Search

Optical coherence tomography (OCT) is an invaluable imaging tool in detecting and assessing diabetic macular edema (DME). Over the past decade, there have been different proposed OCT-based classification systems for DME. In this review, we present an update of spectral-domain OCT (SDOCT)-based DME classifications over the past 5 years. In addition, we attempt to summarize the proposed OCT qualitative and quantitative parameters from different classification systems in relation to disease severity, risk of progression, and treatment outcome. Although some OCT-based measurements were found to have prognostic value on visual outcome, there has been a lack of consensus or guidelines on which parameters can be reliably used to predict treatment outcomes. We also summarize recent literatures on the prognostic value of these parameters including quantitative measures such as macular thickness or volume, central subfield thickness or foveal thickness, and qualitative features such as the morphology of the vitreoretinal interface, disorganization of retinal inner layers, ellipsoid zone disruption integrity, and hyperreflec-tive foci. In addition, we discuss that a framework to assess the validity of biomarkers for treatment outcome is essentially important in assessing the prognosis before deciding on treatment in DME. Finally, we echo with other experts on the demand for updating the current diabetic retinal disease classification.

The coronavirus disease 2019 (COVID-19) came under the attention of the international medical community when China first notified the World Health Organization of a pneumonia outbreak of then-unknown etiology in Wuhan in December 2019. Since then, COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has appalled the world by spreading at a pandemic speed. Although ophthalmologists do not directly engage in the clinical care of COVID-19 patients, the ophthalmology community has become aware of the close ties between its practice and the pandemic. Not only are ophthalmologists at heightened risk of SARS-CoV-2 exposure due to their physical proximity with patients in routine ophthalmic examinations, but SARS-CoV-2 possesses ocular tropism resulting in ocular complications beyond the respiratory tract after viral exposure. Furthermore, patients could potentially suffer from adverse ocular effects in the therapeutic process. This review summarized the latest literature to cover the ophthalmic manifestations, effects of treatments, and vaccinations on the eye to aid the frontline clinicians in providing effective ophthalmic care to COVID-19 patients as the pandemic continues to evolve.

The World Health Organization declared the Coronavirus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 a “Pandemic” on March 11, 2020. As of June 1, 2020, Severe Acute Respiratory Syndrome Coronavirus 2 has infected >6.2 million people and caused >372,000 deaths, including many health care personnel. It is highly infectious and ophthalmologists are at a higher risk of the infection due to a number of reasons including the proximity between doctors and patients during ocular examinations, microaerosols generated by the noncontact tonometer, tears as a potential source of infection, and some COVID-19 cases present with conjunctivitis. This article describes the ocular manifestations of COVID-19 and the APAO guidelines in mitigating the risks of contracting and/or spreading COVID-19 in ophthalmic practices.

The death toll of the coronavirus disease 2019 (COVID-19) sparked much controversy since its advent in December 2019. Underestimation because of under testing and deaths happening outside the hospitals were important causes. Bold revisions of the diagnostic criteria leading to dramatic changes in death tolls by different governments were observed in attempts to generate more accurate estimates. On the other hand, the influence, censorship and manipulation on case and death data from top political leaders of some countries could create important impacts on the death toll. Baseline mortality data of previous years may help make more accurate estimates of the actual death toll. The pitfalls and strategies during such processes could become valuable lessons to leaders and policymakers worldwide as more accurate statistics serve to navigate policies to combat this pandemic in the days and months to come.

The effectiveness of the non-pharmaceutical interventions implemented in Wuhan are described and discussed. In the absence of vaccine and proven specific safe and effective treatments, the experience and results achieved by Wuhan could serve as a good reference for leaders and policymakers around the world in formulating their strategies and policies in fighting against COVID-19.

Ophthalmology has been at the forefront of many innovations in basic science and clinical research. The randomized prospective multicenter clinical trial, comparative clinical trials, the bench to beside development of diagnostic and therapeutic devices, the powerful combination of biostatistics and epidemiology, gene therapy, cell-based therapy, stem cell therapy, regenerative medicine, artificial intelligence, and the development of personalized molecular medicine continue to propel us forward. This article summarizes several critical trends in eye research. Innovative translational research continues to bring new solutions to blinding retinal diseases. The discovery of the genetic code presaged a day when the development of molecular tools and understanding of the basis of disease would lead not only to disease management but potentially lifelong cure. After decades of investigation, gene therapy is now a reality for a single autosomal recessive bi-allelic disease, Lebers Congenital Amaurosis. Its success has paved the way for a myriad of conditions once thought to be untreatable. In parallel, the progress to utilize pluripotential stem cells, immunomodulation, computational biology, and continued investigation into the fundamental mechanisms of cell and molecular biology is breathtaking in its rapidity. The next decade is likely to be the most exciting in the history of medicine. It will be essential that research progresses in a meticulously thoughtful, ethical, and collaborative process that safeguards the trust of our work and that of the society we serve. Presented as the International Award Lecture, Asia-Pacific Vitreoretinal Society meeting, November 2019, Shanghai China.

The Coronavirus Disease 2019 (COVID-19), caused by severe acute respiratory coronavirus-2, was first reported in December 2019. The World Health Organization declared COVID-19 a pandemic on March 11, 2020 and as of April 17, 2020, 210 countries are affected with >2,000,000 infected and 140,000 deaths. The estimated case fatality rate is around 6.7%. We need to step up our infection control measures immediately or else it may be too late to contain or control the spread of COVID-19. In case of local outbreaks, the risk of infection to healthcare workers and patients is high. Ophthalmic practice carries some unique risks and therefore high vigilance and special precautions are needed. We share our protocols and experiences in the prevention of infection in the current COVID-19 outbreak and the previous severe acute respiratory syndrome epidemic in Hong Kong. We also endeavor to answer the key frequently asked questions in areas of the coronaviruses, COVID-19, disease transmission, personal protection, mask selection, and special measures in ophthalmic practices. COVID-19 is highly infectious and could be life-threatening. Using our protocol and measures, we have achieved zero infection in our ophthalmic practices in Hong Kong and China. Preventing spread of COVID-19 is possible and achievable.

