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To evaluate the visual outcomes and the affect of timing of surgical repair of fovea-splitting rhegmatogenous retinal detachments.A retrospective, consecutive cohort from multiple surgeons at a single center. Fovea status (fovea-on, fovea-splitting, or fovea-off) was classified by preoperative optical coherence tomography. The primary outcome measure was the visual acuity at the last follow-up that was further correlated with the timing of surgical repair.One hundred and ninety-five eyes were included with 62 fovea-on, 65 fovea-splitting, and 68 fovea-off detachments. The mean preoperative logarithm of the minimum angle of resolution visual acuity for fovea-on, fovea-splitting, and fovea-off groups was 0.16 ± 0.21, 0.70 ± 0.56, and 1.67 ± 0.87, respectively (P =0.001). Mean postoperative logarithm of the minimum angle of resolution visual acuity for fovea-on, fovea-splitting, and fovea-off groups were 0.07 ± 0.13, 0.10 ± 0.15, and 0.20 ± 0.22, respectively (P =0.001). A statistically significant difference in mean postoperative logMAR visual acuity was found between fovea-off and fovea-on groups (P = 0.003) and between fovea-off and fovea-splitting groups (P = 0.013), however not between fovea-on and fovea-splitting groups (P = 0.827). Visual acuity improved when repair was performed earlier after presentation for fovea-on (R = 0.378, P = 0.002) and fovea-off groups (R = 0.277, P = 0.022), but not for the fovea-splitting group (R = 0.089, P = 0.481).We described the favorable visual outcomes of surgery for fovea-splitting rhegmatogenous retinal detachment and correlated these with the timing of surgical repair, which may help guide the management of this urgent, vision-threatening condition.

To review the autologous retinal transplantation surgical technique, indications, rationale, and current outcomes of data published to date.Review of surgical technique, preoperative and postoperative best-corrected visual acuity, and macular hole (MH) closure rate in studies with at least five eyes.The weighted average macular hole closure rate is 88%, with a MH closure rate ranging from 66.7% to 100%. The weighted average best-corrected visual acuity improved from mean logarithm of the minimum angle of resolution 1.35 (Snellen equivalent of 20/450) preoperatively to mean logarithm of the minimum angle of resolution 1.02 (Snellen equivalent of 20/210) postoperatively. From the largest autologous retinal transplantation case series, 37% of patients gained 3 or more lines of visual acuity after autologous retinal transplantation for primary or refractory MHs and 74% gained 3 or more lines of visual acuity after autologous retinal transplantation for MH-retinal detachments. Functional improvement including negative Watzke-Allen sign and conversion from positive to negative scotoma was reported in large case series.Autologous retinal transplantation is a promising technique for closure of large and refractory MHs otherwise difficult to repair with conventional techniques. This technique may allow for replacement of neural tissue in the macula through cell rehabilitation and regeneration through presumed ectopic synaptogenesis, retinal progenitor cell differentiation and integration, and/or retinal progenitor cell material transfer to host neurons.

Purpose To report the anatomic and functional outcomes of autologous retinal transplantation (ART). Design Multicenter, retrospective, interventional, consecutive case series. Participants One hundred thirty eyes of 130 patients undergoing ART for the repair of primary and refractory macular holes (MHs), as well as combined MH-rhegmatogenous retinal detachment (MH-RRD), between January 2017 and December 2019. Methods All patients underwent pars plana vitrectomy and ART, with surgeon modification of intraoperative variables. A large array of preoperative, intraoperative, and postoperative data was collected. Two masked reviewers graded OCT images. Multivariate statistical analysis and subgroup analysis were performed. Main Outcome Measures Macular hole closure rate, visual acuity (VA), external limiting membrane and ellipsoid zone (EZ) band integrity, and alignment of neurosensory layers (ANL) on OCT. Results One hundred thirty ART surgeries were performed by 33 vitreoretinal surgeons worldwide. Patient demographics were: mean age of 63 ± 6.3 years, 58% female, 41% White, 23% Black, 19% Asian, and 17% Latino. Preoperative VA was 1.37 ± 0.12 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, approximately 20/500), which improved significantly to 1.05 ± 0.09 logMAR (Snellen equivalent, approximately 20/225; P Conclusions In this global experience, patients undergoing ART for large primary and refractory MHs and MH-RRDs achieved good anatomic and functional outcomes, with low complication rates despite complex surgical pathologic features.

This review evaluates the current surgical management options for refractory and atypical macular holes (MH) and proposes a treatment paradigm for approaching complex cases. A review of literature was performed to deliver a thorough discussion of the epidemiology and pathophysiology of MH as well as the historic evolution of surgical management strategies. With this context established, an update on recent surgical advances for management of large, chronic, and highly myopic MH is provided. New small MH may be adequately treated with pars plana vitrectomy, while those ≥300 μm should undergo internal limiting membrane (ILM) peel. For MH ≥400 μm with risk factors for failure, primary intervention should involve creation of an ILM flap and various methods of flap creation are discussed. For very large MH ≥700 μm or in refractory cases, autologous retinal transplants and other recently proposed procedures should be considered. While typical MHs enjoy high initial surgical success rates, atypical and refractory MH require additional intraoperative and postoperative considerations to maximize surgical success and optimize vision. With many techniques at the surgeon's disposal, patient selection becomes critical to improving outcomes.

BACKGROUND AND OBJECTIVE: To describe an under-recognized complication in the surgical management of dense, nonclearing vitreous hemorrhage, specifically, the development of iatrogenic retinal breaks as a result of cutter-associated traction. STUDY DESIGN/PATIENTS AND METHODS: Review of surgical cases with cutter-associated traction from chronic vitreous hemorrhage (CATCH). RESULTS: Cutter-associated traction from chronic vitreous hemorrhage is a commonly encountered surgical entity that may result in complications such as iatrogenic retinal breaks, including giant retinal tears. These complications can be minimized or potentially avoided through the use of open sclerotomies or potentially mixed-gauge vitrectomy. CONCLUSION: Careful surgical planning in cases of dense or chronic vitreous hemorrhage is required to prevent cutter-associated tractional retinal breaks. [ Ophthalmic Surg Lasers Imaging Retina 2022;53:584–585.]

