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Common properties of all contact and noncontact wide-angle systems are an inverted fundus view and a device to convert the image to a normally oriented view of the field. Wide-angle viewing systems may be used for all intraocular procedures involving vitrectomy and diagnostic inspection of the peripheral and posterior retina during surgery. Retained lens material is an example of a situation where a wide-angle viewing system can be used. Complex surgery for diabetic vitreous hemorrhage and traction retinal detachment can be simplified with the use of a wide-angle viewing system. Wide-angle viewing facilitates dissection of anterior proliferative vitreoretinopathy, gas–fluid exchanges, and silicone oil injection, with either a gas–silicone exchange or perfluorocarbon liquid–silicone exchange. True bimanual vitreoretinal surgery can be attained using the multiport illumination system. Visualization for posterior segment vitrectomy surgery was initially accomplished with hand-held, planoconcave contact lenses.

Purpose To report on long-term visual outcomes in patients receiving continuous fixed-interval dosing of anti–vascular endothelial growth factor (VEGF) treatment in neovascular age-related macular degeneration (AMD). Design Single-practice retrospective chart review. Participants One hundred nine eyes with exudative AMD receiving continuous fixed-interval dosing (every 4–8 weeks) of anti-VEGF therapy (ranibizumab, bevacizumab, or aflibercept) for at least 5 years. Eyes were excluded if they averaged fewer than 6.5 injections per year. Methods Snellen visual acuity was recorded at baseline and all subsequent injections. Changes from baseline were calculated at yearly intervals. Main Outcome Measures The primary outcome measure was mean change in letter score at 5, 6, and 7 years; secondary outcomes included the percentage of patients with 20/40 vision or better at 7 years and the mean change in letter score at each yearly time point based on baseline visual grouping (20/40 or better, 20/50–20/100, 20/200 or worse). Results Forty-four, 75, and 109 patients with 7, 6, and 5 years, respectively, of continuous treatment were identified. Mean change in letter score at year 5 was +14.0 letters ( P = 3.9 × 10 −9 ), +12.2 letters at 6 years ( P = 1.5 × 10 −7 ), and +12.1 letters at 7 years ( P = 3.8 × 10 −5 ). Driving vision (20/40 or better) was achieved in 43.2% of treated eyes. Subanalysis revealed that the greatest visual gains at 5 and 7 years were seen in those patients with baseline visual acuity worse than 20/200 (+24.5 and +25.5 letters), followed by those with 20/50 to 20/100 vision (+6.7 and +6.9 letters), and finally those with 20/20 to 20/40 (+3.7 and +3.4 letters). Patients received an average of 10.5 injections per year. Conclusions Continuous fixed-interval dosing of anti-VEGF therapy in patients with exudative AMD results in favorable long-term preservation out to 7 years, with vision stabilizing or improving in 93.2% of eyes. Additionally, 43.2% of patients maintained driving vision in the treatment eye at 7 years compared with 10.1% at baseline. Our data suggest better outcomes with continuous therapy over published results with sporadic, as-needed therapy.

Background and Objectives: To determine the efficacy, durability, and safety of a single treatment with intravitreal ranibizumab plus peripheral scatter laser (RaScaL) in patients with diabetic macular edema associated with peripheral retinal nonperfusion on ultrawide-field fluorescein angiography (UWFA). Study Design: A 6-month, randomized, controlled, prospective phase I/II study of 30 treatment-naïve eyes of 22 patients (8 bilateral patients) with visual impairment secondary to diabetic macular edema associated with peripheral nonperfusion on UWFA. Patients were randomized to receive ranibizumab plus UWFA-guided peripheral scatter laser (n = 15) or triamcinolone acetonide plus macular laser (n = 15). Results: At 6 months, the RaScaL group patients had fewer recurrences warranting retreatment (33% vs. 80%, p < 0.003). Mean change in final visual acuity and central foveal thickness were not statistically significant between groups. Conclusion: This pilot study suggests the efficacy, safety and durability of the RaScaL treatment regimen in patients with diabetic macular edema associated with peripheral nonperfusion on UWFA.