Purpose To analyze and provide an overview of the incidence, management, and prevention of conjunctival erosion in Argus II clinical trial subjects and postapproval patients. Methods This retrospective analysis followed the results of 274 patients treated with the Argus II Retinal Prosthesis System between June 2007 and November 2017, including 30 subjects from the US and European clinical trials, and 244 patients in the postapproval phase. Results were gathered for incidence of a serious adverse event, incidence of conjunctival erosion, occurrence sites, rates of erosion, and erosion timing. Results Overall, 60% of subjects in the clinical trial subjects versus 83% of patients in the postapproval phase did not experience device- or surgery-related serious adverse events. In the postapproval phase, conjunctival erosion had an incidence rate of 6.2% over 5 years and 11 months. In 55% of conjunctival erosion cases, erosion occurred in the inferotemporal quadrant, 25% in the superotemporal quadrant, and 20% in both. Sixty percent of the erosion events occurred in the first 15 months after implantation, and 85% within the first 2.5 years. Conclusion Reducing occurrence of conjunctival erosion in patients with the Argus II Retinal Prosthesis requires identification and minimization of risk factors before and during implantation. Implementing inverted sutures at the implant tabs, use of graft material at these locations as well as Mersilene rather than nylon sutures, and accurate Tenon's and conjunctiva closure are recommended for consideration in all patients.

PURPOSE: To assess the retinal anatomy and array position in the Argus II Retinal Prosthesis recipients. DESIGN: Prospective, non-comparative cohort study METHODS: Setting: international multicenter study Patients: Argus II recipients enrolled in the Post-Market Surveillance Studies. Procedures: Spectral-domain Optical Coherence Tomography images collected for the Surveillance Studies (NCT01860092 and NCT01490827) were reviewed. Baseline and postoperative macular thickness, electrode-retina distance (gap), optic disc-array overlap, and preretinal membrane presence were recorded at 1, 3, 6, and 12 months. Main Outcome Measures: Axial retinal thickness and axial gap along the array’s long axis (a line between the tack and handle), maximal retinal thickness and maximal gap along a B-scan near the tack, midline, and handle. RESULTS: Thirty-three patients from 16 surgical sites in the United States and Germany were included. Mean axial retinal thickness increased from month 1 through month 12 at each location, but reached statistical significance only at the array midline (p- value=0.007). The rate of maximal thickness increase was highest near the array midline (slope=6.02, p=0.004), compared to the tack (slope=3.60, p

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

The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) emerged in December 2019 in Wuhan, China has spread to over 113 countries with 118,326 infected and 4,292 died as of 11 March 2020 and the World Health Organization (WHO) has just announced COVID-19 a global pandemic. A person under investigation (PUI) for COVID-19 is less likely to present initially to the ophthalmologists compared to emergency care or internal medicine physicians. However, in late February 2020, 2 patients presented simultaneously to our eye casualty with sudden onset of unilateral painful red eye associated with a decline in visual acuity, their intraocular pressure (IOP) were over 40 mmHg and slit-lamp examination findings were suggestive of acute primary angle closure (APAC).

Objective To compare the efficacy and safety of macular buckling and vitrectomy for myopic traction maculopathy showing macular schisis (MS) and associated macular detachment (MD) but without full‐thickness macular hole (FTMH). Design Prospective, randomized, parallel, open‐label study. Methods Patients were randomly assigned to either buckling or vitrectomy group. Macular buckling and intravitreal C3F8 gas injection were performed in the buckling group. Small gauge vitrectomy, internal limiting membrane peeling (ILMP) and C3F8 gas tamponade were performed in the vitrectomy group. The patients were followed for 12 months. Main outcome measures Best‐corrected visual acuity (BCVA) at 12 months. Results A total of 85 patients were randomized, 80 eyes were included (41 receiving buckling, 39 received vitrectomy), and 78 patients completed the study. There were less eyes determined as surgical failure and required a second surgery in the buckling group than vitrectomy the group (2.4% versus 18.4%, p = 0.021). After surgery, macular buckling achieved more improvement in BCVA (+21.7 versus +4.5 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, p = 0.002). FTMH development was observed in only 1 (2.4%) eye, after removing of the implant due to recurrent conjunctival erosion, in the buckling group and 10 (26.3%) eyes (seven with‐, three without MD) in the vitrectomy group (p

The Argus II retinal prosthesis (Second Sight Medical Products, Sylmar, CA, USA) is an electronic epiretinal implant designed for use in patients with end-stage retinitis pigmentosa, as well as for other outer retinal degenerative conditions, such as choroideremia, Leber’s congenital amaurosis, Bardet-Biedl syndrome, Usher syndrome and rod–cone disease.1 This device was tested in a clinical trial of 30 subjects in the USA and in Europe to measure the rate of serious adverse events (SAEs) and to assess its effects on functional vision and visual acuity.2–4 Subjects performed better on visual tasks with the device turned on and retained these improvements at 5 years postsurgery.4 Additionally, an acceptable safety profile enabled approval of the device for consumer use by the European regulatory authorities in 2011 (Conformite Europeenne (CE) mark) and by the US Food and Drug Administration (FDA) in 2013 (FDA approval). The implant is composed of an extraocular component, namely, an electronics case and implant coil, as well as an intraocular component involving a 60-electrode array that is tacked over the macula (figure 1). The extraocular and intraocular components are connected by a trans-scleral silicone-coated polyamide electrode cable, and the implantation procedure involves a 5.2 mm pars plana sclerotomy incision to insert the electrode array and the electrode cable into the eye. The sclerotomy is then sutured around the cable and covered by an allograft or autograft material.5 Figure 1 The Argus II retinal prosthesis. Labelled image of the Argus II implant (adapted from Humayun et al 2). As with any system having both intraocular and extraocular components, the trans-scleral electrode cable that traverses the sclerotomy permanently is a high-risk feature of the device, as leakage through the pars plana incision can result in chronic hypotony. The percentages of clinical trial subjects who experienced hypotony were 10.0% at …

To report and discuss a focal oscillopsia in a small area of the visual field produced by, and after the removal of, an epiretinal membrane (ERM) in an individual with infantile nystagmus syndrome (INS) since birth with no associated afferent visual deficits. A retrospective case report. A chart review, including clinical and electrophysiological data. A 74 y/o man with INS and an epiretinal membrane was studied. Detailed studies of the retina post-removal of an epiretinal membrane, with consequent changes in best-corrected visual acuity (BCVA), and subjective oscillopsia compared to INS waveforms. OCT measurements and eye-movement data from digital video and scleral search-coil systems were used. The monocular ERM produced an unexpected focal area of torsional/vertical oscillopsia (noted 1 year prior to the ERM surgery) in the portion of the visual field that corresponded with distortions from the ERM. The remainder of the visual field, corresponding with normal healthy retina was unaffected and stable in all planes. Post-removal, BCVA improved with redevelopment of the foveal pit and focal oscillopsia became less noticeable but remained due to the retinal distortion. In patients with INS, complete oscillopsia suppression across the visual field requires undistorted vision. If a retinal area of visual distortion develops or results from retinal surgery, a symptomatic island of oscillopsia in one or more planes may result.