Background: Multiple studies have described the utility of intraoperative spectral-domain OCT (SD-OCT) with two dimensional (2D) B-scan imaging in the management of numerous vitreoretinal disorders including macular holes, vitreomacular traction disorders, epiretinal membranes and retinal detachment. Some of these studies also described post-processing of the 2D B-scans to obtain 3D images. With the advancement of intraoperative OCT technology, live volumetric (4D, i.e. 3D over time) visualization of different anterior and posterior segment surgeries has been described in recent studies using intraoperative swept-source microscope-integrated OCT (SS-MIOCT). Our study aims to explore the potential utility of SS-MIOCT during vitrectomy for complications of proliferative diabetic retinopathy. Aim of the work: To evaluate the use of live volumetric (4D) intraoperative swept-source microscope-integrated OCT (SS-MIOCT) in vitrectomy for proliferative diabetic retinopathy (PDR) complications.Patient and Methods: In this prospective study, we analyzed a subgroup of cases with PDR complications that required vitrectomy and that were imaged by the research SS-MIOCT system. In near real time, images were displayed in stereo heads-up display facilitating intraoperative surgeon feedback. Postoperative review included scoring image quality, identifying different diabetic retinopathy (DR)-associated pathologies and reviewing the intraoperatively documented surgeon feedback.Results: Twenty eyes were included. Indications for vitrectomy were tractional retinal detachment (TRD, 16 eyes), combined tractional-rhegmatogenous retinal detachment (2 eyes) and vitreous hemorrhage (2 eyes). Useful, good quality 2D (B-scans) and 4D images were obtained in 16/20 eyes (80%). In these eyes, multiple DR pathologies could be imaged. SS-MIOCT provided surgical guidance, e.g. in identifying dissection planes under fibrovascular membranes, and in determining residual membranes and traction that would benefit from additional peeling. In 4/20 eyes (20%) acceptable images were captured, but they were not useful due to high TRD elevation which was challenging for imaging.Conclusion: SS-MIOCT can provide important guidance during surgery for PDR complications through intraoperative identification of different pathologies and facilitation of intraoperative decision making.

Introduction: Despite consistent use of anti-vascular endothelial growth factor (anti-VEGF), prognosis of large, fovea-involving submacular hemorrhage (SMH) has remained guarded, particularly in pa...

Purpose To present representative cases of the most common complications associated with an autologous retinal transplant (ART) for macular hole repair. Methods A retrospective, consecutive case series on patients that underwent an ART by a single provider (THM). Results Four cases were included in this review. Each suffered an ART-specific complication, including graft displacement and dislocation, sub-ART Perfluoron, and a delayed proliferative vitreoretinopathy-associated retinal detachment. Conclusions As more surgeons utilize ART to treat atypical macular holes, an adequate understanding of surgery-specific complications and techniques to treat those complications is increasingly necessary.

Purpose To describe the clinical impact of subfoveal lucency (SFL) seen on OCT before and after treatment of vitreomacular traction (VMT) or symptomatic vitreomacular adhesion (VMA) without macular hole (MH) in the prospective phase 3 trials of ocriplasmin vitreolysis. Design Randomized double-blind placebo-controlled multicenter study. Participants Four hundred ninety-nine eyes with VMT or VMA without MH. Methods Eyes were randomized to either a single intravitreal injection of ocriplasmin or placebo treatment and were followed up for 6 months. Main Outcome Measures Eyes were analyzed for presence, dimensions, and course of SFL on OCT, release of VMT, and their effect on visual acuity (VA). Results Among eyes without baseline SFL, new SFL was more frequent after ocriplasmin than placebo at week 1 (23.1% vs. 6.54%; P = 0.0002) and week 2 (19.7% vs. 3.85%; P = 0.0001), but was similar in frequency by week 4 (8.37% vs. 7.69%; P = 0.83). Six-month VA for eyes demonstrating SFL after ocriplasmin during the first 2 weeks was comparable with those without SFL at any point in the study (P = 0.12). In placebo-treated eyes but not ocriplasmin-treated eyes, SFL was associated with worse VA at all visits. The increase in SFL width from baseline to week 2 was significantly greater with ocriplasmin than placebo (P = 0.029). Among ocriplasmin-treated eyes at month 6, those with SFL and VMT release had better VA than those with SFL and persistent adhesion (P = 0.037) and similar VA to those with persistent adhesion without SFL (P = 0.17). In the placebo group, those with baseline SFL showed low rates of spontaneous VMT release at month 6 compared with those without baseline SFL (3/21 eyes vs. 33/99 eyes; P = 0.045). Conclusions Compared with placebo, SFL occurred more frequently only in the initial weeks after treatment with ocriplasmin. When SFL developed after ocriplasmin administration, VA was not impacted at the 6-month visit. Persistent SFL in ocriplasmin-treated eyes at month 6 was associated with poorer vision if VMT had not released. Eyes with SFL at baseline had low rates of spontaneous VMT release and may need treatment.