PURPOSE To determine the clinical utility of the intraocular videoendoscope for evaluation of the ciliary body in eyes with hypotony and as a visualization tool for surgery of the ciliary body. METHOD A gradient index of refraction rod endoscope was used to evaluate the ciliary body in 14 patients. Videotapes and charts were reviewed retrospectively to correlate the appearance of the ciliary body and to analyze the clinical findings and surgical results. Videoendoscopic surgery to remove fibrous tissue from the ciliary processes was performed in nine eyes. RESULTS The endoscope produced a clear detailed image of the ciliary body in a state that is undisturbed by scleral depression or other forms of mechanical distortion. In eyes without hypotony the normal ciliary processes are uniformly pigmented with a velvet-like surface at high magnification. White surface changes in the peak and crest of individual ciliary processes (white-caps) were seen in 11 of 14 patients with hypotony. At high magnification the white surface changes had a brush-like texture integral to the ciliary processes. Other findings in hypotony were fibrous covering of the ciliary body in 10 patients, loss of pigment epithelium in 5, traction elongation of the ciliary processes in 8, vascular loops in 4, pigmented sheets in 3, and areas of missing ciliary processes in 1. White caps were present in seven of the nine patients who had surgery for fibrous traction of the ciliary processes and hypotony and three patients with hypotony not due to other endoscopically visible abnormalities of the ciliary processes. Endoscopically visualized dissection of ciliary body in 9 patients resulted in normal or elevated tension immediately postoperatively in 7 (78%). At the most recent visit only three of the patients had normal tension, but for these nine patients the pressures were marginally, significantly (P = 0.08) higher compared to the preoperative pressures. CONCLUSION The evaluation and management of hypotony is enhanced by the use of intraocular videoendoscopy. Clinical findings of whitecaps and traction elongation of the ciliary processes were associated with ocular hypotony. The endoscope facilitated surgery for dissection and removal of fibrous tissue over the ciliary processes. Further studies are needed to better understand the pathophysiology of ocular hypotony.

PURPOSE To evaluate the genetic contribution in age-related macular degeneration (ARMD) by a disease-ascertained twin study. METHODS Concordance rates for ARMD in 25 twins were obtained by using four masked graders to confirm the diagnosis of ARMD and place subjects in one of three categories; concordant, intermediate, or discordant. Demographic features and known risk factors for ARMD were compared between monozygotic and dizygotic twin pairs. RESULTS Of the 25 twin pairs, 15 were monzygotic and 10 were dizygotic. All 15 monozygotic twins were concordant or intermediate for ARMD. Of the dizygotic twin pairs, only one was concordant and five were discordant. In the demographic and risk factor analysis no unusual contributing or confounding variables were detected. CONCLUSIONS The association between zygosity and concordance for ARMD suggests a major importance for genetics in the etiology of ARMD. Our data further support a multi-factorial, primarily polygenic etiology for the condition.

Objective To examine the visual and anatomic results of bimanual vitrectomy surgery with the multiport illumination system (MIS) in eyes with advanced diabetic traction retinal detachment. Design Retrospective, noncomparative interventional case series. Participants Sixty-seven consecutive eyes in 62 patients having vitrectomy with the MIS. Methods During surgery, the vitreous, the posterior hyaloid membrane, and fibrovascular proliferative tissue were removed by using bimanual dissection made possible by the MIS. Main outcome measures Retinal reattachment rate, visual function, and postoperative complications were compared with previously published series of vitrectomy for diabetic traction retinal detachment. Results With a minimum of 6 months of follow-up, complete retinal reattachment was achieved in 62 eyes (93%), and macular attachment was achieved in all 67 eyes. Vision was stabilized or improved in 51 eyes (72%), and 5/200 vision was achieved in 47 eyes (70%). No unique complications, such as incision-related retinal tears, occurred. Conclusion MIS allows bimanual surgery during vitrectomy for diabetic traction retinal detachment, with good visual and anatomic results.

