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To describe a case of a dislocated Descemet stripping automated endothelial keratoplasty (DSAEK) graft retained in-the-bag removed with pars plana vitrectomy (PPV).Case report.A 69- year-old pseudophakic male who underwent a repeat DSAEK due to bullous keratopathy in the setting of multiple previous ocular surgeries presented with a vision of counting fingers. Upon examination a DSAEK graft was appreciated behind the intraocular lens obscuring the visual axis and presumed to be in the anterior vitreous. The patient underwent a 23-gauge vitrectomy and after a posterior capsulotomy, the dislocated graft was removed with a 23-gauge vitrector without complications. Best corrected visual acuity was 20/50 six months after the PPV.Grafts can dislocate posteriorly between the intraocular lens and the posterior capsule. The dislocated graft can be successfully extricated with a 23-gauge vitrector after a careful posterior capsulotomy, with good visual outcomes.To our knowledge, this is the first reported case of an in-the-bag DSAEK graft posterior dislocation. Furthermore, we showed an innovative surgical technique for the removal of the dislocated graft with a 23-gauge vitrectomy and posterior capsulotomy.

Introduction: To describe a patient who presented with visual loss and an apparent hypopyon but none of the other symptoms or signs most common with infectious endophthalmitis. Methods: A case and its findings were analyzed. Results: A 73-year-old woman was treated with intravitreal triamcinolone acetonide (IVTA) for cystoid macular edema. The eye had 12 previous injections without complication. After the 13th injection, the patient noted painless visual loss. An examination showed a visual acuity (VA) of finger counting and an apparent hypopyon, which shifted after a head-tilt test, suggesting a noninfectious “pseudohypopyon.” Two days later, the VA worsened to hand motions and the hypopyon had increased in size. The eye was treated with a vitreous tap and injection with vancomycin and ceftazidime. The inflammation resolved, VA improved to 20/40, and cultures showed no growth. Conclusions: Distinguishing infectious endophthalmitis from noninfectious inflammation remains challenging. There is no definitive technique by which to distinguish between the 2 conditions; thus, clinicians must use their best judgment and follow the patient closely.

Landon J Rohowetz,1 Sayena Jabbehdari,2 Nicolas A Yannuzzi,1 Jayanth Sridhar,1 William E Smiddy,1 Audina M Berrocal,1 Thomas A Albini,1 Justin H Townsend,1 Jorge A Fortun,1 Harry W Flynn Jr1 1Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, FL, USA; 2Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USACorrespondence: Harry W Flynn Jr, Tel +1 305 326 6118, Fax +1 351 207 3928, Email hflynn@med.miami.eduPurpose: To evaluate the outcomes and complications in patients with retained lens fragments (RLF) after cataract surgery, comparing those who received pars plana vitrectomy (PPV) on the same day, within 1 week, or later than 1 week after cataract surgery.Patients and Methods: Retrospective case series of all patients who underwent PPV for RLF at Bascom Palmer Eye Institute between January 1, 2012 and September 30, 2020. Individuals with less than 3 months of follow-up, chronic uveitis, congenital cataract, previtrectomy retinal detachment (RD), and severe trauma were excluded. All analyses for categorical and binary variables used chi-squared tests. Analyses for continuous variables were performed using multivariate analyses of covariance, adjusting for differences in baseline visual acuity before cataract surgery.Results: The study included 246 eyes of 246 patients. The timing distribution included the following: 140 (57%) eyes underwent same-day PPV, 33 (13%) eyes underwent same-week PPV, and 73 (30%) eyes underwent PPV after 1 week (up to 90 days). When all eyes were included in analysis, there were no statistically significant differences in mean best-corrected visual acuity (BCVA) between groups at last follow-up examination (P = 0.07). When only eyes without known pre-existing ocular disease (N = 157) were included in analysis, there were no differences in mean BCVA between groups at all postoperative timepoints (P > 0.05). The rate of RD did not differ between groups when eyes with and without pre-existing ocular disease were analyzed (P > 0.05).Conclusion: In the current study, there were no statistically significant differences in postoperative BCVA or rates of RD at last follow-up examination in eyes undergoing PPV for RLF on the same day, within 1 week, or later than 1 week after cataract surgery.Keywords: retained lens fragments, pars plana vitrectomy, cataract surgery, retinal detachment