To evaluate the clinical course of patients with neovascular age-related macular degeneration (nAMD) after developing endophthalmitis during their treatment with intravitreal injections.Multicenter, retrospective series.From April 2013 to October 2018, 196,598 intravitreal anti-vascular endothelial growth factor (VEGF) injections were performed, with 75 cases of endophthalmitis (incidence 0.0381%). There was no association between intravitreal anti-VEGF drug (P = 0.29), anesthetic method (P = 0.26), povidone concentration (P = 0.22), or any intraprocedure variable and endophthalmitis incidence. Seventy-two patients (96%) were treated with intravitreal tap and inject , while 3 underwent immediate pars plana vitrectomy. After endophthalmitis resolution, 17 patients (22.7%) were not re-treated for nAMD (in 10 cases due to inactive disease; follow-up, 115 ± 8.4 weeks). Patients required less frequent anti-VEGF injections after infection (7.4 ± 0.61 weeks vs. 11.5 ± 1.8 weeks; P = 0.004). Preinfection logarithm of the minimum angle of resolution visual acuity was 0.585 ± 0.053 (∼20/77). It worsened with endophthalmitis (1.67 ± 0.08, ∼20/935; P0.001) and again on postendophthalmitis treatment day 1 (1.94 ± 0.064; count fingers; P0.001), but improved after reinitiating nAMD therapy (1.02 ± 0.11; ∼20/209; P0.001). Better visual acuity on postendophthalmitis week 1 (P = 0.002) and reinitiation of nAMD treatment (P = 0.008) were associated with better final visual acuity, and streptococcal culture with worse visual acuity (P = 0.028). The postendophthalmitis treatment interval was associated with the anti-VEGF drug used (aflibercept = ranibizumabbevacizumab; P0.001).Patients with nAMD required fewer injections after endophthalmitis, suggesting a biological change in disease activity. Neovascular age-related macular degeneration became quiescent in 13.3% of eyes. Most achieved better outcomes with anti-VEGF reinitiation.

Purpose To evaluate the retinal periphery in patients with idiopathic juxtafoveal telangiectasis or macular telangiectasis type 2 (MacTel2), using widefield fluorescein angiography (WFA). Methods Single-center, retrospective, observational case series of 50 eyes of 50 patients with MacTel2 and 50 eyes of 50 age-matched controls. Results Thirty-seven eyes in the MacTel2 group (74%) showed peripheral capillary nonperfusion or dropout, compared to 37 eyes in the control group (74%, p=1.0). Morphologically, the MacTel2 group trended towards having a higher proportion of pruning-type capillary dropout (44%) compared to controls (28%), but this was not statistically significant (p=0.12). Patients with MacTel2 had a higher incidence of microaneurysms compared to controls (MacTel2 56%; Controls 42%; p=0.048), independent of age or systemic risk factors. There was no difference in the incidence of venous-venous shunts (MacTel2 10%; Controls 10%; p=1.0), arteriovenous shunts (MacTel2 14%; Controls 18%; p=0.60), venous tortuosity (MacTel2 60%; Controls 66%; p=0.58), or arterial tortuosity (MacTel2 54%; Controls 68%; p=0.20), which was mild in the majority of cases. Conclusions We note a high incidence of peripheral vascular and retinal findings in both patients with MacTel2 and age-matched controls, using WFA. Patients with MacTel2 had significantly more microaneurysms, independent of age or other systemic risk factors.Summary SUMMARY:: We note a high incidence of peripheral retinal vascular findings in both patients with macular telangiectasis type 2 and age-matched controls. Patients with MacTel2 had significantly more microaneurysms compared to controls, independent of age or other systemic risk factors.

The classification of macular hole closure patterns (MHCPs) currently relies on time domain OCT allowing only “open” and “closed” statuses or is based on inner foveal contour shape. Both classification types give no information on retinal layer reconstitution. Novel sophisticated surgical techniques lead to previously unknown MHCPs, outdating existing classifications and urging new ones. The purpose of the present study is to introduce a new classification allowing proper description of all MHCPs resulting from newer surgeries and based on the restoration of retinal layers. Retrospective analysis of patients undergoing MH surgery with five different surgical techniques was performed. MHCPs were classified according to spectral domain optical coherence tomography (SD-OCT). Type 0: open MH (0A: flat margin, 0B: elevated, 0C: oedematous); type 1: closed MHs (1A: reconstitution all retinal layers; 1B interruption of the external layers; 1C interruption of internal layers); type 2: MH closed with autologous or heterologous filling tissue interrupting the normal foveal layered anatomy (2A: filling tissue through all layers; 2B reconstitution of normal inner retinal layers; 2C reconstitution of normal outer retinal layers; 2D H-shaped bridging of filling tissue). Closure rate was 95.2% (241/253). Surgical technique and vision correlated to closure pattern (p < 0.001). Type 1 MHCPs had the best post-operative visual acuity (VA) compared with type 2 and type 0 (p < 0.001). MHCPs 1A and 1C performed better than all others. MHCP at months 1 and 3 changed in 42/254 (16.5%) and remained stable in 212/254 (83.5%). Improvement in vision was higher in eyes with shifting closure pattern (0.57 ± 0.33 vs 0.51 ± 0.48 logMAR; p 0.021). MHCP classification based on retinal layer restoration properly comprises post-operative anatomic morphologies. MHCPs correlate the surgical technique and post-operative visual outcomes.

To report the anatomic and functional outcomes of autologous retinal transplantation (ART).Multicenter, retrospective, interventional, consecutive case series.One hundred thirty eyes of 130 patients undergoing ART for the repair of primary and refractory macular holes (MHs), as well as combined MH-rhegmatogenous retinal detachment (MH-RRD), between January 2017 and December 2019.All patients underwent pars plana vitrectomy and ART, with surgeon modification of intraoperative variables. A large array of preoperative, intraoperative, and postoperative data was collected. Two masked reviewers graded OCT images. Multivariate statistical analysis and subgroup analysis were performed.Macular hole closure rate, visual acuity (VA), external limiting membrane and ellipsoid zone (EZ) band integrity, and alignment of neurosensory layers (ANL) on OCT.One hundred thirty ART surgeries were performed by 33 vitreoretinal surgeons worldwide. Patient demographics were: mean age of 63 ± 6.3 years, 58% female, 41% White, 23% Black, 19% Asian, and 17% Latino. Preoperative VA was 1.37 ± 0.12 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, approximately 20/500), which improved significantly to 1.05 ± 0.09 logMAR (Snellen equivalent, approximately 20/225; P0.001) after surgery (mean follow-up, 8.6 ± 0.8 months). Autologous retinal transplantation was performed for primary MH repair in 27% of patients (n = 35), for refractory MH in 58% of patients (n = 76; mean number of previous surgeries, 1.6 ± 0.2), and for MH-RRD in 15% of patients (n = 19). Mean maximum MH diameter was 1470 ± 160 μm, mean minimum diameter was 840 ± 94 μm, and mean axial length was 24.6 ± 3.2 mm. Overall, 89% of MHs closed (78.5% complete; 10% small eccentric defect), with a 95% closure rate in MH-RRD (68.4% complete; 26.3% small eccentric defect). Visual acuity improved by at least 3 lines in 43% of eyes and by at least 5 lines in 29% of eyes. Reconstitution of the EZ (P = 0.02) and ANL (P = 0.01) on OCT were associated with better final VA. Five cases of ART graft dislocation (3.8%), 5 cases of postoperative retinal detachment (3.8%), and 1 case of endophthalmitis (0.77%) occurred.In this global experience, patients undergoing ART for large primary and refractory MHs and MH-RRDs achieved good anatomic and functional outcomes, with low complication rates despite complex surgical pathologic features.