Purpose: The purpose of the study is to assess the hospital charges associated with the treatment of endophthalmitis using a sample of patients from the Endophthalmitis Vitrectomy Study (EVS). Methods: The Endophthalmitis Vitrectomy Study was a multicenter, randomized clinical trial with a two-by-two factorial design to compare immediate pars plana vitrectomy to tap—biopsy and to compare the use of systemic antibiotics (intravenous) to no intravenous antibiotics in the management of postoperative endophthalmitis. Hospital charge data were collected retrospectively from 129 patients from the 4 clinical centers participating in this ancillary study. This represents 31 % of the total Endophthalmitis Vitrectomy Study population. An analysis of variance was used to compare hospital charges across center and treatment. A charge-effectiveness analysis compared measures the effectiveness across treatment groups. The annual savings of hospital charges in the United States was estimated for a range of annual incidence rates of endophthalmitis. Results: The use of intravenous antibiotics significantly increased hospital charges. Patients undergoing vitrectomy had significantly higher hospital charges than did patients undergoing tap—biopsy. The most charge-effective treatment for patients presenting with light perception only vision was immediate vitrectomy, whereas the most charge-effective treatment for patients presenting with better vision was tap—biopsy. Factors other than treatment independently associated with hospital charges were female sex, history of diabetes, symptom of red eye, and baseline vision of light perception only. Conclusions: Assuming the results of the Endophthalmitis Vitrectomy Study were used as a guide for the treatment of endophthalmitis, the estimated annual nationwide reduction of hospital charges would be between $7.6 million and $40.0 million.

Background: Pneumatic retinopexy is a procedure for reattaching the retina by injecting an expanding gas bubble and using either laser or cryopexy. The procedure is controversial because there may be a lower initial success rate, and intraocular gas may increase the risk of proliferative vitreoretinopathy. Methods: The authors performed a retrospective review of 107 unpublished consecutive cases of pneumatic retinopexy together with a literature review of 25 statistical series with primary attention to failures. Univariate and multivariate analyses were carried out on the data set, and adjusted odds ratios for risk factors associated with failure were calculated using logistic regression. Results: Initially, 74 (69%) of 107 patients had successful results, and with reoperations the success rate increased to 98%. Failure of the procedure to achieve retinal reattachment occurred soon after the initial procedure, with 86% of recorded failures occurring within the first month. The initial cause of failure was new or missed breaks in 14.9%,reopened initial breaks in 11.2%, and breaks never closed in 4.6%. Risk factors that showed a correlation with failure were patients being male (adjusted odds ratio=2.65), eyes with preoperative visual acuity worse than 20J50 (adjusted odds ratio=1.21), eyes with four quadrants of retinal detachment or total detachment (adjusted odds ratio=2.03), aphakic or pseudophakic eye's (adjusted odds ratio=1.91), and eyes with additional pathologic findings (adjusted odds ratio=3.14). Poor visual outcome was associated with initial visual acuity less than 20/50 (adjusted odds ratio=15.7) and eyes with four quadrants of retinal detachment or total detachment (adjusted odds ratio=5.01). Conclusions: Failures of pneumatic retinopexy occur early in the postoperative course. Factors known to be associated with failure of retinal reattachment using scleral buckling also were associated with failure in pneumatic retinopexy. A higher success rate in females was noted, suggesting that educational efforts may need to be greater in males. Poorer visual results occurred in patients with poor initial vision and in eyes with four quadrants of retinal detachment or total detachments

