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Background: It is unclear whether post-operative errors after toric intraocular lens implantation would be more amenable to pre-operative correction with a fixed adjustment or a correction ratio that scales with the magnitude of pre-operative astigmatism. Purpose: To investigate the effect of pre-operative anterior corneal astigmatism orientation on outcomes of toric intraocular lens implantation in a large population. Methods: A retrospective cohort study of 625 patients undergoing refractive lens exchange through a superior clear corneal incision with Oculentis M-Plus toric intraocular lens implantation at an Optical Express, Inc. located in the United Kingdom and Ireland. Patients were stratified by axis of astigmatism on automated keratometry as with-the-rule, against-the-rule, or oblique. Analysis of visual acuity and refractive outcomes was performed using American National Standards Institute (ANSI) guidelines on astigmatic corrections with non-vector as well as vector analyses. Analysis was limited to one eye per patient. Results: Patients who had with-the-rule (WTR) astigmatism, compared with oblique and against-the-rule (ATR), had higher vector magnitudes of surgically induced refractive correction (2.89D, 2.55D, 2.42D; p < 0.001), and larger correction ratios (1.18, 1.02, 1.07; p < 0.001). This created a change of astigmatic axis in the with-the-rule cohort from WTR pre-operative astigmatism to an average ATR post-operative astigmatism. The overcorrection in the WTR cohort averaged 0.30D. We found that the absolute dioptric overcorrection among WTR patients did not differ significantly with magnitude of corneal astigmatism, but the correction ratio was lower among those with higher baseline cylindrical errors (p = 0.93 and 0.0002, respectively). Conclusions: Refractive lens exchange surgery using toric intraocular lenses overcorrected patients who had with-the-rule astigmatism. Degree of overcorrection did not vary with severity of pre-operative astigmatism. Incorporation of axis of astigmatism in lens selection and reduction of astigmatic correction among with-the-rule patients by an absolute value of 0.25D - 0.35D, rather than proportional adjustments, may reduce cylindrical over-correction.

Purpose Pain associated with panretinal photocoagulation (PRP) can adversely affect the number and quality of retinal burns delivered and subsequently increase the number of treatment sessions required to achieve regression of proliferative diabetic retinopathy (PDR). We assessed comfort in patients undergoing treatment with yellow (577 nm) vs. green (532 nm) PRP for PDR. Design Prospective, single-center, randomized crossover clinical trial. Subjects Patients with PDR with high-risk characteristics. Methods Subjects were equally randomized to first receive PRP with a laser indirect ophthalmoscope with either green (IQ 532; IRIDEX, Mountain View, CA) or yellow (IQ 577; IRIDEX) laser, followed by additional treatment with the opposite laser using standardized settings in the superior hemisphere of a single treatment eye per patient. Topical anesthetic was used in all study eyes before each treatment and power was titrated until moderate grey-white retinal burns were achieved. Main Outcome Measures The primary outcome measure was patient's perceived pain as measured with a standardized 10-point pain scale. Secondary outcome measures included laser power, treatment time, number of treatment shots with each laser, and physician ease-of-use score with each laser on a 10-point scale. Results Forty patients (40 eyes) with a mean age of 54.0 years were enrolled. Mean pain scores were similar when comparing treatment with yellow and green laser (3.1 ± 2.3 vs. 2.8 ± 2.6; P = 0.40). No significant difference was seen in visual acuity ( P = 0.44) or central macular thickness ( P = 0.39) 1 month after PRP. Additionally, there were no significant differences when comparing minimum power required (243.2 ± 74.2 vs. 234.0 ± 59.6 mW; P = 0.55), treatment time (5.1 ± 3.6 vs. 5.6 ± 3.9 minutes; P = 0.384), and number of treatment shots (257.6 ± 12.6 vs. 258.0 ± 2.3; P = 0.68). Six of 7 co-investigators (85%) preferred using yellow laser over green and reported ease-of-use scores of 9.0 ± 1.2 and 7.6 ± 1.4, respectively ( P = 0.07). No severe adverse events occurred. Conclusions Patient comfort during PRP for PDR utilizing laser indirect ophthalmoscopy is similar for green and yellow wavelengths.