BMC ophthalmology 16, 129 (2016). doi:10.1186/s12886-016-0259-4, Published by BioMed Central, London

Cytochrome P450 enzymes (CYP or P450) 46A1 and 27A1 play important roles in cholesterol elimination from the brain and retina, respectively, yet they have not been quantified in human organs because of their low abundance and association with membrane. On the basis of our previous development of a multiple reaction monitoring (MRM) workflow for measurements of low-abundance membrane proteins, we quantified CYP46A1 and CYP27A1 in human brain and retina samples from four donors. These enzymes were quantified in the total membrane pellet, a fraction of the whole tissue homogenate, using (15)N-labled recombinant P450s as internal standards. The average P450 concentrations/mg of total tissue protein were 345 fmol of CYP46A1 and 110 fmol of CYP27A1 in the temporal lobe, and 60 fmol of CYP46A1 and 490 fmol of CYP27A1 in the retina. The corresponding P450 metabolites were then measured in the same tissue samples and compared to the P450 enzyme concentrations. Investigation of the enzyme product relationships and analysis of the P450 measurements based on different signature peptides revealed a possibility of retina-specific post-translational modification of CYP27A1. The data obtained provide important insights into the mechanisms of cholesterol elimination from different neural tissues.

Objective To examine the evidence about the safety and efficacy of anti–vascular endothelial growth factor (VEGF) pharmacotherapies for the treatment of neovascular age-related macular degeneration (AMD). Design Literature searches were conducted in May and October 2007 in PubMed with no date restrictions, limited to articles published in English, and in the Cochrane Central Register of Controlled Trials without a language limitation and yielded 310 citations. The first author reviewed the abstracts of these articles and selected 73 articles of possible clinical relevance for review by the panel. The panel deemed 64 of these articles sufficiently clinically relevant to review in full text and assigned ratings of level of evidence to each of the selected articles with the guidance of the panel methodologists. Results Eleven studies provided level I evidence for intravitreal pegaptanib and ranibizumab for neovascular AMD; there were no studies rated level I for bevacizumab for neovascular AMD. Five studies were rated as level II, which included studies of ranibizumab and bevacizumab, and the remaining 38 articles retrieved were rated as level III. The studies do not provide information about long-term results or the value (comparative effectiveness) and cost-effectiveness of combined therapies. Conclusions Review of the available literature to date suggests that anti-VEGF pharmacotherapy, delivered by intravitreal injection, is a safe and effective treatment for neovascular AMD for up to 2 years. There is level I evidence to support this conclusion for pegaptanib and ranibizumab, but none for bevacizumab at this time. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

Purpose After the recent approval of ocriplasmin by the Food and Drug Administration, postmarketing safety concerns have been raised by the vitreoretinal community. The American Society of Retina Specialists Therapeutic Surveillance Committee was commissioned to monitor postmarketing drug-related and device-related adverse events. The purpose of this report is to analyze the postmarketing safety experience in the context of available premarketing safety data. Methods Periodic aggregate safety reports consisting of premarketing, or clinical trial, data (n = 999 injections) and postmarketing reports through July 16, 2013 (n = 4,387 injections), were retrospectively analyzed by the TSC. The aggregate data were analyzed to classify adverse events, and the postmarketing safety data for each event type were compared with the premarketing data. Results Eight categories of adverse events were identified. Acute reduction in visual acuity attributable to either worsening of macular pathology or development of subretinal fluid, electroretinogram changes, dyschromatopsia, retinal tears and detachments, lens subluxation or phacodonesis, impaired pupillary reflex, and retinal vessel findings were reported in both the premarketing and postmarketing experiences. Ellipsoid zone (inner segment/outer segment) findings were only reported in the postmarketing experience. Rates of postmarketing reports were lower than in the premarketing data. Adverse events were generally transient, and characteristics of these adverse events were generally similar between the premarketing and postmarketing experience. Conclusion Postmarket analyses are limited by significant underreporting, and in the case of ocriplasmin as a first in-class drug, they may not have captured safety events that have only more recently been identified. Nonetheless, postmarket analyses can identify the scope of potential safety events based on real-world experiences. Ocriplasmin administration should be guided by an appropriate and informed risk-benefit discussion with the patient. Ongoing active postmarket surveillance by all practitioners will continue to be critical to better understand this safety profile.

Importance Aflibercept-related sterile inflammation, an event that is poorly understood, has been the subject of ongoing postmarketing reports. Objective To analyze cases of aflibercept-related sterile inflammation reported to the American Society of Retina Specialists (ASRS) Therapeutic Surveillance Committee (TSC), an independent task force formed to monitor drug- and device-related safety events. Design, Setting, and Participants A retrospective review of 56 cases in 55 patients was performed of all cases of sterile inflammation after aflibercept injection that were voluntarily reported by 12 practices throughout the United States to the ASRS TSC from December 1, 2011, through February 12, 2014. Main Outcomes and Measures Cases of aflibercept-related sterile inflammation were analyzed for baseline and demographic information, presenting symptoms and findings, visual acuity changes, injection technique, and management details. Results Among 56 reported cases of sterile inflammation, mean time to onset was 3.5 days (median, 2 days; range, 0-30 days). Most cases consisted of initial loss of vision and intraocular inflammation without prominent redness, severe pain, or hypopyon. Thirty-seven cases (66%) were treated with topical corticosteroids and/or observation alone. Mean time to resolution was 28.6 days (median, 28 days; range, 4-84 days). Although final vision was overall unchanged, some patients developed permanent vision loss, which may have resulted from inflammation and/or progression of the underlying disease. Age older than 80 years was associated with worse visual outcomes. No difference in visual outcome was detected in patients with sterile inflammation undergoing topical therapy alone vs invasive procedures (vitreous biopsy and/or intravitreal antibiotic administration and/or vitrectomy). Conclusions and Relevance With the largest number of reported cases of aflibercept-related sterile inflammation to our knowledge, this analysis suggests typical findings and an often favorable prognosis of this event. Analysis of real-world, postmarketing data has limitations, and these findings should be considered as hypothesis-generating assessments rather than a definitive reflection of this event or its typical course. Distinguishing sterile inflammation and infectious endophthalmitis at the time of presentation may often be difficult, and cautious evaluation and management of these patients are warranted. The ASRS TSC encourages active postmarketing surveillance by all physicians.