Purpose: To describe the clinical course and incidence of culture-proven Postvitrectomy endophthalmitis in 18 patients from five academic centers and three private practices. Methods: Patients undergoing pars plana vitrectomy for recent trauma or endophthalmitis were excluded. The average age was 58 years (range, 21–85 year). Sixty-one percent of the patients (11/18) had diabetes mellitus. The indication for initial vitrectomy was vitreous hemorrhage (n = 10), macular epiretinal membrane (n = 3), recurrent retinal detachment with proliferative vitreoretinopathy (n = 2), retinal detachment with retinoschisis (n =1), proliferative diabetic retinopathy with tractional retinal detachment (n =1), and dislocated intraocular lens (n =1). None of these eyes received prophylactic intraocular antibiotics during the vitrectomy. Results: All eyes were treated with intraocular antibiotics after the diagnosis of Postvitrectomy endophthalmitis was made. Final visual acuity ranged from 20/20 to no light perception and included five eyes with 20/50 or better visual acuity and 11 eyes with less than 5/200 visual acuity. Nine eyes had a final visual acuity of no light perception. Of the 16 eyes infected with a single organism, 71 % (5J7) of eyes infected with coagulasenegative staphylococci retained 20/50 or better final visual acuity compared with no eyes (0/9) infected with other organisms ( P = 0.005). Two eyes infected with both coagulase-negative Staphylococcus and Streptococcus had a final visual acuity of 20/ 400. Three eyes with a total hypopyon later had enucleation or evisceration. Based on the data from four medical centers, the incidence of endophthalmitis after pars plana vitrectomy performed over the last 10 years was 9/12,216 (0.07%). Conclusion: Endophthalmitis after vitrectomy is rare. Postvitrectomy bacterial endophthalmitis caused by organisms other than coagulase-negative staphylococci has a poor visual prognosis.

One hundred and twenty-three preoperative, intraoperative, and postoperative variables were evaluated to assess their effect on anatomic success of scleral buckling for retinal detachment. The relative importance of each variable was tested in a logistic regression equation. This equation identified ten significant variables for predicting the outcome of retinal detachment surgery. The significant variables were: preoperative proliferative vitreoretinopathy (adjusted odds ratio, AOR, 13.60), previous buckle by G.F. Hilton (AOR = 8.03), total detachment (AOR = 5.72), preoperative vitreous hemorrhage (AOR = 3.08), tension less than 10 mm Hg (AOR = 2.40), hemorrhagic complications (AOR = 2.62), previous buckles by others (AOR = 2.10), injection into the vitreous at surgery with either saline or balanced salt solution (AOR = 2.32) or air/sulfahexafluoride (AOR = 7.06), and preoperative vision less than 0.3 (20/60 or worse) (AOR = 2.14). The number of cryopexy applications was specifically tested in the equation, but while significant in a univariate analysis, it was not found to be significant in the multivariate analysis.

The authors report 2-year follow-up information on 179 of 198 eyes (90%) enrolled in a previously published multicenter, randomized, controlled clinical trial comparing pneumatic retinopexy (PR) with scleral buckling (SB) for the management of selected retinal detachments. Scleral buckling was compared with PR with regard to redetachment after the initial 6-month follow-up period (1% versus 1%), overall attachment (98% versus 99%), subsequent cataract surgery (18% versus 4%; P less than 0.05), preoperative visual acuity (no significant difference), and final visual acuity of 20/50 or better in eyes with macular detachment for a period of 14 days or less (67% versus 89%; P less than or equal to 0.05). Reoperations after a failed PR attempt did not adversely affect visual outcome. After 2 years, PR continues to compare favorably with SB.