Purpose To calculate costs required to prevent center-involved diabetic macular edema (CI-DME) or proliferative diabetic retinopathy (PDR), and to improve the diabetic retinopathy severity score (DRSS) with intravitreal anti-VEGF injections as reported for aflibercept in two randomized control trials. Design Cost-effectiveness analysis modeling based on published data Subjects None Methods Results from PANORAMA and the Diabetic Retinopathy Clinical Research Network ( DRCR.net ) Protocol W were analyzed. Parameters collected included DRSS score, risk reduction of PDR, risk reduction of CI-DME, and number of treatments required. Costs were modeled based on 2020 Medicare reimbursement data practice settings of hospital-based facility and non-facility. Main Outcome Measure Cost to prevent case of PDR and CI-DME, and to improve DRSS stage Results Over 2 years in Protocol W, the cost required to prevent 1 case of PDR was $83,000 ($72,400) in the facility (non-facility) setting; in PANORAMA, the corresponding 2 year costs were $89,400 ($75,000) for the 2Q16 arm, and $91,200 ($89,900) for the 2Q8PRN arm. To prevent 1 case of CI-DME with vision loss in Protocol W, the cost was $154,000 ($133,000). For all CI-DME, with and without vision loss; in PANORAMA, the costs to prevent a case were $70,900 ($59,500) for the 2Q16 arm, and $90,000 ($88,800) for the 2Q8PRN arm. In Protocol W, the overall accumulated total for cost /DRSS unit change at the 2 year point for facility (non-facility) setting was $2700 ($2400)/DRSS. In the first year alone, it was $2100 ($1800)/DRSS and in the second year alone, $6100 ($5300)/DRSS. Conclusion There is a considerable cost associated with the prevention of PDR and CI-DME with intravitreal aflibercept injections. A price per unit of change in diabetic retinopathy severity score is a new parameter which might serve as a benchmark in future utility analyses that could be used to bring perspective to cost-utility considerations.

Patrick C Staropoli,1 Harsh V Moolani,1 Abdelrahman M Elhusseiny,2 Harry W Flynn Jr,1 William E Smiddy1 1Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA; 2Department of Ophthalmology, Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USACorrespondence: William E Smiddy, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL, 33136, USA, Tel +1 305-302-2704, Fax +1 305-326-6114, Email wsmiddy@med.miami.eduPurpose: Identify the long-term rate of fellow eye full-thickness macular hole (FTMH) development.Patients and Methods: In this single site, single provider retrospective consecutive case series, idiopathic FTMH patients who underwent surgery from 2003 to 2014 who also had at least 5 years of follow-up information within our electronic medical record (EMR) which was started in 2014 were identified. Cases with secondary causes (ie, trauma), high myopia, bilateral FTMH on presentation, previous retinal surgery, retinal breaks, or intraocular inflammation were excluded. Demographics, medical and ocular history, refractive error, phakic status, best corrected visual acuity, follow-up duration, surgical technique, single operation anatomic success, and reoperations were recorded.Results: The rate of fellow eye FTMH was 2.6% (2/77) at 1 year, 5.2% (4/77) at 3 years, 9.1% (6/66) at 6 years, and 9.1% (7/77) as of final follow up. There were 2 cases by year 1, 2 additional cases by year 3, 2 additional cases by year 6, and 1 additional case reported thereafter. The average follow up was 11.1 ± 4.5 years. There was no significant difference in visual outcomes between primary eyes and fellow eyes. There was no significant difference in gender, age, ocular comorbidities, refractive error, phakic status, and visual acuity between the unilateral and bilateral groups.Conclusion: The rate of FTMH in the fellow eye was low but significant, increased during long-term follow up, and may stabilize after 6 years.Keywords: macular hole, fellow eye, surgical outcomes, counseling

Jason Fan, Julia L Hudson, Parastou Pakravan, Thomas A Lazzarini, Benjamin R Lin, Kenneth C Fan, Nicolas A Yannuzzi, Jayanth Sridhar, Justin H Townsend, Audina M Berrocal, William E Smiddy, Elizabeth A Vanner, Harry W Flynn Jr Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL, USACorrespondence: Harry W Flynn Jr, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL, 33136, USA, Email HFlynn@med.miami.eduObjective: The purpose of the current study is to report outcomes of suprachoroidal hemorrhage (SCH) after anterior segment surgery at a single institution, and to identify clinical features associated with visual prognosis.Methods and Analysis: Retrospective consecutive case series of patients with SCH occurring after anterior segment surgery.Results: The study includes 112 eyes of 112 patients between 2014 and 2020. There were 76 cases of non-appositional SCH versus 36 cases of appositional SCH. The mean presenting visual acuity for patients with non-appositional versus appositional SCH was 2.03 logMAR (SD 0.78) versus 2.39 logMAR (SD 0.43), respectively. Visual acuity outcomes generally remained poor at last follow-up: 64 (58%) patients had a visual acuity (VA) of ≤ 20/200, including 19 (17%) with light perception (LP), and 11 (10%) with no light perception (NLP). Regarding management of non-appositional versus appositional SCH, observation was selected in 46 (61%) vs 12 (33%), delayed drainage in 14 (18%) vs 15 (42%), delayed pars plana vitrectomy in 16 (21%) vs 13 (36%), and VA at last follow-up was 1.2 versus 1.86 logMAR (p=0.002). In patients that were observed, both appositional SCH (p=0.01) and duration of apposition (p=0.04) were correlated with worse outcome.Conclusion: Appositional SCH was associated with poorer visual outcomes compared to non-appositional SCH. Observation remains a reasonable management strategy for non-appositional SCH.Keywords: suprachoroidal hemorrhage, non-appositional, appositional, anterior segment surgery

PURPOSE To present a surgical technique that allows rescue (repositioning) of a dislocated Crystalens model intraocular lens (IOL) using scleral sutures. METHODS The surgical technique is described with supplemental video. RESULTS The technique was used in one patient with 3 months of followup information. The IOL was well positioned and the visual acuity is 20/20, without adverse events. CONCLUSION Scleral suture techniques for repositioning of the Crystalens offers a suitable alternative to IOL exchange.