Cholesterol elimination from nonhepatic cells involves metabolism to side-chain oxysterols, which serve as transport forms of cholesterol and bioactive molecules modulating a variety of cellular processes. Cholesterol metabolism is tissue specific, and its significance has not yet been established for the retina, where cytochromes P450 (CYP27A1 and CYP46A1) are the major cholesterol-metabolizing enzymes. We generated Cyp27a1(-/-)Cyp46a1(-/-) mice, which were lean and had normal serum cholesterol and glucose levels. These animals, however, had changes in the retinal vasculature, retina, and several nonocular organs (lungs, liver, and spleen). Changes in the retinal vasculature included structural abnormalities (retinal-choroidal anastomoses, arteriovenous shunts, increased permeability, dilation, nonperfusion, and capillary degeneration) and cholesterol deposition and oxidation in the vascular wall, which also exhibited increased adhesion of leukocytes and activation of the complement pathway. Changes in the retina included increased content of cholesterol and its metabolite, cholestanol, which were focally deposited at the apical and basal sides of the retinal pigment epithelium. Retinal macrophages of Cyp27a1(-/-)Cyp46a1(-/-) mice were activated, and oxidative stress was noted in their photoreceptor inner segments. Our findings demonstrate the importance of retinal cholesterol metabolism for maintenance of the normal retina, and suggest new targets for diseases affecting the retinal vasculature.

Purpose Muller cells, a major type of glial cell found in the eye, are postulated to play an important role in many retinal diseases, including diabetic retinopathy (DR). Complement is an integral part of innate immunity, and the activation of complement has been associated with retinal diseases. However, the role of complement in the regulation of Muller cell function remains unclear. We were trying to address these issues in this study. Methods Using primary human Muller cells and a spontaneously immortalized human Muller cell line, we examined the expression of complement receptor C5aR both at mRNA and protein levels. Regulation of C5aR expression on Muller cells by prostaglandin E2 and by hyperglycemia, both of which are integrally involved in DR, were studied. Significance of C5aR on Muller cells was also investigated by examining relevant cytokine productions and their impacts on retinal endothelial cell proliferation/permeability after ligating the receptor using its ligand, C5a. Results C5aR is constitutively expressed in human Muller cells. Prostaglandin E2 and hyperglycemia individually and synergistically upregulate C5aR expression in Muller cells. Signaling through C5aR on Muller cells upregulates production of IL-6 and VEGF, which promotes the proliferation of human retinal endothelial cells and increases their permeability. Conclusions These results indicate that complement can regulate Muller cells through C5aR, which may contribute to the pathogenesis of retinal diseases, including DR.

All injections were performed with standard techniques based on survey responses. Povidone-iodine 5% was applied before injection in all cases. Thirteen of 15 eyes were administered topical anesthesia, and 2 eyes were given subconjunctival lidocaine. All eyes were injected with the Becton Dickinson (Franklin Lakes, NJ) 1-ml Luer-Lok syringe included in the aflibercept packaging. The majority of eyes were injected in the superotemporal quadrant (12 of 15 eyes) and with a 32-G needle (13 of 15 eyes), while the remainder were injected in the inferotemporal quadrant (3 of 15 eyes) and with a 30-G needle (2 of 15 eyes). These differences likely represent individual practice pattern differences and are not an implication of these techniques. Five physicians practicing in the Northeast, the Southeast, and the Southern United States reported cases of sterile inflammation. Three physicians practiced in the same retina group, and 9 of 15 cases (60%) were reported by a single retina specialist in this practice, consistent with a clustering pattern previously reported with other intravitreal therapies. 2 All cases were attributed to 5 separate drug lots, with 3 lots accounting for 13 of 15 cases. All but 1 patient experienced symptoms within 3 days. Visual acuity generally recovered to baseline levels with nearly identical mean visual acuities at baseline (0.4 logarithm of the minimum angle of resolution) and after resolution (0.32 logarithm of the minimum angle of resolution) and a mean time to resolution of 30 days. No patient lost 1 Snellen line of visual acuity. In contrast with previous reports associating sterile inflammation from other intravitreal therapies with painless loss of vision, 3 9 of these 15 aflibercept-related cases (60%) presented with pain. Redness was noted only in eyes presenting with pain and in 6 of these 9 painful cases. It is possible that aflibercept-related sterile inflammation may be associated with higher rates of pain than previously reported. Alternatively, this difference may reflect differences in the treatment cohorts. Distinguishing between infectious and sterile endophthalmitis was at the discretion of the treating physician. Although all reported cases were culture negative, some of the cases treated with intravitreal antibiotics may have represented culture-negative infectious endophthalmitis, which is associated with increased pain, and not true sterile inflammation. However, 5 of 9 cases associated with pain were treated with vitreous tap and intravitreal antibiotic injection, and the remaining 4 cases were treated with topical steroids only, suggesting that potential misclassification of these symptoms is not fully responsible for this difference. It is likely that patients presenting with more pain were biased toward an initial diagnosis of infectious endophthalmitis (treated with tap/antibiotic injection) compared with those patients managed with topical steroids alone. Small sample size, clinical variation, and the limitations of voluntary reporting preclude definitive conclusions. Subgroup analysis did not detect any variables significantly affecting visual outcome or number of days to resolution (Tables 4 and 5; available at http://www.aaojournal.org). This letter serves as a descriptive case series to better understand the clinical characteristics of a cluster of aflibercept-related sterile inflammation. The manufacturer reports that approximately 30 000 injections had been administered during the reporting period, corresponding with a sterile inflammation rate of approximately 0.05%. Although there may certainly be additional, nonreported cases resulting in a higher actual rate, this frequency lies within the range documented by pivotal, prospective trials with aflibercept and other intravitreal agents and by retrospective analyses (Tables 6 and 7; available at http://www.aaojournal.org). The manufacturer continued to closely observe without public recalls or testing, and use of aflibercept has continued without persistent reports of unexpected rates of complications. The American Society of Retina Specialists Therapeutic Surveillance Subcommittee strongly urges practitioners to actively participate in postmarket surveillance of drug- and device-associated adverse events.