Between February 1988 and May 1990, the authors treated 12 perforating ocular injuries caused by anesthetic injections around the eye. All 12 injections were performed by nonophthalmologists. Eleven were performed by anesthesiologists and one by a certified nurse anesthetist. Five were caused by blunt needles and seven by sharp needles. Two of the eyes had multiple posterior exit wounds. The five eyes that had sharp needle, single perforations (i.e., one entrance wound and one exit wound) were easily managed with cryopexy, laser, or observation. All five of these eyes have a visual acuity of 20/40 or better. Six vitrectomies were performed on the five patients with single perforations caused by blunt needles; three of these eyes have a visual acuity of counting fingers or worse. The two patients who had multiple posterior exit wounds required a total of four procedures. The visual acuity in these eyes is 20/400 and light perception. Anesthesia personnel should be well trained before attempting ocular anesthesia. The use of blunt needles does not prevent ocular penetration.

Purpose: To report a case of circumscribed choroidal hemangioma effectively managed with transpupillary thermotherapy. Method: A 53-year-old man affected by extramacular circumscribed choroidal hemangioma had sustained a decline in visual acuity caused by subretinal fluid exudation into the macular area. Multiple attempts at treatment with scatter photocoagulation over the surface of the lesion for several years had been unsuccessful in reducing tumor-related exudation. The patient was examined on referral and underwent a single session of treatment employing transpupillary thermotherapy. The course of the lesion after treatment was documented with fundus photography and ultrasonography. Result: Complete atrophy of the choroidal hemangioma with resorption of subretinal fluid was documented over the 6 months after transpupillary thermotherapy, with improvement in visual acuity. Conclusion: Transpupillary thermotherapy is an effective alternative to conventional scatter photocoagulation or radiation therapy for precise ablation of circumscribed choroidal hemangioma.

Purpose To compare photodynamic therapy (PDT) with verteporfin (Visudyne; Novartis Pharma AG, Basel, Switzerland) using either standard or delayed light application. Design Phase II, multicenter, masked, randomized clinical trial. Methods Sixty patients with occult with no classic choroidal neovascularization (CNV) resulting from age-related macular degeneration were assigned randomly (1:1) to verteporfin infusion followed by light application either at 15 minutes (standard light) or 30 minutes (delayed light) after the start of the infusion. The assigned treatment was repeated every three months if fluorescein leakage was detected. Results At month 12, patients lost a mean of 15.7 letters and 11.4 letters from baseline in the standard and delayed light groups, respectively ( P = .38). Twelve (52%) of 23 patients in the standard light group and 11 (42%) of 26 in the delayed light group lost at least 15 letters of visual acuity ( P = .57). Conclusions There were no statistically significant differences between verteporfin therapy using the delayed light regimen of 30 minutes or the standard light regimen of 15 minutes in eyes with occult with no classic CNV.

The article on aminoglycoside toxicity by Campochiaro et al 1 in theArchivespurports to show 13 cases of toxic reaction to aminoglycoside that occurred with recommended doses of gentamicin sulfate and amikacin sulfate. What the article does show is 13 cases of macular ischemia following treatment for possible endophthalmitis. As discussed by Doft and Barza 2 for the Endophthalmitis Vitrectomy Study Group in the same issue, macular ischemia can be caused by the infection itself, incorrect dosage of antibiotics, retrobulbar injections, or drug interactions. In the article by Campochiaro and associates, no mention is made of the possibility that retrobulbar complications can give a similar fundus appearance. It was particularly disingenuous of the authors to include the reference from Judson, 3 which purported to show toxic reaction to tobramycin following a subconjunctival injection. Subsequent correspondence about that report, which was reviewed and published, raised questions as to the cause

Pneumatic retinopexy was compared with scleral buckling in a multicenter (7 centers), randomized, controlled, clinical trial with 198 patients. Admission criteria included detachments with retinal break(s) no greater than 1 clock hour in size, within the superior two thirds of the fundus, without significant proliferative vitreoretinopathy (PVR). All patients were followed for at least 6 months. Scleral buckling was compared with pneumatic retinopexy with regard to single-operation reattachment (82 versus 73%), reattachment with one operation and postoperative laser/cryotherapy (84 versus 81 %), overall reattachment with reoperations (98 versus 99%), final visual acuity of 20/50 or better in eyes with preoperative detachment of the macula for 2 weeks or less (56 versus 80%), PVR (5 versus 3%), and new retinal breaks (13 versus 23%). Complications, including reoperations, as measured by the "score" system, were similar. The anatomic results of the two operations were not significantly different ( P > 0.05), but pneumatic retinopexy had less morbidity and better postoperative visual acuity ( P = 0.01). Pneumatic retinopexy is recommended for cases meeting the admission criteria.