To describe the surgical technique for subretinal transplantation of an autologous retinal free flap in cases of chronic retinal detachment with proliferative vitreoretinopathy with and without a macular hole.Descriptive case series.Two patients with recurrent retinal detachment with proliferative vitreoretinopathy were referred for surgical evaluation. The first patient had high myopia and a macular hole. Acuity at the last time of sustained retinal reattachment was 20/400 for the first patient and counting fingers for the second patient and, in both cases, declined to light perception in the months after redetachment. Despite membrane/internal limiting membrane peeling, surgical repair required an inferior retinectomy in both cases. A retinal free flap was placed subfoveally. In the first patient, the flap was placed with the photoreceptors facing bare retinal pigment epithelium. In the second patient, the flap was inverted so its photoreceptors faced residual macular photoreceptors. The retina was flattened over the flap. Postoperatively, vision improved to 20/160 and 20/400 in the first and second patient respectively.Subretinal placement of a retinal flap is possible in eyes with retinal detachment and proliferative vitreoretinopathy with and without macular hole. Whether such a flap results in superior visual and anatomical outcomes remains to be seen.

To evaluate the feasibility and initial functional and anatomical outcomes of transplanting a full-thickness free graft of choroid and retinal pigment epithelium (RPE), along with neurosensory retina in advanced fibrosis and atrophy associated with end-stage exudative age-related macular degeneration with and without a concurrent refractory macular hole.During vitrectomy, an RPE-choroidal and neurosensory retinal free graft was harvested in nine eyes of nine patients. The RPE-choroidal and neurosensory retinal free graft was either placed subretinally (n = 5), intraretinally to cover the foveal area inside an iatrogenically induced macular hole over the RPE-choroidal graft (n = 3) or preretinally (n = 1) without a retinotomy wherein both free grafts were placed over the concurrent macular hole. Silicone oil endotamponade was used in all cases.Mean follow-up was 7 ± 5.5 months (range 3-19). The mean preoperative visual acuity was ∼count fingers (logarithm of the minimum angle of resolution = 2.11, range 2-3), which improved to ∼20/800 (logarithm of the minimum angle of resolution 1.62 ± 0.48, range 0.7-2, P = 0.04). Vision was stable in 5 eyes (55.6%) and improved in 4 eyes (44.4%). Reading ability improved in 5 eyes (55.6%). Postoperative complications were graft atrophy (n = 1), epiretinal membrane (n = 1), and dislocation of neurosensory retina-choroid-RPE free graft (n = 1).Combined autologous RPE-choroid and neurosensory retinal free graft is a potential surgical alternative in eyes with end-stage exudative age-related macular degeneration, including concurrent refractory macular hole.

Purpose To assess outcomes and complication rates in patients undergoing pars plana vitrectomy (PPV) and implantation of an anterior chamber intraocular lens (ACIOL). Design Retrospective chart review. Participants A total of 50 eyes that underwent secondary ACIOL placement in the setting of concurrent PPV from October 2000 to August 2016 were included. Methods A retrospective chart review was conducted. Main Outcome Measures The primary outcome measure was the occurrence of postoperative complication including persistently elevated intraocular pressure, persistent or recurrent hyphema, persistent or recurrent vitreous hemorrhage, persistent corneal edema, or persistent uveitis, macular edema, epiretinal membrane, lens dislocation, retinal tear, or retinal detachment. The secondary outcome measure was best-corrected visual acuity (BCVA). Results Postoperative complications occurred as follows: persistently elevated intraocular pressure in 4 eyes (8%), persistent corneal edema in 1 eye (2%), persistent postoperative uveitis in 1 eye (2%). Seven eyes (14%) had new macular edema and 2 eyes (4%) had new epiretinal membranes after combined PPV and ACIOL surgery. No patient had persistent postoperative hyphema, vitreous hemorrhage, retinal tear, retinal detachment, or lens dislocation after ACIOL placement. Mean preoperative BCVA was 20/200 (logarithm of the minimum angle of resolution 0.96) and improved to 20/40 (logarithm of the minimum angle of resolution 0.28, P ≤ 0.0001) at 1 year postoperatively. Conclusions Whereas there is a recent emphasis on new intraocular lens placement techniques in the setting of PPV including sutured and scleral-fixated intraocular lenses, ACIOL placement in the setting of concurrent PPV is a safe procedure, with few eyes developing long-term complications if careful case selection is employed.