Retinal vascular tortuosity is associated with retinopathy of differing etiologies, including hypertension, diabetes, and hypoxia. However, detailed understanding of the underlying pathophysiology is lacking. The aim of this study was to map changes in tortuosity associated with hypoxia at high altitude, and to determine the influence of sildenafil and an antioxidant preparation on altitude-induced tortuosity.We measured the tortuosity of retinal vessels using a semi-automated method in 35 young, healthy subjects exposed to hypobaric hypoxia for 7 days at 5200 m, and compared the measurements to those from the same vessels at sea level. These subjects simultaneously took part in a randomized double-blind placebo-controlled trial of sildenafil and antioxidant. Comparison of tortuosity between these subgroups was performed.High altitude was associated with the development of retinal tortuosity in individual vessels. A nonsignificant trend suggests this is limited by prophylaxis with sildenafil or antioxidant.Retinal vessel tortuosity increases rapidly at high altitude. We suggest that retinal vessel tortuosity at altitude may result from increased sheer stress causing elongation of vessel segments and that this might be limited by agents that act to preserve nitric oxide dependent vasodilation.NCT00664001, NCT00627965.

Background The retina is a light-sensitive tissue lining the inner surface of the eye and one of the few human organs whose cholesterol maintenance is still poorly understood. Challenges in studies of the retina include its complex multicellular and multilayered structure; unique cell types and functions; and specific physico-chemical environment. Methodology/Principal Findings We isolated specimens of the neural retina (NR) and underlying retinal pigment epithelium (RPE)/choroid from six deceased human donors and evaluated them for expression of genes and proteins representing the major pathways of cholesterol input, output and regulation. Eighty-four genes were studied by PCR array, 16 genes were assessed by quantitative real time PCR, and 13 proteins were characterized by immunohistochemistry. Cholesterol distribution among different retinal layers was analyzed as well by histochemical staining with filipin. Our major findings pertain to two adjacent retinal layers: the photoreceptor outer segments of NR and the RPE. We demonstrate that in the photoreceptor outer segments, cholesterol biosynthesis, catabolism and regulation via LXR and SREBP are weak or absent and cholesterol content is the lowest of all retinal layers. Cholesterol maintenance in the RPE is different, yet the gene expression also does not appear to be regulated by the SREBPs and varies significantly among different individuals. Conclusions/Significance This comprehensive investigation provides important insights into the relationship and spatial distribution of different pathways of cholesterol input, output and regulation in the NR-RPE region. The data obtained are important for deciphering the putative link between cholesterol and age-related macular degeneration, a major cause of irreversible vision loss in the elderly.

Conclusions: To investigate the long-term visual and systemic prognosis of patients with idiopathic recurrent branch retinal artery occlusions, and to test recent hypotheses regarding possible causes of this syndrome. Methods: The authors retrospectively reviewed the medical and photographic records of 16 eligible patients. Each of 15 living patients was interviewed by one of the authors, then underwent follow-up ophthalmic examination, formal visual field testing, and a battery of clinical laboratory tests. Results: Over a mean follow-up of 9 years, only three eyes (9%) lost visual acuity from foveal ischemia, although nine eyes (28%) had central and/or extensive peripheral visual field loss at final examination. Ocular neovascular complications developed in eight eyes (25%). Eight patients (50%) had associated vestibuloauditory and/or transient sensorimotor symptoms, but serious permanent neurologic deficits or recurrent systemic thromboembolic events did not develop. Although most patients had one or more vasoocclusive risk factors, extensive laboratory testing failed to define the etiology of the arterial occlusions. Conclusions: On long-term follow-up, the visual, neurologic, and systemic prognosis for most patients with idiopathic recurrent branch retinal arterial occlusions remains favorable. Although it is probable that such patients are etiologically heterogeneous, the authors theorize that many have mild or partial manifestations of the microangiopathic syndrome of encephalopathy, hearing loss, and retinal arteriolar occlusions. Ophthalmology 1994;101:480-489

To test the hypothesis that retinal pericytes (RPCs) are immunosuppressive; therefore, their loss of function under hyperglycemic conditions favors retinal inflammation and contributes to the pathogenesis of diabetic retinopathy (DR).Isolated mouse and human RPCs were tested in T cell function assays to evaluate their capability of inhibiting T cell responses. To elucidate the underlying mechanisms, transwell systems, blocking mAbs against PD-L1 and IL-10 were used. The efficacy of RPCs in protecting retinal endothelial cells (RECs) from inflammation-induced apoptosis was assessed by apoptosis detection staining. Finally, to test whether hyperglycemic conditions impair the immunomodulatory activity of RPCs, RPCs pre-incubated in high glucose or methylglyoxal (MGO) were evaluated using the T cell proliferation assays.RPCs profoundly inhibited activated T cell proliferation and inflammatory cytokine production. The T cell inhibitory activity of RPCs was decreased, but was not abolished, in transwell experiments. RPCs express PD-L1, and blocking PD-L1 reduced RPCs' efficacy of T cell inhibition. RPCs also produce IL-10, and neutralization of IL-10 reduced their immunosuppressive activity. There were significantly reduced numbers of inflammation-induced apoptosis-detected RECs in the presence of RPCs. Incubation of RPCs with either high glucose or MGO reduced the activity of RPCs to inhibit activated T cell proliferation.RPCs are highly immunosuppressive and they protected RECs from inflammation-mediated apoptosis. Hyperglycemic conditions impaired the T cell inhibitory activity of RPCs. These results reveal a new function of RPCs, and its regulation under hyperglycemic conditions. This may represent a novel mechanism by which RPCs contribute to preservation of retinal integrity in diseases, including DR.