PRCIS The multiplicity of treatment options for lowering intraocular pressure (IOP) is both a blessing and a challenge. Some attention to cost-analysis might assist in choosing an optimal therapy, especially in a cost-constrained, international setting. PURPOSE The aim of this study was to quantify and to analyze the relative cost of various glaucoma surgical procedures and selective laser trabeculoplasty surgery per mm Hg IOP reduction ($/mm Hg) since standard cost-utility methods are not well suited to the study of glaucoma which characteristically only claims visual acuity in its end stages. METHODS Published glaucoma treatment studies were reviewed to quantitate the reduction of mean IOP and glaucoma medications for a given treatment modality. A US perspective was adopted, using Medicare allowable costs were used to calculate a newly introduced parameter-cost per mm Hg IOP reduction-at 1 year postoperatively. RESULTS The cost per mm Hg IOP reduction after 1 year of treatment ranged from $190/mm Hg for trabeculectomy to $1376/mm Hg for iStent. For reference, the cost of selective later trabeculoplasty surgery was $121/mm Hg. After the first year, cost/mm Hg ranged from $12 to $61/mm Hg. CONCLUSIONS Conventional glaucoma surgeries and selective laser trabeculoplasty surgery were the most cost-efficient surgical methods to lower IOP compared with the various minimally invasive glaucoma surgeries options. They may be more appropriate management when cost is an important issue.

Determine clinical characteristics and long-term outcomes of fellow eyes for patients with prior repair of rhegmatogenous retinal detachments due to a giant retinal tear (GRT).Retrospective case series of patients who underwent vitreoretinal surgery between January 2005 and August 2017 for GRT at the Bascom Palmer Eye Institute with a minimum of one year of follow-up information. Patients with a traumatic or post-vitrectomy GRT were excluded.Visual acuity and rate of retinal events in fellow eyes.The study group included 51 patients; 40 others were excluded due to having less than one year of follow-up (Retinal tears and/or detachments were encountered relatively frequently in the fellow eye of patients with a history of GRT-RD during follow-up, but the rate of GRTs in the fellow eye (4%) was below what has been generally reported in the literature. Regular dilated fundus exams are warranted for patients with a history of GRT.

To calculate costs of treatment for diabetic macular edema (CI-DME) with bevacizumab-first (step therapy) compared to aflibercept monotherapy.Cost analysis of treatment arms based on a published study SUBJECTS: None METHODS: Published results from the Diabetic Retinopathy Clinical Research Network (DRCR.net) protocol AC were used to assess costs. Data incorporated in a usage and outcome model included frequency of injections, medication type, visits, and imaging. Costs were modeled based on 2022 Medicare reimbursement data for both facility (hospital-based) and non-facility settings in Miami. Outcomes were similar in Protocol AC so were not differentially studied. Results were extrapolated so as to estimate lifetime (17 years for the age of the cohort).Over the 2 years reported in protocol AC, the cost required to treat in the facility (nonfacility setting) was $42,000 ($32,000) in the aflibercept monotherapy group and $29,000 ($22,000) in the bevacizumab-first group. Extrapolated modeled lifetime costs were $158,000 ($136,000) and $125,000 ($103,000), respectively. The total cost with bevacizumab-first was 33% lower at year 2 and 21% lower at year 17 compared with aflibercept monotherapy. Savings per year for the 2 year results were $6,500 ($5000) in the facility (non-facility) setting. For the extrapolated 17 year model annual savings were $1900 ($1900) in the facility (non-facility) setting. The professional fees accounted for a minority of overall costs; in contrast, medication costs accounted for 82% of the total costs for the aflibercept monotherapy and 73% in the bevacizumab-first group at 2 years. Our model predicted an additional 15% lifetime cumulative savings if patients still not meeting threshold criteria after switching to aflibercept were placed back on bevacizumab, and a similar degree of improvement if those on not meeting threshold criteria on aflibercept monotherapy were switched to bevacizumab.Cost of treatment options.Medication is the dominant driver of the total expenses associated with the treatment of diabetic macular edema. While cost savings are realized with bevacizumab-first step therapy, the magnitude was not as much as might be intuited, probably due to the high (70%) incidence of patients switching to aflibercept within Protocol AC.

PURPOSE To evaluate histopathologic features of preretinal tissues removed from eyes with myopic traction maculopathy (MTM). METHODS We retrospectively studied preretinal tissue specimens from eyes with MTM removed during pars plana vitrectomy. A control group of six idiopathic epiretinal membranes was studied for comparison. RESULTS Six MTM specimens were studied histopathologically. Outer retinal schisis-like thickening was present in 100% of preoperative optical coherence tomography images; four of the six eyes had subfoveal neurosensory retinal detachment. Postoperative optical coherence tomography images demonstrated complete resolution of the schisis-like appearance in all eyes; a full-thickness macular hole occurred in two of the six eyes. Histopathologic examination disclosed fibrocellular tissue that was strongly positive for glial fibrillary acidic protein, weak to moderately positive for cytokeratin, and weakly positive for smooth muscle actin and CD68. There were no apparent histopathologic or immunohistochemical differences between preretinal tissues from eyes with MTM and idiopathic epiretinal membranes from control eyes. CONCLUSION The outer retinal schisis-like thickening, commonly associated with subretinal fluid, that characterizes MTM is associated with preretinal tissues that are histopathologically indistinguishable from idiopathic epiretinal membranes. These findings suggest that anteroposterior traction caused by axial elongation rather than a uniquely abnormal cellular process is the etiologic mechanism of MTM.