Purpose To associate detection of potential pathogen DNA in endophthalmitis with clinical outcomes. Design Prospective cohort study. Methods Patients in whom endophthalmitis was diagnosed following an intraocular procedure were recruited. Clinical outcome data from baseline, week-1, month-1, and month-3 visits were collected. Intraocular biopsy samples were cultured by standard methods. Quantitative polymerase chain reaction (qPCR) was performed for specific pathogens and whole-genome sequencing (WGS). Results A total of 50 patients (mean age 72 years old; 52% male) were enrolled. Twenty-four cases were culture-positive and 26 were culture-negative. WGS identified the cultured organism in 76% of culture-positive cases and identified potential pathogens in 33% of culture-negative cases. Month-1 and -3 visual acuities did not vary by pathogen-positive versus pathogen-negative cases as detected by either culture or WGS. Visual outcomes of Staphylococcus epidermidis endophthalmitis were no different than those of pathogen-negative cases, whereas the patients infected with other pathogens showed worse outcome. Higher baseline bacterial DNA loads of bacteria other than those of S epidermidis detected by WGS were associated with worse month-1 and -3 visual acuity, whereas the S epidermidis loads did not appear to influence outcomes. Torque teno virus (TTV) and Merkel cell polyomavirus (MCV) were detected by qPCR in 49% and 19% of cases, respectively. Presence of TTV at presentation was associated with a higher rate of secondary pars plana vitrectomy (P = .009) and retinal detachment (P = .022). Conclusions The presence and higher load of bacteria other than S epidermidis detected by WGS or DNA from TTV by qPCR in ocular fluids is associated with worse outcomes in post-procedure endophthalmitis.

To describe two cases of vasculitis: one hemorrhagic and one nonhemorrhagic after uncomplicated cataract surgery with intracameral vancomycin.Retrospective case series.A 74-year-old female and a 54-year-old female developed severe visual loss within 2 weeks of uncomplicated cataract surgery with intracameral vancomycin. The first patient developed a fulminant hemorrhagic vasculitis, whereas the second patient developed a less severe nonhemorrhagic vasculitis. Partial visual recovery and prevention of neovascular glaucoma was achieved using a combination of topical, oral, and intravitreal corticosteroids, along with intravitreal antivascular endothelial growth factor agents in the first patient and a combination of topical and oral corticosteroids alone in the second patient.Hemorrhagic occlusive retinal vasculitis and nonhemorrhagic vasculitis after uncomplicated cataract surgery with intracameral vancomycin have been rarely reported. Early recognition and treatment may prevent devastating visual outcomes.

Loss to follow-up (LTFU) after anti-vascular endothelial growth factor (anti-VEGF) injections increases the risk of vision loss among patients with neovascular age-related macular degeneration (nAMD).To report rates of LTFU among patients with nAMD after anti-VEGF injections and to identify risk factors associated with LTFU in this population.This retrospective cohort study of data from 9007 patients who received anti-VEGF injections for treatment of nAMD was performed at an urban, private retina practice with multiple locations from April 1, 2012, to January 12, 2016.Rates of LTFU after anti-VEGF injections. Loss to follow-up was defined as receipt of 1 or more injections with no subsequent follow-up visit within 12 months.Among the 9007 patients (mean [SD] age, 81.2 [8.8] years; 5917 [65.7%] female; 7905 [87.8%] white), 2003 (22.2%) were LTFU. Odds of LTFU were greater among patients 81 to 85 years of age (odds ratio [OR], 1.58; 95% CI, 1.38-1.82; P .001), 86 to 90 years of age (OR, 2.29; 95% CI, 2.00-2.62; P .001), and more than 90 years of age (OR, 3.31; 95% CI, 2.83-3.86; P .001) compared with patients 80 years of age and younger. Odds of LTFU among African American patients (OR, 1.47; 95% CI, 1.00-2.16; P = .05), Asian patients (OR, 2.63; 95% CI, 1.71-4.03; P .001), patients of other race (OR, 3.07; 95% CI, 1.38-6.82; P = .006), and patients of unreported race (OR, 2.29; 95% CI, 1.96-2.68; P .001) were greater than odds of LTFU among white patients. Odds of LTFU were greater among patients with regional adjusted gross income of $50 000 or less (OR, 1.52; 95% CI, 1.30-1.79; P .001), $51 000 to $75 000 (OR, 1.35; 95% CI, 1.17-1.56; P .001), and $76 000 to $100 000 (OR, 1.28; 95% CI, 1.08-1.50; P = .004) compared with patients with incomes greater than $100 000. Odds of LTFU for patients living 21 to 30 miles (OR, 1.33; 95% CI, 1.05-1.69; P = .02) and more than 30 miles (OR, 1.55; 95% CI, 1.28-1.88; P .001) from clinic were greater compared with patients who lived 10 miles or less from the clinic. Odds of LTFU were greater among patients who received unilateral injections (OR, 1.44; 95% CI, 1.28-1.61; P .001) than among patients who received bilateral injections.We found a high rate of LTFU after anti-VEGF injections among patients with nAMD and identified multiple risk factors associated with LTFU among this population. Although our results may not be generalizable, data on LTFU in a clinical practice setting are needed to understand the scope of the problem so that interventions may be designed to improve outcomes.