While not trained to specifically diagnose or treat ophthalmic conditions, primary care physicians can play a significant role in the visual health of their patients, specifically those with diabetes. Diabetic retinopathy is a leading cause of vision loss and blindness in the United States and because of its asymptomatic nature, patients often do not seek eye care until they notice changes in their vision. Patients with diabetes look to their physicians for guidance in managing all aspects of the disease, and research has shown people are more likely to have their eyes examined if their physician suggests it. Physicians should discuss visual health with patients and make referrals for annual comprehensive dilated eye examinations. Vision loss and blindness from diabetes can often be prevented through early detection and timely treatment; however, many patients seek eye care at a stage too late for treatment to be effective.

Twelve phakic eyes (11 patients) with culture-positive endophthalmitis were treated without removal of the uninvolved crystalline lens. Eight eyes were treated by pars plana vitrectomy and intraocular injection of antibiotics. Four eyes were treated with intraocular antibiotic injection alone. The clinical infection was successfully eradicated in all patients, including one patient treated with reinjection of antibiotics. During follow-up after successful treatment, eight eyes had progression of a preexisting lens opacification, two eyes had stable lens opacification, and two eyes maintained clear lenses. Six of 12 eyes achieved 20/80 or better visual acuity with an average follow-up time of 13 months. Six of eight eyes treated with pars plana vitrectomy and intraocular antibiotic injection achieved this level of visual acuity in contrast to none of four eyes treated with only intraocular antibiotic injection. These results indicated that endophthalmitis in phakic eyes can be successfully treated while preserving a clear, uninvolved crystalline lens by the use of pars plana vitrectomy and intraocular administration of appropriate antibiotics.

Pneumocystis carinii choroiditis is a well-documented but rare infection that has been described as a bilateral, multifocal process. Treatment efficacy has not been well established. In this report, three cases of presumed P. carinii choroiditis that developed during aerosolized pentamidine therapy for the prophylaxis of P. carinii pneumonia are described. All patients had unilateral choroiditis, and two patients were first observed to have unifocal choroiditis. In all patients, choroidal lesions decreased in size with intravenous pentamidine treatment. Choroiditis exacerbated in the two unifocal cases after the frequency of maintenance intravenous pentamidine therapy was decreased. P. carinii choroiditis may appear as a unifocal, unilateral lesion that may represent an earlier stage of infection than previously described. Intravenous pentamidine therapy appears to control P. carinii choroiditis but may need to be continued to prevent exacerbation. Patients receiving prophylactic aerosolized pentamidine therapy are not protected against extrapulmonary disease, and presumed P. carinii choroiditis may serve as a marker for disseminated infection.

To examine the evidence about the safety and efficacy of anti-vascular endothelial growth factor (VEGF) pharmacotherapies for the treatment of neovascular age-related macular degeneration (AMD).Literature searches were conducted in May and October 2007 in PubMed with no date restrictions, limited to articles published in English, and in the Cochrane Central Register of Controlled Trials without a language limitation and yielded 310 citations. The first author reviewed the abstracts of these articles and selected 73 articles of possible clinical relevance for review by the panel. The panel deemed 64 of these articles sufficiently clinically relevant to review in full text and assigned ratings of level of evidence to each of the selected articles with the guidance of the panel methodologists.Eleven studies provided level I evidence for intravitreal pegaptanib and ranibizumab for neovascular AMD; there were no studies rated level I for bevacizumab for neovascular AMD. Five studies were rated as level II, which included studies of ranibizumab and bevacizumab, and the remaining 38 articles retrieved were rated as level III. The studies do not provide information about long-term results or the value (comparative effectiveness) and cost-effectiveness of combined therapies.Review of the available literature to date suggests that anti-VEGF pharmacotherapy, delivered by intravitreal injection, is a safe and effective treatment for neovascular AMD for up to 2 years. There is level I evidence to support this conclusion for pegaptanib and ranibizumab, but none for bevacizumab at this time.

A surgical technique for implanting a posterior chamber intraocular lens (IOL) in eyes without capsular or zonular support is presented. A 10-0 polypropylene suture attached to a standard needle is tied to the apex of each haptic and passed transclerally through the ciliary sulcus to secure the haptics at the 3 o'clock and 9 o'clock meridians. This technique produced good visual results in six aphakic patients who were contact lens intolerant, two patients in whom capsular or zonular rupture at the time of cataract surgery precluded standard nonsuture fixation techniques, one patient who had intracapsular cataract extraction for a subluxated, cataractous lens, and one patient who had secondary IOL implantation in combination with penetrating keratoplasty for aphakic bullous keratopathy. Advantages over other techniques o£ posterior chamber lens implantation in the absence of capsular support include technical ease, avoidance of iris fixation, and more precise placement of scleral fixation sutures, thus minimizing IOL decentration.

Importance For the management of retinal disease, the use of intravitreous injections of anti–vascular endothelial growth factor has increased. Recent reports have suggested that this therapy may cause sustained elevation of intraocular pressure (IOP) and may potentially increase the risk of glaucoma for patients with retinal disease. Objective To assess the risk of sustained IOP elevation or the need for IOP-lowering treatments for eyes with diabetic macular edema following repeated intravitreous injections of ranibizumab. Design, Setting, and Participants An exploratory analysis was conducted within a Diabetic Retinopathy Clinical Research Network randomized clinical trial. Study enrollment dates were from March 20, 2007, to December 17, 2008. Of 582 eyes (of 486 participants) with center-involved diabetic macular edema and no preexisting open-angle glaucoma, 260 were randomly assigned to receive a sham injection plus focal/grid laser treatment, and 322 were randomly assigned to receive ranibizumab plus deferred or prompt focal/grid laser treatment. Main Outcomes and Measures The cumulative probability of sustained IOP elevation, defined as IOP of at least 22 mm Hg and an increase of at least 6 mm Hg from baseline at 2 consecutive visits, or the initiation or augmentation of ocular hypotensive therapy, through 3 years of follow-up. Results The mean (SD) baseline IOP in both treatment groups was 16 (3) mm Hg (range, 5-24 mm Hg). The cumulative probability of sustained IOP elevation or of initiation or augmentation of ocular hypotensive therapy by 3 years, after repeated ranibizumab injections, was 9.5% for the participants who received ranibizumab plus prompt or deferred focal/grid laser treatment vs 3.4% for the participants who received a sham injection plus focal/grid laser treatment (difference, 6.1% [99% CI, −0.2% to 12.3%]; hazard ratio, 2.9 [99% CI, 1.0-7.9]; P = .01). The distribution of IOP and the change in IOP from baseline at each visit through 3 years were similar in each group. Conclusions and Relevance In eyes with center-involved diabetic macular edema and no prior open-angle glaucoma, repeated intravitreous injections of ranibizumab may increase the risk of sustained IOP elevation or the need for ocular hypotensive treatment. Clinicians should be aware of this risk and should consider this information when following up with patients who have received intravitreous injections of anti–vascular endothelial growth factor for the treatment of diabetic macular edema.