Purpose To report the outcomes of autologous neurosensory retinal transplant as a primary treatment for patients with large chronic macular holes and evaluate the safety and feasibility of the procedure. Design Retrospective study, consecutive case series. Methods We reviewed seven patients with a primary chronic large macular hole, who underwent autologous neurosensory retinal transplant. Mean preoperative minimum and maximum hole diameters were 643 µm and 1214 µm, respectively. Changes in visual acuity were measured postsurgery, and optical coherence tomography, fluorescein angiography, and microperimetry-3 were analyzed after the procedure. Results Closure of the macular hole was achieved in all seven eyes in the study. At 1 year post-surgery, there was significant improvement in mean visual acuity (LogMAR 1.10 vs. 0.68, P = 0.001). Optical coherence tomography showed that all grafts had formed attachments to the retinal epithelial cells of the recipient retina. Mean preoperative ellipsoid zone defect was 1,089 ± 403.8 µm (range, 918-1,329 µm) which further decreased to 921 ± 129.1 µm (range, 670-1,201 µm) at final follow up (P = 0.09). Microperimetry-3 testing indicated retinal sensitivity in the graft in five eyes. Conclusion Autologous retinal transplantation may help rebuild the macular structure resulting in functional improvement for eyes with primary chronic large macular hole.

Purpose To evaluate the images produced in an initial surgical series of intraoperative near–real-time volumetric swept-source (SS) OCT imaging. Design Prospective translational study. Participants Forty-one consecutive adult patients undergoing vitreoretinal surgery between July 22, 2014, and July 1, 2015, at the Duke University Eye Center who agreed to participate. Methods A novel microscope-integrated SS-OCT prototype captured volumetric renderings of imaging of macular surgery in near-real-time and showed them to the surgeon via a heads-up display through the microscope oculars. Then the images were analyzed formally after surgery. Main Outcome Measures Image quality, successful capture of surgical instruments, maneuvers and associated retinal deformation volumetrically over time, and qualitative image analysis. Results Volumetric SS-OCT images were graded as acceptable in 92% of patients. Volumetric imaging of scraping and peeling procedures was achieved in 75% and 78% of patients in whom it was performed, respectively. Imaging provided the surgeon with near–real-time volumetric visualization of the position of the instrument relative to the retinal surface, flap initiation, flap removal, and retinal deformation during instrumentation via a heads-up display. Conclusions This volumetric, microscope-integrated SS-OCT prototype seems to provide high-detail, near–real-time volumetric imaging of delicate maneuvers during macular surgery.

Purpose To present the initial multicenter experience of using subretinal air injection in combination with tissue plasminogen activator (tPA) at the time of pars plana vitrectomy (PPV) to displace submacular hemorrhage (SMH). Design Retrospective, noncomparative, interventional case series. Participants Patients with SMH resulting from age-related macular degeneration or polypoidal choroidal vasculopathy. Methods Chart review of patients who underwent displacement of SMH with PPV, subretinal injection of air and tPA (125 mg/mL), partial fluid–air exchange with gas tamponade, and preoperative, intraoperative, or postoperative intravitreal injection of anti–vascular endothelial growth factor agent at 5 sites in the United States. None of the surgeons had prior experience with using subretinal air. Main Outcome Measures Frequency and extent of SMH displacement, preoperative and postoperative visual acuities and retinal thickness, and postoperative complications. Results Twenty-four eyes of 24 patients were included (11 men; mean age, 79.1 years) with a mean follow-up of 12.5 months (range, 3–28 months). At 3 months after surgery, complete displacement of SMH from the foveal center was achieved in 24 eyes (100%), displaced beyond the arcades in 75% and beyond the equator in 20%. Residual subretinal pigment epithelial hemorrhage was seen in 5 eyes (20.8%). Mean preoperative and postoperative visual acuity was 1.95 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/1783) and 0.85 logMAR (Snellen equivalent, 20/141; P Conclusions This initial experience of injecting subretinal air at the time of tPA injection during PPV showed the technique to be effective, with high consistency to displace SMH away from the fovea and even out to the periphery, and resulted in improved VA and retinal thickness. Some cases of subretinal pigment epithelial hemorrhage also benefit from this technique.

Purpose To report differences in visual acuities among patients with Coats' disease who sought treatment at a tertiary care university-based practice. Design Single-center retrospective cohort study. Participants Patients with Coats' disease diagnosed clinically, angiographically, or both from 1995 through 2015. Methods Patients were divided into 2 groups based on date of presentation: decade 1 (1995–2005) and decade 2 (2006–2015). Main Outcome Measures Visual acuity (VA). Results Thirty-nine eyes of 39 patients were included with 19 eyes presenting in decade 1 and 20 eyes presenting in decade 2. Three patients demonstrated bilateral disease, but only the worse eye was included for analysis. Forty-seven percent of eyes in decade 1 demonstrated advanced stages of disease (stage 3B or worse) compared with 20% of eyes in decade 2. There was a trend for the mean initial presenting VA (±standard deviation) for decade 1 eyes to be worse (2.05±1.29 logarithm of the minimum angle of resolution [logMAR]) than for decade 2 eyes (1.45±0.99 logMAR; P = 0.1). From initial to final follow-up visit, mean VA also worsened for decade 1 eyes ( P = 0.03), but remained stable for decade 2 eyes ( P = 1.0). At the end of follow-up, there was a trend for mean VA for decade 1 eyes (2.28±1.17 logMAR) to be worse than for decade 2 eyes (1.60±1.15 logMAR; P = 0.07). Eight eyes were observed initially in decade 1 compared with 1 eye in decade 2, and only 1 of the observed eyes (in decade 2) developed painful glaucoma requiring enucleation. Decade 2 eyes had a higher average number of procedures per eye (6.5±4.9) compared with decade 1 eyes (1.4±1.7; P Conclusions The earlier presentation of disease in decade 2 suggests improvements in disease detection over time. Furthermore, there was a trend for eyes to have better final VA in this decade. This is due to a combination of factors, including earlier presentation of disease, fewer eyes being observed without treatment, and eyes, when treated, receiving a higher number of procedures.