BACKGROUND AND OBJECTIVE: This study evaluated the residual subfoveal fluid (SFF) immediately after rhegmatogenous retinal detachment (RRD) repair using intraoperative optical coherence tomography (iOCT). PATIENTS AND METHODS: This retrospective cohort study assessed fovea-involving RRD repaired by pars plana vitrectomy (PPV) using different drainage techniques. iOCT images were acquired through the fovea at the start of the case prior to initiating vitrectomy and then again immediately prior to introduction of tamponade. RESULTS: Ten eyes (32.3%) received perfluoro-n-octane (PFO), 12 (38.7%) underwent a posterior drainage retinotomy, and nine (29.0%) had drainage through the retinal break. There was no significant difference in the mean SFF thickness between eyes in either group ( P = .85). There was no significant association between SFF thickness on iOCT and functional or anatomic outcomes ( P > .05). CONCLUSION: There is no difference in the amount of residual SFF as measured on iOCT during RRD repair with pars plana vitrectomy using either direct drainage, drainage retinotomy, or PFO. [ Ophthalmic Surg Lasers Imaging Retina . 2019;50:497–503.]

The authors present a case of aggressive idiopathic orbital inflammation producing necrotizing scleritis along with synchronous tumefactive fibroinflammatory lesion of the temporal bone. A young woman with no medical history presented with sectoral scleritis and mildly reduced vision. Response to initial treatment, which included topical and systemic corticosteroids, as well as systemic nonsteroidal anti-inflammatory drugs, was limited. Over the following months, signs of orbital inflammation developed, including ptosis, proptosis, and limited extraocular motility. MRI revealed both orbital and ipsilateral temporal bone masses. An orbital biopsy was performed revealing a mixed inflammatory infiltrate, whereas a biopsy of the temporal bone mass revealed a tumefactive fibroinflammatory lesion. Biopsy showed no histopathologic evidence of infection nor neoplasm. The patient eventually responded to treatment with systemic prednisone, azathioprine, and rituximab.

Purpose: To describe an unusual presentation of bilateral HIV-associated multifocal retinal infiltrates with phlebitis and optic neuropathy in a pediatric patient from Zimbabwe, Africa. Methods: Retrospective case report of a 15-year-old boy from Zimbabwe, Africa. Results: The patient was found to have bilateral vitritis, multifocal retinitis with phlebitis, and optic neuropathy in the setting of previously unrecognized HIV infection. Vision improved and the clinical findings resolved after treatment with intravenous corticosteroids and highly active retroviral therapy (HAART). Conclusion: The authors describe the occurrence and treatment of bilateral, HIV-associated multifocal retinal infiltrates with phlebitis and HIV-associated optic neuropathy in a pediatric patient from Zimbabwe, Africa.

PURPOSE To report a prospective, randomized comparative study assessing clinical outcomes of plain gut versus polyglactin 910 (PG910) sutures for sclerotomy closure after 23-gauge pars plana vitrectomy. METHODS A single-masked, randomized, prospective study was undertaken with 49 eyes of 49 patients undergoing 23-gauge pars plana vitrectomy randomized to sclerotomy closure with either plain gut suture, PG910 (Vicryl) suture or a combination of the two. Assessment was based on both a postoperative pain scale and a standardized assessment of scleral inflammation at each suture site. RESULTS No wound leakage was noted postoperatively in any patient. Across all groups, scleral inflammation was significantly higher at the PG910 suture sites compared with the plain gut suture sites at both the 1-week (P = 0.04) and 1-month postoperative visits (P < 0.001). Patients with PG910 sutures reported greater pain at the 1-month postoperative visit than those with plain gut sutures (P = 0.018). CONCLUSION This prospective study suggests improved tolerability and reduced inflammation using plain gut suture compared with an 8-0 PG910 suture to close 23-gauge sclerotomies.