High altitude retinopathy (HAR) was first described in 1969 as engorgement of retinal veins with occasional papilloedema and vitreous hemorrhage. Since then various studies have attempted to define the incidence, etiology and significance of this phenomenon, usually with small numbers of subjects. Recently studies on relatively large groups of subjects in Nepal, Bolivia and Tibet have confirmed that the retinal vasculature becomes engorged and tortuous in all lowlanders ascending above 2500m. Sometimes this leads to hemorrhages, cotton wool spots and papilloedema, which is the pathological state better known as high altitude retinopathy. These studies have also shown a significant change in both corneal thickness and intraocular pressure at altitude. The retinal blood vessels are the only directly observable vascular system in the human body and also supply some of the most oxygen-demanding tissue, the photoreceptors of the retina. New techniques are being applied in both hypobaric chamber and field expeditions to observe changes in retinal function during conditions of hypobaric hypoxia. This work allows better advice to be given to lowlanders traveling to altitude either if they have pre-existing ocular conditions or if they suffer from visual problems whilst at altitude. This especially applies to the effect of altitude on refractive eye surgery and results of recent studies will be discussed so that physicians can advise their patients using the latest evidence. Retinal hypoxia at sea level accounts for the developed world's largest cause of blindness, diabetic retinopathy. The investigation of retinal response to hypobaric hypoxia in healthy subjects may open new avenues for treatment of this debilitating disease.

High altitude retinopathy (HAR) was first described in 1969 as engorgement of retinal veins with occasional papilloedema and vitreous hemorrhage. Since then various studies have attempted to define the incidence, etiology and significance of this phenomenon, usually with small numbers of subjects. Recently studies on relatively large groups of subjects in Nepal, Bolivia and Tibet have confirmed that the retinal vasculature becomes engorged and tortuous in all lowlanders ascending above 2500m. Sometimes this leads to hemorrhages, cotton wool spots and papilloedema, which is the pathological state better known as high altitude retinopathy. These studies have also shown a significant change in both corneal thickness and intraocular pressure at altitude. The retinal blood vessels are the only directly observable vascular system in the human body and also supply some of the most oxygen-demanding tissue, the photoreceptors of the retina. New techniques are being applied in both hypobaric chamber and field expeditions to observe changes in retinal function during conditions of hypobaric hypoxia. This work allows better advice to be given to lowlanders traveling to altitude either if they have pre-existing ocular conditions or if they suffer from visual problems whilst at altitude. This especially applies to the effect of altitude on refractive eye surgery and results of recent studies will be discussed so that physicians can advise their patients using the latest evidence. Retinal hypoxia at sea level accounts for the developed world's largest cause of blindness, diabetic retinopathy. The investigation of retinal response to hypobaric hypoxia in healthy subjects may open new avenues for treatment of this debilitating disease.

Summary 1. The obese SHR (Koletsky rat; SHR-k) is a unique animal model for the study of microvascular changes associated with genetic obesity, spontaneous hypertension, endogenous hyper-lipidaemia, and hyperinsulinaernic, non-insulin dependent diabetes mellitus (Type II). 2. Lean and obese SHR-k exhibit retinal vascular changes which have not been previously characterized and are more severe than previously described in other animal models of experimental hypertension or non-insulin dependent diabetes. 3. Progressive retinal capillary dropout, capillary cell changes, vascular tortuosity and dilatation are severe. Vessels form elevated varicose vascular tortuosities which leak fluo-rescein dye and which are more frequent in the obese SHR-k. This study suggests that lean and obese SHR may be unique models for the study of multivariate factors in the pathogenesis of ischaemic neovascular proliferation.

PURPOSE. To test the hypothesis that autoantibodies against retinal pericytes could develop in diabetic retinopathy, and that these autoantibodies could induce retinal pericyte dysfunction/ death via complement. METHODS. Human primary retinal pericytes cultured in media containing normal (5 mM) or high (30 mM) glucose concentrations were incubated with normal human sera in the presence of a retinal pericyte-reactive antibody, then their viability was assessed by a BCECF-based cytotoxicity assay, and their function was assessed by a T-cell proliferation assay. The pericytes were also analyzed by RT-PCR and flow cytometry to detect CD38, an established diabetes-associated cell surface autoantigen. The potential of the anti-CD38 antibodies in inducing pericyte cellular injury was evaluated using the same cytotoxicity assays. In addition, autoantibody-mediated cytotoxicity in mouse retinal pericytes sensitized by sera from mice with developing diabetic retinopathy or control normal mice were also studied. RESULTS. Retinal pericyte‐reactive antibodies induced cellular damage by activating complement in the serum. The antibodyinjured pericytes had reduced efficacy in inhibiting T cells. Hyperglycemic culture conditions rendered pericytes more susceptible to antibody-mediated attack. CD38 was expressed in retinal pericytes, and upregulated by TNF-a and IFN-c, and anti-CD38 antibodies induced pericyte cytotoxicity. Retinal pericytes sensitized with sera from chronic diabetic mice suffered significantly augmented cytotoxicity compared with those sensitized with sera from the control mice. CONCLUSIONS. The autoantibody-initiated complement activation could be a mechanism underlying the loss of function, and eventually, death of retinal pericytes in diabetic patients, suggesting that inhibiting complement activation could be a novel therapeutic approach. (Invest Ophthalmol Vis Sci. 2012; 53:5520‐5526) DOI:10.1167/iovs.12-10010