Purpose To compare foveal anatomic features on OCT after macular hole (MH) closure, and their association with visual function, in the ocriplasmin phase III trials. Design Randomized clinical trial. Participants One hundred fifty-three participants. Methods Each participant had 1 eye with baseline MH randomized to single intravitreal injection of placebo or ocriplasmin. After enrollment in 1 of the 2 nonsurgical treatment groups, a subset of eyes were analyzed in a surgical treatment group that had pars plana vitrectomy (PPV) after placebo or ocriplasmin. Main Outcome Measures Subfoveal lucency after MH closure was graded on time-domain OCT (TD-OCT) at all visits, and was compared with visual acuity (VA) and fluorescein angiography (FA) leakage at the final study visit. In a subset of visits with spectral-domain OCT (SD-OCT), subfoveal lucency, ellipsoid zone (EZ), and external limiting membrane (ELM) defects were graded and measured. Results Eyes in the placebo, ocriplasmin, and PPV groups with MH closure 1 month after treatment had subfoveal lucency in 5 of 5 (100%), 42 of 43 (98%), and 8 of 37 (22%) eyes, respectively; and eyes with MH closure 6 months after treatment had subfoveal lucency in 3 of 8 (38%), 30 of 44 (68%), and 11 of 60 (18%) eyes, respectively. Resolution of subfoveal lucency lagged behind EZ and ELM recovery in the ocriplasmin group, whereas it preceded EZ and ELM recovery in the PPV group. Subfoveal lucency base width increased after MH closure with ocriplasmin (+662±139 μm) but decreased after placebo (−255±154 μm) and PPV (−777±243 μm), when compared with pretreatment MH base width. Subfoveal lucency was not associated with FA leakage or VA outcomes in any treatment group. Conclusions After MH closure with ocriplasmin, subfoveal lucency width was greater than pretreatment MH and persisted longer during follow-up compared with placebo or PPV. Subfoveal lucency was not a marker for visual function regardless of treatment group.

A 54-year-old male developed symptomatic scleral buckle exposure 16 years after placement and presented with large conjunctival defects with fibrosed edges. Following surgical removal of the buckle elements, primary conjunctival closure could not be achieved due to significant wound tension despite undermining the conjunctival edges to mobilize the conjunctiva. A dehydrated amniotic membrane graft (Ambio5; IOP Ophthalmics, Costa Mesa, CA) was placed on the scleral bed and secured in place with fibrin sealant (TISSEEL; Baxter International, Westlake Village, CA). The amniotic membrane allowed successful closure of the large conjunctival defect with a good cosmetic outcome and resolution of symptoms. [ Ophthalmic Surg Lasers Imaging Retina . 2016;47:948–951.]

Purpose To report the structural and functional outcomes of autologous neurosensory retinal transplant for closure of refractory large macular holes (MHs). Design Multicenter, retrospective, consecutive case series. Participants A total of 41 eyes of 41 patients with a full-thickness MH refractory to prior vitrectomy with internal limiting membrane (ILM) peel and tamponade. Methods All patients underwent pars plana vitrectomy, autologous neurosensory retinal transplant with gas, silicone oil tamponade, or short-term perfluoro-n-octane heavy-liquid tamponade. All patients had at least 6 months’ follow-up. Main Outcome Measures Anatomic closure of MH, change in ellipsoid zone (EZ) and external limiting membrane (ELM) defect on OCT, visual acuity (VA) recovery, and surgical complications were analyzed. Results Mean number of prior surgeries was 1.5±0.94 (range, 1–3), and patients were followed for a mean of 11.1±7.7 months (range, 6–36 months). Complete anatomic closure of MH by OCT was achieved in 36 of 41 eyes (87.8%). Mean corrected VA (logarithm of the minimum angle of resolution [logMAR]) improved (P = 0.03) from 1.11±0.66 (range, 0.48–3) to 1.03±0.51 (range, 0.1–2) at the last postoperative visit. The VA improved (≥0.3 logMAR units) in 15 eyes (36.6%), was stable in 17 eyes (41.5%), and worsened in 9 eyes (21.9%). Among eyes with anatomic closure, VA improved in 52.3% and worsened in 13.8%, whereas in those without closure, VA worsened in 40% and improved in none. Mean preoperative largest basal diameter was 1468.1±656.4 μm (range, 621–2600 μm), and mean inner-opening diameter was 825±422.5 μm (range, 336–1649 μm). Mean preoperative EZ defect was 1777.3±513.8 μm (range, 963–2808 μm), which decreased to 1370±556.9 μm (range, 288–2000 μm) at final follow-up (P = 0.007). Mean preoperative ELM was 1681.5±429 μm (range, 1172–2606 μm), which decreased to 1408.5±571.2 μm (range, 200–2000 μm) at final follow-up (P = 0.017). Major postoperative complications were retinal detachment (n = 1) and vitreous hemorrhage (n = 1). There were no cases of proliferative vitreoretinopathy, endophthalmitis, suprachoroidal hemorrhage, or choroidal neovascularization. Conclusions The autologous retinal transplant technique offers a high degree of anatomic success and proved safe in this initial experience for closure of refractory MHs.

Purpose To evaluate the use of live volumetric (4D) intraoperative swept-source microscope-integrated optical coherence tomography in vitrectomy for proliferative diabetic retinopathy complications. Methods In this prospective study, we analyzed a subgroup of patients with proliferative diabetic retinopathy complications who required vitrectomy and who were imaged by the research swept-source microscope-integrated optical coherence tomography system. In near real time, images were displayed in stereo heads-up display facilitating intraoperative surgeon feedback. Postoperative review included scoring image quality, identifying different diabetic retinopathy-associated pathologies and reviewing the intraoperatively documented surgeon feedback. Results Twenty eyes were included. Indications for vitrectomy were tractional retinal detachment (16 eyes), combined tractional-rhegmatogenous retinal detachment (2 eyes), and vitreous hemorrhage (2 eyes). Useful, good-quality 2D (B-scans) and 4D images were obtained in 16/20 eyes (80%). In these eyes, multiple diabetic retinopathy complications could be imaged. Swept-source microscope-integrated optical coherence tomography provided surgical guidance, e.g., in identifying dissection planes under fibrovascular membranes, and in determining residual membranes and traction that would benefit from additional peeling. In 4/20 eyes (20%), acceptable images were captured, but they were not useful due to high tractional retinal detachment elevation which was challenging for imaging. Conclusion Swept-source microscope-integrated optical coherence tomography can provide important guidance during surgery for proliferative diabetic retinopathy complications through intraoperative identification of different complications and facilitation of intraoperative decision making.