PURPOSE To describe the utility of microperimetry testing in the diagnosis of a bilateral occipital stroke. METHODS Retrospective case report. RESULTS A 57-year-old male with hypertension presented with complaints of bilateral blurred central vision and bilateral hypertensive retinopathy with cotton-wool spots. Automated perimetry demonstrated a central scotoma in both eyes that did not respect the vertical midline; however, microperimetry testing revealed a bilateral homonymous hemianopia that suggested cerebrovascular disease which was subsequently confirmed with magnetic resonance imaging. DISCUSSION In cases of unexplained central visual loss, microperimetry testing may be a useful ancillary test for the diagnosis of cerebrovascular disease.

The current dogma is that the oculocardiac reflex from orbital trapdoor fractures occurs only in children and young adults. We present the occurrence of the oculocardiac reflex in an adult with a non-displaced orbital floor fracture. CT demonstrated the adventitia surrounding the inferior rectus trapped in and below the orbital floor fracture. The patient's oculocardiac reflex resolved by early next morning, presumably from the tissue escaping from the orbital floor defect.

Purpose To prospectively determine the long-term success of medial rectus advancement alone or in combination with other procedures in the management of consecutive exotropia. Methods All patients with consecutive exotropia who underwent medial rectus advancement alone or in combination with medial rectus resection or lateral rectus recession or both, performed by a single surgeon between 1999 and 2010, were included. Initially, a retrospective review was performed. Patients were then recalled and examined by a masked observer. Good results were defined as final alignment within 10 Δ of orthotropia. Results A total of 46 patients were enrolled in the study with a mean age of 43 ± 15.5 years (range, 14-76) and a mean exotropia of 32 ± 18 Δ (range, 10-90). Good results were achieved in 33 patients (72%) at a mean follow-up time of 2.5 years. Of the 21 patients returning for prospective examination, 15 (71%) had good alignment at an average follow-up of 4.2 years (range, 6.9 months to 8.6 years). Adduction deficits were improved in 30 of 33 (91%) patients at final follow-up. Conclusions In patients with consecutive exotropia, surgery including medial rectus advancement alone or in combination with resection or lateral rectus recession or both usually is effective.

Background Anemia is common among patients with newly diagnosed cancer, may be exacerbated by cancer therapies, and leads to radioresistance by lowering oxygen levels in the tumor microenvironment. Herein, the effect of breast irradiation on hemoglobin levels and outcomes in breast conservation therapy is reported. Patients and Methods Medical records of 1368 women with stage 0, I, and II breast cancer treated with breast conservation therapy from 1977–2002 were reviewed. Hemoglobin levels at baseline as well as during and after radiation were recorded. Patterns of hemoglobin changes and the effect of anemia on local control and survival outcomes were assessed. Median follow-up time was 8 years for the normal group and 6 years for the anemic group. Results Baseline anemia was seen in 18% of the patients, 90% of whom had mild anemia (hemoglobin, 11.9–10.0 g/dL). Anemia was recorded in 21% during radiation. Among patients with normal baseline hemoglobin levels, 6.5% of the patients became anemic during radiation. Of those with baseline anemia, 72% had stable to improved hemoglobin levels during radiation, and 22% declined by a median of 0.3 g/dL. There were no significant differences in local or regional recurrence, overall, disease-free, cause-specific, or distant disease-free survival between patients with baseline anemia or with normal hemoglobin. Conclusion Radiation does not contribute significantly to anemia during breast conservation treatment, and mild anemia does not affect outcomes. It is unnecessary to obtain routine hemoglobin levels during radiation therapy. There is no difference in outcomes based on hemoglobin levels; thus, there is no reason to transfuse or provide erythropoiesis-stimulating agents for hemoglobin levels > 10 g/dL during radiation treatment of the breast.