney function in diabetes.

Purpose To report on the characteristics, accomplishments, and past experiences of current academic ophthalmology department chairs. Design Cross-sectional study. Methods Setting: A confidential online survey. Study Population: Total of 111 chairs of US academic ophthalmology departments. Main Outcome Measures: Chairs' general characteristics, training/former positions held, academic accomplishments, previous organization/committee involvement, motivation/insight, and overall work satisfaction. Results Fifty-five chair responses were received (96% male, mean age 57 years, mean term 7 years). The majority were American medical graduates (93%), full professors of ophthalmology (93%), and permanent chairs (96%). All completed their residency in the US and 96% completed a fellowship (25% vitreoretinal surgery, 22% cornea and external disease, and 20% glaucoma). On average, chairs authored 98 peer-reviewed articles, 2 books, and 11 book chapters. They were also significantly involved in peer-reviewed journal literature, serving as editors (20%), associate editors (18%), or editorial board members (60%). The majority of chairs indicated they decided to seek their position late in their career, having already become a full (33%) or associate professor (26%), primarily owing to a desire to build and promote an academic ophthalmology department (61%). Chairs regarded their experience as head of service as most important for their current performance as department heads. Their principal advice to aspiring ophthalmology chairs was to focus on developing skills as a clinician, researcher, and educator ("triple threat"). Conclusions Overall, academic department chairs are accomplished leaders in ophthalmology and prolific authors with an established academic record. Chairs regarded their previous leadership roles within the department as invaluable to their effectiveness as chair.

A 77-year-old woman with exudative macular degeneration underwent bilateral intravitreal injections of “stem cells” at a clinic in Georgia. One month and 3 months after injection, she developed retinal detachments in the left and right eyes, respectively. Increased awareness within the medical community of such poor outcomes is critical so that clinics offering untested practices that have been shown to be potentially harmful to patients can be identified and brought under U.S. Food and Drug Administration oversight. [ Ophthalmic Surg Lasers Imaging Retina . 2017;48:772–775.]

PurposeTo quantitatively assess choriocapillaris (CC) flow deficits in eyes with diabetic retinopathy (DR) using swept-source optical coherence tomography angiography (SS-OCTA).MethodsDiabetic subjects with different stages of DR and age-matched healthy subjects were recruited and imaged with SS-OCTA. Theen faceCC blood flow images were generated using previously published and validated algorithms. The percentage of CC flow deficits (FD%) and the mean CC flow deficit size were calculated in a 5-mm-diameter circle centered on the fovea from the 6×6-mm scans.ResultsForty-five diabetic subjects and 27 control subjects were included in the study. The CC FD% in diabetic eyes was on average 1.4-fold greater than in control eyes (12.34±4.14% vs 8.82±2.61%,P< 0.001). The mean CC FD size in diabetic eyes was on average 1.4-fold larger than in control eyes (2151.3± 650.8μm2vs 1574.4±255.0 μm2,P< 0.001). No significant difference in CC FD% or mean CC FD size was observed between eyes with nonproliferative DR and eyes with proliferative DR (P= 1.000 andP= 1.000, respectively).ConclusionsCC perfusion in DR can be objectively and quantitatively assessed with FD% and FD size. In the macular region, both CC FD% and CC FD size are increased in eyes with DR. SS-OCTA provides new insights for the investigations of CC perfusion status in diabetes in vivo.

Background To implement an ultra-wide optical coherence tomography angiography imaging (UW-OCTA) modality in eyes with diabetic retinopathy (DR) with the aim of quantifying the burden of microvascular disease at baseline and subsequent clinic visits. Methods UW-OCTA was implemented on a 1,060 nm swept source (SS) OCTA engine running at 100 kHz A-line rate with a motion tracking mechanism. A montage scanning protocol was used to capture a 100-degree field of view (FOV) using a 4×4 grid of sixteen total individual 6×6 mm2 scans. Typical OCTA images with a FOV of 3×3, 6×6 and 12×12 mm2 were obtained for comparison. DR patients were scanned at baseline and follow-up. They were treated at the clinician's discretion. Vessel density and non-perfusion area maps were calculated based on the UW-OCTA images. Results Three proliferative DR patients were included in the study. UW-OCTA images provided more detailed visualization of vascular networks compared to 50-degree fluorescein angiography (FA) and showed higher burden of pathology in the retinal periphery that was not captured by typical OCTA. Neovascularization complexes were clearly detected in the two patients with active PDR. Vessel density and non-perfusion maps were used to measure progressive capillary non-perfusion and regression of neovascularization between visits. Conclusions UW-OCTA provides approximately 100-degree OCTA images of the fundus comparable to that of wide-angle fundus photography, and may be more applicable in conditions such as DR which affect the peripheral retina in contrast to standard OCTA.

Purpose To explore whether cataract surgery contributes to the progression of wet age-related macular degeneration (wet AMD). Design Retrospective cohort study. Methods Retrospective review was performed of consecutive patients with wet AMD who underwent cataract surgery at the midpoint of a 1-year study window. A control arm included wet AMD eyes treated with anti-vascular endothelial growth factor (VEGF) injections that did not undergo cataract surgery for a 1-year period. Best-corrected visual acuity (BCVA), number of anti-VEGF injections, and optical coherence tomography (OCT) features were compared between the 2 arms. Results Forty eyes in the surgical group and 42 in the nonsurgical group were included. BCVA was equivalent in the first half of the study, and became significantly better in the surgical group vs the nonsurgical group (0.23 ± 0.65 vs 0.11 ± 0.59 logMAR improvement, P = .049). There was no change in the number of injections given 6 months before vs after the midpoint in the surgical group (P = .921). The mean OCT central retinal thickness became greater in postsurgical eyes compared to nonsurgical eyes (265.4 ± 98.4 μm vs 216.4 ± 58.3 μm, P = .011). Surgical eyes were more likely to develop new or worse cystoid changes after the study midpoint (13 surgical eyes [54.2%] vs 9 nonsurgical eyes [28.1%], P = .048). Conclusions Cataract surgery leads to vision improvement and does not appear to contribute to worsening of wet AMD. However, anatomic changes based on OCT analysis suggest a subclinical susceptibility to postoperative cystoid macular edema or exacerbation of choroidal neovascularization.

A previously healthy 18 year-old African-American female presented with unilateral vision loss associated with headaches. Initial ocular examination revealed an exudative retinal detachment involving the macula, disc edema, and choroidal striae worse in the right than the left eye. Fluorescein angiography showed multiple punctate hyperfluorescent lesions with leakage into the subretinal space. Extensive work up led to the diagnosis of Vogt- Koyanagi-Harada syndrome. The patient was treated with a prolonged taper of systemic prednisone and approximately 4 months after presentation, vision improved to 20/20 in the right eye and 20/25 in the left eye.