Cerebral malaria (CM) is a significant cause of mortality and morbidity in sub-Saharan Africa, particularly among young children. Malarial retinopathy is the most specific clinical finding in CM, and fundus examination could help clinicians distinguish CM from other causes of encephalopathy in resource-poor areas. To assess clinician knowledge, practice patterns, and barriers to the use of funduscopy in the diagnosis of CM, we designed a descriptive multinational survey of clinicians in malaria endemic areas. Results of this survey showed that 19% of respondents were not aware of the utility of eye examinations for malarial retinopathy, and almost half (49%) never or almost never examine the eyes in cases of suspected CM. Educating clinicians about malarial retinopathy could be important in improving diagnostic specificity for CM.

BACKGROUND AND OBJECTIVE: To investigate cases of retained intraocular perfluoro-n-octane (PFO) after pars plana vitrectomy (PPV) for retinal detachment (RD). PATIENTS AND METHODS: Retrospective, noncomparative case series of six eyes with retained intraocular PFO after RD repair. Clinical data were supplemented with an experimental silicone eye model. RESULTS: A cluster of six cases of retained intraocular PFO after PPV for RD repair were noted shortly after transitioning to valved cannulas. PFO was noted in the anterior chamber (AC) and/or vitreous and removed with AC paracentesis, AC wash-out, and/or PPV. A silicone eye model demonstrated that PFO levels are maintained anterior to cannula insertion with valved cannulas only. CONCLUSION: The authors hypothesize that anterior PFO fill using valved cannulas can lead to sequestration within the AC, zonules, ciliary sulcus, ciliary teeth, and/or capsular bag. They suggest vigilance in not overfilling PFO, particularly when transitioning to use of valved cannulas, to minimize the risk of intraocular retention. [ Ophthalmic Surg Lasers Imaging Retina . 2015;46:451–456.]

To present the initial multicenter experience of using subretinal air injection in combination with tissue plasminogen activator (tPA) at the time of pars plana vitrectomy (PPV) to displace submacular hemorrhage (SMH).Retrospective, noncomparative, interventional case series.Patients with SMH resulting from age-related macular degeneration or polypoidal choroidal vasculopathy.Chart review of patients who underwent displacement of SMH with PPV, subretinal injection of air and tPA (125 mg/mL), partial fluid-air exchange with gas tamponade, and preoperative, intraoperative, or postoperative intravitreal injection of anti-vascular endothelial growth factor agent at 5 sites in the United States. None of the surgeons had prior experience with using subretinal air.Frequency and extent of SMH displacement, preoperative and postoperative visual acuities and retinal thickness, and postoperative complications.Twenty-four eyes of 24 patients were included (11 men; mean age, 79.1 years) with a mean follow-up of 12.5 months (range, 3-28 months). At 3 months after surgery, complete displacement of SMH from the foveal center was achieved in 24 eyes (100%), displaced beyond the arcades in 75% and beyond the equator in 20%. Residual subretinal pigment epithelial hemorrhage was seen in 5 eyes (20.8%). Mean preoperative and postoperative visual acuity was 1.95 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/1783) and 0.85 logMAR (Snellen equivalent, 20/141; P0.0001), respectively. Visual acuity improved in 23 eyes (95.8%) and was unchanged in 1 eye. Mean central retinal thickness improved from 463.7 μm before surgery to 311.3 μm at the final visit (P = 0.026).This initial experience of injecting subretinal air at the time of tPA injection during PPV showed the technique to be effective, with high consistency to displace SMH away from the fovea and even out to the periphery, and resulted in improved VA and retinal thickness. Some cases of subretinal pigment epithelial hemorrhage also benefit from this technique.

To report differences in visual acuities among patients with Coats' disease who sought treatment at a tertiary care university-based practice.Single-center retrospective cohort study.Patients with Coats' disease diagnosed clinically, angiographically, or both from 1995 through 2015.Patients were divided into 2 groups based on date of presentation: decade 1 (1995-2005) and decade 2 (2006-2015).Visual acuity (VA).Thirty-nine eyes of 39 patients were included with 19 eyes presenting in decade 1 and 20 eyes presenting in decade 2. Three patients demonstrated bilateral disease, but only the worse eye was included for analysis. Forty-seven percent of eyes in decade 1 demonstrated advanced stages of disease (stage 3B or worse) compared with 20% of eyes in decade 2. There was a trend for the mean initial presenting VA (±standard deviation) for decade 1 eyes to be worse (2.05±1.29 logarithm of the minimum angle of resolution [logMAR]) than for decade 2 eyes (1.45±0.99 logMAR; P = 0.1). From initial to final follow-up visit, mean VA also worsened for decade 1 eyes (P = 0.03), but remained stable for decade 2 eyes (P = 1.0). At the end of follow-up, there was a trend for mean VA for decade 1 eyes (2.28±1.17 logMAR) to be worse than for decade 2 eyes (1.60±1.15 logMAR; P = 0.07). Eight eyes were observed initially in decade 1 compared with 1 eye in decade 2, and only 1 of the observed eyes (in decade 2) developed painful glaucoma requiring enucleation. Decade 2 eyes had a higher average number of procedures per eye (6.5±4.9) compared with decade 1 eyes (1.4±1.7; P0.001).The earlier presentation of disease in decade 2 suggests improvements in disease detection over time. Furthermore, there was a trend for eyes to have better final VA in this decade. This is due to a combination of factors, including earlier presentation of disease, fewer eyes being observed without treatment, and eyes, when treated, receiving a higher number of procedures.