To describe results in two cases of a dislocated silicone plate haptic intraocular lens (SPHIOL) managed with vitrectomy and repositioning with scleral suture fixation.small case series.Two patients present with dislocated SPHIOL underwent a 23-gauge vitrectomy with a "handshake" maneuver to pass a 9-0 prolene suture through the positioning holes to allow scleral fixation. Best corrected visual acuity was returned to predislocation level 2 and 8 months after the PPV.SPHIOLs can be managed with scleral suture fixation using this adapted technique, avoiding removal and exchange techniques.These are the first reported cases of SPHIOL managed with scleral suture repositioning.

To report long-term outcomes of patients with asymptomatic retinal detachments (RDs) who did not undergo initial surgical intervention.Retrospective case series.A retrospective chart review of patients diagnosed with asymptomatic RD. Patients with symptoms of photopsias or a visual field defect at presentation were excluded.Eighteen patients seen and evaluated at the Bascom Palmer Eye Institute between 2011 and 2021.Best-corrected visual acuity (BCVA), presence or absence of progression of RD, and whether surgical intervention occurred during follow-up.The study group included 18 patients (20 eyes). The mean follow-up duration was 5.1 years (range, 0-30 years). Risk factors included myopia (95%), lattice retinal degeneration (60%), and pseudophakia (5%). Most asymptomatic RDs were located in the inferotemporal quadrant (80%), followed by the superotemporal (15%) and inferonasal (5%). No RDs were confined to the superonasal quadrant. The majority (80%) extended posterior to the equator and were ≤ 3 clock hours in size (65%). Five (25%) patients were previously treated with prophylactic laser demarcation. Final BCVA was 20/40 or better in 19 (95%) eyes and between 20/40 and 20/200 in 1 (5%) eye. During the follow-up, 2 (10%) patients exhibited progression of their asymptomatic RD and underwent surgical intervention. Retinal pathology in fellow eyes was previously diagnosed or identified during follow-up in 14 (78%) of 18 patients, of which 2 (11%) patients had bilateral asymptomatic RDs.Nonsurgical management with observation may be reasonable as an initial management strategy for asymptomatic patients with RDs in select cases.

Purpose We compared the ability of ophthalmologists to identify neovascularization (NV) in patients with proliferative diabetic retinopathy using swept-source optical coherence tomography angiography (SS-OCTA) and fluorescein angiography (FA). Design Retrospective study comparing diagnostic instruments. Methods Eyes with proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy and a high suspicion of NV based on clinical examination were imaged using SS-OCTA and FA at the same visit. Two separate grading sets consisting of scrambled, anonymized SS-OCTA and FA images were created. The ground truth for presence of NV was established by consensus of 2 graders with OCTA experience who did not participate in the subsequent assessment of NV in this study. The 2 anonymized image sets were graded for presence or absence of NV by 12 other graders that included 2 residents, 6 vitreoretinal fellows, and 4 vitreoretinal attending physicians. The percentage of correct grading of NV using SS-OCTA and FA was assessed for each grader and across grader training levels. Results Forty-seven eyes from 24 patients were included in this study. Overall, the mean percentage of correct NV grading was 87.8% using SS-OCTA with B-scans and 86.2% using FA (P = .92). Assessing each grader individually, there was no statistically significant asymmetry in correct grading using SS-OCTA and FA. Conclusions Ophthalmologists across training levels were able to identify diabetic NV with equal accuracy using SS-OCTA and FA. Based on these results, SS-OCTA may be an appropriate standalone modality for diagnosing diabetic NV.

Noy Ashkenazy, Lediana Goduni, William E Smiddy Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USACorrespondence: William E Smiddy Tel +1 305-326-6172Email wsmiddy@med.miami.eduPurpose: To determine secondary effects of the mandated COVID-19 pandemic closure period for elective treatment on non-elective, injection-based retina care and outcomes.Patients and Methods: In this cross-sectional, retrospective analysis of a single-provider outpatient clinic across multiple satellites, consecutive patients returning for intravitreal injections (IVIs) of anti-vascular endothelial growth factor or corticosteroids were identified as “delayed” or “undelayed” during a six-week study interval during the COVID-19 pandemic that closely following a mandated period of prohibited elective encounters. A “delayed” encounter was defined as having a follow-up interval exceeding 33% of the recommended cycle. Patients seen for IVIs during the corresponding six-week interval a year previously were identified for study as pre-COVID-19 controls. Main outcome measures included best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) assessment based on findings of intraretinal or subretinal fluid consistent with new or recurrent neovascular events.Results: The study included 183 eyes of 144 patients who underwent IVI-based care from June 18, 2020, through August 7, 2020, compared to 193 eyes of 154 patients injected during the corresponding interval 1 year before. There were 62 eyes of 46 patients seen in the study period later than scheduled (among 144 patients of 183 eyes in total), which represented a larger proportion of delayed patients compared to the previous year (31.9% vs. 14.9%, p< 0.0005). Considering the patterns from the control group, the attributed delay due to COVID-19 was 15.0% of patients. The delayed return eyes had a greater decline in BCVA (3 letters), higher rates of worsened OCT results (48%), and prompted reduction in previously prescribed injection intervals (p< 0.02).Conclusion: The unintended consequence of delayed care of patients on established care regimens should be anticipated, and mitigate strategies considered if similar restrictions are mandated in the future.Keywords: COVID-19, SARS-CoV-2, pandemic, retinal vascular diseases, anti-vascular endothelial growth factor, treatment outcomes