A 3 1/2-month-old boy with the cerebro-oculo-facio-skeletal syndrome had low birth weight, microcephaly, microphthalmia, cataracts, blepharophimosis, high nasal bridge, micrognathia, kyphosis, rocker-bottom feet, and a longitudinal foot groove. The product of a consanguineous parentage, he showed marked developmental retardation, suggesting abnormal recessive inheritance.

We examined members of a family in whom hereditary spherocytosis had appeared in three generations. Angioid streaks were confirmed in the second generation and presumed to exist in the first generation. A woman in the third generation with hereditary spherocytosis did not have angioid streaks but these are age-related and may develop later. The one individual in the second generation without hereditary spherocytosis did not have angioid streaks. Angioid streaks associated with hereditary spherocytosis in this family did not appear to be coincidental. Patients with hereditary spherocytosis should be examined for angioid streaks because of the implications for their vision.

Four members of a consanguineous middle eastern family had a lipid storage disease characterized by congenital ichthyosiform erythroderma, neurosensory deafness, cataracts, mild myopathy, and leukocyte vacuoles. These patients are similar to several others recently reported and represent a unique disorder of lipid metabolism. The clinical and biochemical manifestations of this lipid storage disease are reviewed. Evidence is presented that the disorder is inherited as an autosomal recessive trait, and that heterozygotes may be detected by the presence of vacuoles within circulating eosinophils.

Diseases that primarily affect the pigment epithelium, Bruch's membrane, or the choroid may lead to secondary subretinal neovascularization and its sequelae of hemorrhage and scarring. We studied three cases of presumed congenital rubella retinopathy with congenital deafness, which developed unilateral subretinal neovascularization, hemorrhage, and scarring.

Pulsed Doppler imaging provides an accurate, noninvasive technique for evaluation of the carotid bifurcation. We have found it useful in evaluating patients with amaurosis fugax and ocular emboli. It can also be used to evaluate blood flow within ocular and orbital tumors. The continuous wave Doppler is useful for detection of abnormal orbital blood flow in patients with dural-cavernous fistulae.

To the Editor. —We would like to report a second case of death associated with acute, multifocal, placoid pigment epitheliopathy,1as previously reported by Wilson et al.2 Report of a Case. —A 25-year-old woman, who was six months post partum, presented with a headache of two weeks' duration and bilateral visual loss of one week's duration. Her initial visual acuity was counting fingers at 3 ft bilaterally. Patches of cream-colored lesions at the choroidal level were present in the posterior and midperipheral fundi of both eyes (Fig 1). A fluorescein angiogram showed patches of early hypofluorescence and late staining at the choroidal level but no overlying retinal vasculitis. An initial medical evaluation showed no evidence of collagen vascular disease. The chest roentgenogram and sinus films were normal. The antinuclear antibody and rheumatoid factor titers were normal. The erythrocyte sedimentation rate was elevated to 95 mm/h. A regimen

A 47-year-old man with a large (20 X 20 X 12-mm) choroidal melanoma in his only eye was treated with helium ion radiation. The patient retained 6/7.5 visual acuity for 2 1/2 years before he was killed in an automobile accident. The eye was ruptured at the time of death; however, histopathologic examination of the eye revealed no residual tumor. The residual ocular mass was composed of eosinophilic amorphous material and macrophages. Necropsy failed to reveal any evidence of metastasis at the time of death. Helium ion charged-particle irradiation in this case was able to completely eradicate the tumor while preserving useful vision.