Steady state levels of cholesterol in any organ represent a balance between the pathways of accumulation and elimination. These pathways have been studied extensively in the liver, the central organ for regulation of total body cholesterol homeostasis,1 and less intensively in the brain and eye (see Refs. 2–7 for reviews), whose contribution to total body cholesterol balance are deemed not very significant. Cholesterol homeostasis in the brain and retina, however, is now drawing more attention because of the putative links between cholesterol and Alzheimer's disease and cholesterol and age-related macular degeneration (AMD).8,9 Because cholesterol cannot cross the blood-brain barrier, most of the brain's cholesterol is derived from local synthesis.10 The retina also has a barrier, the blood-retinal barrier,11 and thus synthesizes cholesterol endogenously.12,13 Yet, in contrast to the brain, plasma low-density lipoprotein (LDL) containing high amounts of cholesterol can enter the retina through the underlying retinal pigment epithelium (RPE).14 The relative contributions of LDL-derived cholesterol and endogenously synthesized cholesterol to total retinal cholesterol are unknown. It has also been established that cholesterol trafficking in the central nervous system is mediated by apolipoprotein E7 and that elimination is achieved by enzymatic conversion to 24S-hydroxycholesterol (24-OH) by cytochrome P450 46A1 (CYP46A1).15–17 24-OH spontaneously diffuses across cellular membranes and the blood-brain barrier, becomes associated with plasma lipoproteins, and is delivered to the liver for further degradation to bile acids.2 Systematic elucidation of cholesterol transport and metabolism in the retina began only recently. Many proteins involved in the reverse transport of cholesterol from extrahepatic tissues to the liver—apolipoproteins E and A1; cholesterol efflux transporter ABCA1; class B scavenger receptors SR-BI, SR-B-II and CD36; lecithin-cholesterol acyltransferase; and cholesteryl ester transfer protein—were also found to be expressed in the retina.18–22 Based on the retinal localization of these proteins, it was proposed that lipids move within the retina in the form of high-density lipoprotein (HDL) and may be secreted back to the circulation to maintain homeostasis.19 The importance of HDL and cholesterol transport are also supported by two recent genetic studies that revealed association between AMD and several genes (hepatic triglyceride lipase, cholesteryl ester transfer protein, ABCA1, and lipoprotein lipase) involved in the metabolism of HDL.23,24 In parallel, significant efforts are being directed toward elucidating the source of age-dependent lipid deposition in Bruch's membrane (BrM), where drusen, the clinical hallmark of AMD, develop. BrM is located between the RPE and the choriocapillaris. Evidence from light microscopy, ultrastructural studies, lipid histochemistry, isolated lipoprotein assays, and gene expression analysis suggests that lipid deposition in BrM is, at least in part, due to the accumulation of apolipoprotein B-containing particles complexed with esterified cholesterol (see Refs. 5 and 6 for reviews). A model was developed according to which, in younger eyes, cholesterol-rich lipoprotein particles leave the RPE and cross the BrM for egress to the plasma. With advanced age, transit time across BrM increases, resulting in lipoprotein accumulation and modification. This eventually leads to the formation of drusen.5,6 Incorporation into lipoprotein particles is not the only mechanism whereby extrahepatic cells dispose of excess cholesterol. Cholesterol is also eliminated enzymatically through metabolism to more polar 27-OH or 24-OH or by conversion to steroid hormones (Fig. 1). Cholesterol 27-hydroxylation, catalyzed by cytochrome P450 27A1 (CYP27A1), takes place in many extrahepatic cells, complementing HDL-mediated reverse cholesterol transport.25,26 CYP27A1, however, probably does not contribute significantly to cholesterol elimination from the brain under normal conditions, where hydroxylation at position 24 represents the major mechanism of cholesterol removal.2,27 Also expressed in the brain is cytochrome P450 11A1 (CYP11A1), which catalyzes the conversion of cholesterol to pregnenolone (Preg), the first step in steroid hormone biosynthesis.28 Similarly to CYP27A1, CYP11A1 plays only a minor role in cerebral cholesterol removal; this enzyme is important for cholesterol metabolism in steroidogenic tissues. All three cholesterol-metabolizing P450s—CYPs 27A1, 46A1, and 11A1—were found to be expressed in the retina,29–33 but their significance for retinal cholesterol homeostasis has not yet been investigated, and it is still unknown whether the major mechanism for enzymatic elimination of cholesterol from the retina involves 24- or 27-hydroxylation or the conversion to Preg. To gain insight into the initial steps of retinal cholesterol biotransformations, we measured the levels of five oxysterols that represent the products of cholesterol-metabolizing P450s. Analytical procedures were first optimized on bovine tissues, followed by sterol quantifications in human specimens. Retinal and RPE sterols were also compared with sterol profiles in extraocular organs in which cholesterol-metabolizing P450s are the most abundant. Quite unexpectedly, 3β-hydroxy-5-cholestenoic acid (27-COOH), an oxidation product of 27-OH, was found to be the predominant oxysterol in the human retina. These and other data indicate that cholesterol metabolism in the retina is significantly different from that in the brain. Figure 1. Schematic representation of cholesterol elimination pathways in different extrahepatic organs and cytochrome P450 enzymes involved in these pathways. Bold lines and bold font indicate the major contributors and products of cholesterol elimination.

In complex cases of retinal detachment, perfluoropropane (C3F8) is frequently used after vitrectomy for tamponade of retinal breaks. Results of previous studies of C3F8 disappearance using 10% C3F8 after vitrectomy in human eyes have differed significantly. A wide variation in the decay rate and half life of C3F8 after vitrectomy was observed in eyes that had similar clinical settings and received the same C3F8 concentration (15%, 20%, or 25%). This occurred even in those eyes where there was no change in the geometric contour of the eye after a repeat vitrectomy.

We describe a patient with a preexisting, functioning Molteno implant in whom acute endophthalmitis developed following cataract extraction. The condition was treated successfully without removing the implant.