Purpose: This work compares the relative cost utility of ranibizumab and aflibercept with and without verteporfin photodynamic therapy (vPDT) for the treatment of polypoidal choroidal vasculopathy. Methods: A retrospective cost and outcomes analysis of the PLANET (Efficacy and Safety of Intravitreal Aflibercept for Polypoidal Choroidal Vasculopathy) and EVEREST II (Efficacy and Safety of Ranibizumab With or Without Verteporfin Photodynamic Therapy for Polypoidal Choroidal Vasculopathy) studies was performed. Clinical utilization and outcomes were based on data from these clinical trials, and costs were obtained from Medicare fee schedules. Cost utility was derived from published visual outcomes and expressed as quality-adjusted life-years (QALYs). Cost per QALY and cost per line of vision gained for each treatment strategy (in US dollars) were assessed as the main outcome measure. Results: The 1-year facility (nonfacility) costs per QALY were $295,744.41 ($260,088.19), $209,574.09 ($182,831.77), $211,072.63 ($188,425.33), and $212,275.22 ($189,703.05) for ranibizumab as-needed monotherapy, ranibizumab as-needed with combination therapy, aflibercept monotherapy, and aflibercept with delayed vPDT combination therapy, respectively. Conclusions: Ranibizumab as-needed monotherapy was the least clinically effective and least cost efficient over 1 year. Ranibizumab as-needed with combination therapy, aflibercept monotherapy, and aflibercept with deferred vPDT combination therapy all had similar overall cost utility at 1 year. If bevacizumab were to be substituted for ranibizumab, the cost per QALY could be reduced by approximately a factor of 5, showing the benefit of bevacizumab for increasing the cost utility of polypoidal choroidal vasculopathy treatment.

Purpose To report both the unoperated clinical course and the surgical outcomes of eyes with a central foveal bouquet (CB) secondary to idiopathic epiretinal membranes (iERMs). Design Retrospective, consecutive, and observational case series. Methods All patients examined between January 1, 2014, and December 31, 2019, for evaluation of epiretinal membrane with a CB lesion identified on spectral domain optical coherence tomography (SD-OCT) were included. Exclusion criteria included vitreoretinal comorbidities associated with secondary ERMs and an absence of CB lesions on SD-OCT. Patients were divided into two groups: those who were followed with observation (Group I) and those who received surgery (Group II). Each group had 3 different types of mechanical abnormalities of the CB previously described as cotton ball sign, subfoveal detachment, or acquired vitelliform lesion, without a subanalysis discrimination. Main outcome measures Best-corrected visual acuity (BCVA) at baseline and last follow-up, subjective metamorphopsia, central retinal thickness (CMT), mechanical stress lesions of the CB, and resolution or evolution of the CB lesions during the follow-up interval. Results Two hundred seventy-six eyes with iERM were reviewed, and 46 eyes met the inclusion criteria. Among these, 21 of 46 (46%) were observed, and 25 of 46 (54%) underwent surgery. Metamorphopsia was identified in 61.9% of patients in Group I and 81.2% of patients in Group II, at baseline. The mean BCVA was 0.19 ± 0.17 (20/30) in Group I and 0.31 ± 0.33 (20/40) in Group II at presentation. At the final exam, patients in Group I achieved a mean BCVA of 0.24 ± 0.18 (20/30), while patients in Group II obtained a mean BCVA of 0.15 ± 0.21 (20/30). Spontaneous resolution of the CB sign occurred in 5 of 21 eyes (23.8%) that were observed, whereas, after surgery, the CB sign resolved in 16 of 25 eyes (61.5%). Mean CMT was 422 ± 84.2μm in Group I and 531 ± 143.9μm in Group II, at baseline, while at the latest follow-up, the mean CMT was 400 ± 40.8μm in the cases followed with observation and 454 ± 148.7μm in the surgical cases. Conclusion The clinical course and surgical outcomes of CB findings in iERM are favorable in terms of visual acuity. However, those receiving surgery had an increase in visual acuity and resolution of the CB abnormality.