Pars plana vitrectomy represents an important treatment tool in eyes with diabetic macular edema (DME). Vitrectomy primarily promotes resolution of DME by relieving tangential and vitreomacular traction, but has additional benefits of removing depot of VEGF and pro-inflammatory cytokines, and improving macular oxygen delivery and perfusion. Therefore, vitrectomy has most significant benefit in tractional DME, and potential efficacy in non-tractional DME. The advent of modern vitrectomy with advanced visualization techniques has made macular surgery significantly more safe and improved treatment outcomes. The purpose of the article is to review major studies on the surgical treatment of DME and offer perspectives on strategies to maximize anatomic and functional outcomes of diabetic vitrectomy.

Purpose To describe a new classification of stellate nonhereditary idiopathic foveomacular retinoschisis (SNIFR). Design Retrospective case series and literature review. Participants A total of 17 patients from 5 institutions. Methods Detailed case history, multimodal imaging, and genetic testing were reviewed for patients with macular schisis without a known predisposing condition. Patients with a stellate appearance centered on the fovea with correlating confirmed expansion of the outer plexiform layer (OPL) by optical coherence tomography (OCT) were included. Exclusion criteria included a family history of macular retinoschisis, a known genetic abnormality associated with retinoschisis, myopic traction maculopathy, epiretinal membrane, vitreoretinal traction, optic or scleral pit, or advanced glaucomatous optic nerve changes. Main Outcome Measures Clinical features, anatomic characteristics, and visual acuity. Results A total of 22 eyes from 16 female patients and 1 male patient with foveomacular schisis were reviewed from 5 institutions. Initial visual acuity was ≥20/50 in all eyes (mean, 20/27), but visual acuity in a single eye decreased from 20/20 to 20/200 after the development of subfoveal fluid. The refractive status was myopic in 16 eyes, plano in 3 eyes, and hyperopic in 2 eyes. Three eyes had a preexisting vitreous separation, and 19 eyes had an attached posterior hyaloid. Follow-up ranged from 6 months to >5 years. Conclusions In this largest known series of patients with SNIFR, all patients demonstrated splitting of the OPL in the macula with relatively preserved visual acuity (≥20/40) except in a single patient in whom subretinal fluid developed under the fovea.

The authors describe three vitrectomized eyes that each subsequently developed a full-thickness macular hole (FTMH) that then spontaneously closed and summarize the current literature reporting these rare events. Clinical history, imaging, and course of three patients were reviewed and compiled. All three cases in this series developed a FTMH less than 7 months following vitrectomy (for epiretinal membrane [ERM], n = 1) and retinal detachment (n = 2) that demonstrated spontaneous resolution within 2 months of symptom onset, without intervention. All three vitrectomized eyes had small holes ranging from 48 µm to 189 µm in inner opening diameter and had an ERM or lamellar hole epiretinal proliferation documented before FTMH formation. These cases demonstrate that spontaneous closure of FTMH is possible in vitrectomized eyes with small holes despite the presence of ERM. On reviewing similar cases reported in the current literature, the presence of a mild ERM with a small FTMH may even be a favorable characteristic for spontaneous closure. [ Ophthalmic Surg Lasers Imaging Retina . 2017;48:183–190.]

To report a case of tubulointerstitial nephritis and uveitis syndrome with a primary presentation of acute posterior multifocal placoid pigment epitheliopathy after use of lamotrigine.Retrospective case report with ultra-widefield fundus imaging, optical coherence tomography, and fluorescein angiography.A 19-year-old woman presented with decreased visual acuity and acute renal failure after starting lamotrigine. Her examination demonstrated 1+ anterior chamber cell and numerous white deep retinal plaque-like lesions predominantly in the macula in both eyes. After extensive ophthalmic and systemic evaluation, the patient was diagnosed with tubulointerstitial nephritis and uveitis syndrome with a primary presentation of acute posterior multifocal placoid pigment epitheliopathy. She had excellent visual recovery with topical and systemic steroids.Acute posterior multifocal placoid pigment epitheliopathy is a rare but important clinical presentation of tubulointerstitial nephritis and uveitis syndrome. Oral corticosteroid treatment can be considered for tubulointerstitial nephritis but is generally not necessary for acute posterior multifocal placoid pigment epitheliopathy.

We introduce a metric in graph search and demonstrate its application for segmenting retinal optical coherence tomography (OCT) images of macular pathology. Our proposed “adjusted mean arc length” (AMAL) metric is an adaptation of the lowest mean arc length search technique for automated OCT segmentation. We compare this method to Dijkstra’s shortest path algorithm, which we utilized previously in our popular graph theory and dynamic programming segmentation technique. As an illustrative example, we show that AMAL-based length-adaptive segmentation outperforms the shortest path in delineating the retina/vitreous boundary of patients with full-thickness macular holes when compared with expert manual grading.

The purpose of this study was to provide further information about the risks of perioperative hemorrhage in diabetic vitrectomy in patients on anticoagulation. This may help us to better understand more about the fine balance between the risks of stopping anticoagulation versus continuation for intraocular surgery.A retrospective, comparative cohort study of all patients undergoing a diabetic pars plana vitrectomy by a single surgeon over a 30-month period at a single institution was conducted.Ninety-seven eyes were included for analysis. Twenty-seven eyes remained on anticoagulation during the surgery. There were no perioperative complications related to the anticoagulation. Surgical intervention resulted in a significant increase in visual acuity in both groups. There was no difference in the incidence of postoperative vitreous hemorrhage or surgical reoperation between the two groups. Patients on anticoagulation had significantly worse postoperative vision compared with those not on anticoagulation (best-corrected visual acuity of 20/230 vs. 20/100, P = 0.03).Patients undergoing diabetic vitrectomy, who are on anticoagulation or antiplatelet agents, do not exhibit a higher risk of intraoperative or postoperative vitreous hemorrhage. Anticoagulants and antiplatelets may be safely continued perioperatively to avoid complications secondary to their systemic disease.