Objective To report visual acuity in patients undergoing pars plana vitrectomy (PPV) reoperations for complications of proliferative diabetic retinopathy (PDR). Design Retrospective case series. Subjects Diabetic patients undergoing reoperation with PPV between 2015 and 2018 at a university referral center. Methods Patient charts were reviewed for indication for initial and repeat PPV, baseline clinical characteristics including gender, age, and lens status, and pre- and post-operative best-corrected visual acuity. Main outcome measures Best-corrected visual acuity at last follow-up. Results Of 538 eyes (409 patients) undergoing a PPV for diabetic retinopathy, 153 (28.4%) eyes had reoperation. Among the 130 eyes (119 patients) that met the inclusion criteria, 55 eyes (50 patients) underwent reoperation for complications of PDR, defined as non-clearing vitreous hemorrhage (NCVH) and/or tractional retinal detachment (TRD). Within this subgroup of 55 eyes, 19 (34.5%) eyes had an indication for the first surgery of NCVH. Fourteen (73.7%) of these NCVH eyes achieved a visual acuity of 20/80 or better. When the indication for the first surgery was TRD (33 eyes, 60%), 8 (24.2%) eyes achieved this same outcome (p=0.0011). Conclusion Approximately one of every four eyes treated with PPV for PDR will undergo repeat PPV during follow-up. VA outcomes after the repeat PPV were variable, with NCVH cases achieving better outcomes compared to TRD.

Aim To report outcomes of patients after intraocular lens (IOL) repositioning or exchange for the version of the uveitis-glaucoma-hyphema (UGH) syndrome that does not include closed loop anterior chamber IOL (nUGH). Methods Chart review of patients with nUGH who underwent IOL repositioning or exchange by one surgeon were reviewed. The main outcome measures were best corrected visual acuity (BCVA) as a decimal fraction preoperatively and postoperatively after IOL repositioning or exchange. Clinical findings evaluated included the presence of uveitis, hyphema, elevated intraocular pressure (IOP), and other complications such as pigment dispersion or vitreous hemorrhage. The number of anti-inflammatory and glaucoma medications were assessed before and after IOL repositioning or exchange. Results The study included 14 pseudophakic eyes. The median time at the onset of contemporary UGH after cataract extraction and IOL implantation (CE/IOL) was 7.5y. IOL repositioning or exchange was performed at a mean duration of 8.1±4.7mo (median: 4mo) after onset of UGH. The mean BCVA was improved from 0.45±0.26 preoperatively after onset of UGH syndrome to 0.76±0.22 (P=0.016) after IOL repositioning or exchange. Among the 14 eyes, uveitis, elevated IOP, and hyphema were present preoperatively in 13, 13, and 6 eyes, respectively. Uveitis and hyphema resolved in all cases after IOL surgery. The mean IOP was reduced from 26.4±4.5 mm Hg preoperatively to 14.7±4.9 postoperatively (P=0.01). The mean number of glaucoma medications used was reduced from 1.7±1.1 medications preoperatively to 0.8±1.08 (P=0.04) postoperatively. Conclusion IOL repositioning or exchange is an effective treatment in many cases for medically resistant contemporary UGH syndrome.

To evaluate the structural and visual outcomes after pars plana vitrectomy (PPV) for idiopathic full-thickness macular hole (MH) with at least 5 years of follow-up information.Retrospective case series.Patients with idiopathic MH who had at least 5 years of follow-up information after PPV.Best-corrected visual acuity (BCVA) was recorded preoperatively and, when available, at 1, 2, 3, 5, 8, and 10 years after surgery. Reestablishment of the postoperative integrity of the ellipsoid zone (EZ) and the external limiting membrane (ELM) and presence of cystoid spaces were evaluated using spectral-domain (SD) OCT.Postoperative BCVA and its correlation with different SD OCT parameters.Eighty-seven eyes of 80 patients with a mean age at surgery of 68.9±7.03 years were included. The mean postoperative follow-up was 9.6±4.3 years (median, 9 years; range, 5-22 years). The mean preoperative BCVA was 0.20±0.14 (range, 0.03-0.66). Postoperative BCVA was improved at all time points compared with preoperative BCVA (P0.05). Improvement in the postoperative BCVA remained stable 10 years after surgery. Initial successful closure of MH was achieved in 82 eyes (94%). Macular hole reopening occurred in 7 eyes (8.0%). Eleven eyes (13%) were reoperated: 4 eyes (4.5%) for persistence and 7 eyes (8.0%) for reopening of MH. Indocyanine green (ICG) stain was used in 22 eyes (25.2%). Among 57 patients (66%) who were phakic before surgery, 52 eyes (91.2%) underwent cataract extraction after PPV at a mean duration of 32.7±38.5 months (range, 2-187 months). Postoperative EZ integrity was restored in 52 eyes (60%), ELM integrity was restored in 54 eyes (62%), and cystoid spaces of variable severity were observed in 28 eyes (32%). Preoperative BCVA of 20/60 or better and postoperative reestablished ELM and EZ integrity were associated significantly with better postoperative BCVA at different postoperative follow-up visits (P0.05).Visual acuity improvement after MH surgery continued during the first 3 years after PPV and was maintained thereafter in a substantial fraction of patients, and final BCVA correlated with better preoperative BCVA and better postoperative OCT parameters.

Purpose To report anatomic and logMAR best-corrected visual acuity (BCVA) outcomes with long-term follow-up after pars-plana vitrectomy and epiretinal membrane peeling (PPV-MP). Design A retrospective case-series. Participants Patients with epiretinal membrane (ERM) who underwent PPV-MP performed by one surgeon. Methods Best-corrected visual acuity (BCVA) was recorded as a logMAR preoperatively and, when available, at 1, 2, 3, 5, 8, 10 years after surgery. The integrity of outer retinal layers was evaluated using spectral domain optical coherence tomography (SD-OCT). Main Outcome Measures Postoperative BCVA at different follow-up visits and its correlation with different OCT parameters. Results Fifty-five eyes of 49 patients were followed postoperatively with a mean of 8.6± 2.6 years (median: 9 years, range 5-16 years). The mean BCVA improved from 0.56±0.29 (20/72) preoperatively to 0.33±0.25 (20/42) at 1 year, 0.29±0.27 (20/38) at 2 years, 0.25±0.28 (20/35) at 3 years, 0.29±0.32 (20/38) at 5 years, 0.28±0.31 (20/38) at 8 years, and 0.28±0.25 (20/38) at 10 years (p

This study assessed the prevalence of progression to surgery on idiopathic epiretinal membrane (iERM) and compared the results with those of immediate surgery.Retrospective study with nested case-control comparison.Patients with mild iERM at initial presentation METHODS: A retrospective study with a nested case-control study was conducted to compare the outcomes of those who later progressed to surgery ("deferred surgery") with those of a control group that underwent surgery within 6 months of initial presentation ("immediate surgery").The prevalence of performing vitrectomy with membrane peeling after initial deferral, features associated with deferred surgery, and the visual acuity (VA) outcomes of surgery compared with those with immediate surgery.A total of 413 patients were included in the base study cohort: 369 did not undergo iERM peeling, whereas 44 (10.7%) underwent deferred surgery at a mean duration of 18.1 months after initial presentation. The factor most associated with later progression to surgery, determined using a multivariate analysis, was symptoms at initial presentation (odds ratio [95% confidence interval], 8.75 [3.80-20.15]; P0.0001). The immediate surgical group (controls) had a poorer logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) at presentation compared with the deferred surgery group (cases), but this decreased in the latter group to about the same preoperative level immediately before the deferred surgery (typically why they underwent surgery). The final logMAR BCVA was similar in the deferred and immediate surgical groups when only pseudophakic cases were analyzed. An analysis of the change from preoperative BCVA (instead of initial) to final BCVA showed no difference in the magnitude of change between the pseudophakic subgroups of the deferred and immediate surgery groups (median [interquartile range] preoperative VA of 0.52 [0.40-0.60] in the deferred surgery group and 0.44 [0.39-0.60] in the immediate surgery group [P = 0.7256]). Within the deferred and immediate surgery groups, the median change from preoperative BCVA to final BCVA in the pseudophakic subgroups was 0.22 (P = 0.0082) in the former and 0.21 (P = 0.0001) in the latter.The vast majority of eyes with iERM remain stable after initial presentation. The deferral of surgery in the minority of patients who progress does not have a disadvantageous final outcome compared with immediate surgery.

Background/aims To report the clinical course of patients with idiopathic epiretinal membranes (iERMs) and good baseline best-corrected visual acuity (BCVA) managed without surgical treatment. Methods Retrospective, observational case series of patients with iERMs and 20/50 or better BCVA who did not undergo surgery between January 2014 and December 2017 with a 1-year follow-up. Secondary epiretinal membranes were excluded. iERMs were stratified into two groups: Group I (BCVA 20/30 or better) and Group II (BCVA 20/40 to 20/50). The main outcome measures included baseline and final follow-up BCVA, central macular thickness (CMT) on OCT. Results The study included 174 eyes (145 patients): 139 eyes (79.8%) had typical iERMs and 35 eyes (18%) had LMH. For Group I typical iERMs, the logMAR baseline and final mean BCVA were 0.09 ± 0.1 (Snellen equivalent 20/25) and 0.10 ± 0.1 (20/25+) respectively (p = 0.22). In this group, the baseline and final mean CMT were 335 ± 73µm and 342 ± 78µm, respectively (p = 0.47). For Group II typical iERMs, the logMAR baseline and final mean BCVA were 0.3 ± 0.1 (20/44) and 0.4 ± 0.2 (20/45) respectively (p = 0.31). In this group, the baseline and final mean CMT were 386 ± 95µm and 391 ± 93µm, respectively (p = 0.84). Conclusion The clinical course of patients with iERM and good baseline BCVA is generally favorable without surgery and includes stable BCVA and OCT measurements after at least one year.

To evaluate acute-onset postoperative endophthalmitis following cataract surgery and to compare rates between resident and attending physician-performed cohorts.Bascom Palmer Eye Institute, Miami, Florida.Retrospective chart review.Records of patients diagnosed with endophthalmitis within 6 weeks of surgery performed by attending and resident physicians between January 1, 2015, and December 31, 2020, were reviewed. Total cataract volume was obtained from institutional records, and resident case totals were obtained from case logs. Endophthalmitis cases were obtained from billing records and confirmed with chart review.There were 22 cases of endophthalmitis among 32 505 cases (0.068%). Endophthalmitis occurred in 6 of 6447 (0.093%) resident cases and 16 of 26 058 (0.061%) attending cases ( P = .55). The most common bacterial isolates were coagulase-negative Staphylococcus (8/22, 36.3%) and Streptococcus species (3/22, 13.6%), with negative cultures in 10 (10/22, 45.5%). Initial treatment with vitreous tap and injection of intravitreal antibiotics was performed in 21 eyes (21/22, 95.4%) and vitrectomy with intravitreal antibiotic injection in one (1/22, 4.5%). Vitrectomy was performed secondarily in 9 patients (9/22, 40.9%). Corrected distance visual acuity (CDVA) at last follow-up was ≥20/40 in 13 eyes (13/22, 59%) and ≤hand motions in 3 eyes (3/22, 13.6%). CDVA (logMAR mean ± SD) was 1.22 ± 1.16 in resident and 0.49 ± 0.79 in attending cases ( P = .11).In the current study, acute-onset postoperative endophthalmitis developed infrequently following cataract surgery. The rates and visual outcomes of endophthalmitis were similar in resident and attending cases.

To compare the cost and utility of scleral buckle (SB), pars plana vitrectomy (PPV), and PPV with SB (PPV/SB) for moderately complex rhegmatogenous retinal detachment repair.Cost-utility analysis using data from the Primary Retinal Detachment Outcomes Study. The model estimated costs, lifetime utility, and lifetime cost per quality-adjusted life year for treatment of moderately complex rhegmatogenous retinal detachment with SB, PPV, or PPV/SB. Data from the Centers for Medicare and Medicaid Services were used to calculate costs in hospital and ambulatory surgery center settings.Total costs (2020 US dollars) for repair of a moderately complex rhegmatogenous retinal detachment in hospital (ambulatory surgery center) settings were $5,975 ($3,774) for the SB group, $8,125 ($5,082) for the PPV group, and $7,551 ($4,713) for the PPV/SB group. The estimated lifetime quality-adjusted life years gained were 5.4, 4.7, and 4.7 in the SB, PPV, and PPV/SB groups, respectively. The cost per quality-adjusted life year for hospital and ambulatory surgery center settings was $1,106 a ($699) for the SB group, $1729 ($1,081) for the PPV group, and $1,607 ($1,003) for the PPV/SB group.Scleral buckle, PPV, and PPV/SB yielded very favorable cost-utility results for the repair of moderately complex rhegmatogenous retinal detachment, with slightly better results for SB, compared with current willingness to pay standards.

Purpose:Pediatric macular holes occur often related to trauma and rarely require surgical intervention. The purpose of the present study was to evaluate outcomes of microincisional vitrectomy surgery.Methods:A multicenter retrospective consecutive case series was conducted of pediatric patients undergoing surgery for macular hole repair.Results:A total of 31 eyes from 8 centers were included in this study. The mechanism of macular hole development was blunt trauma in 30 eyes (97%) and industrial laser in 1 eye (3%). The rate of anatomic closure after primary vitrectomy was 81% (25 eyes); the final anatomic closure rate after a secondary vitrectomy was 94% (29 eyes). There was a statistically significant improvement in visual acuity from initial presentation (20/164) to final follow-up (20/100) ( P = .009).Conclusions:Microincisional vitrectomy surgery for pediatric macular holes results in substantial anatomic success and modest improvement in visual acuity.

Purpose The purpose of this study is to investigate associations with and surgical outcomes of rhegmatogenous retinal detachment (RRD) in young adults. Methods This is a retrospective consecutive case series of patients aged 18-30 years who underwent surgical repair for RRD between January 1, 2014 and December 1, 2016 at a university referral center. Results The current study includes 38 eyes with RRD. Documented high or moderate myopia was present in 28 (74%) eyes. Connective tissue disease was present in 3 (8%) eyes. Median pre-operative visual acuity (VA) was 20/70. Surgery was performed via scleral buckle (SB) alone in 27/38 (71%) and via combined SB and pars plana vitrectomy (SB/PPV) in 11/38 (29%) eyes. Single surgery anatomical success (SSAS) rate was 20/27 (74%) for SB and 7/11 (64%) for SB/PPV. The retina was reattached at last follow-up in 25/27 (93%) for SB and 11/11 (100%) for SB/PPV. The median postoperative VA was 20/40. Conclusion In the current study of young adults with RRD, the most common association was high or moderate myopia. Visual and anatomic outcomes at last follow-up were generally favorable.

Purpose: This article evaluates the influence of baseline diabetic macular edema (DME) on cost-utility analysis of treatment for proliferative diabetic retinopathy (PDR) based on 5-year Diabetic Retinopathy Clinical Research Network ( DRCR.net ) Protocol S results. Methods: A decision-analysis model calculated comparative cost utility of panretinal photocoagulation (PRP) and intravitreal ranibizumab (IVR) treatment for PDR with and without baseline DME. Centers for Medicare & Medicaid Services data were used to calculate associated modeled costs in a hospital/facility-based and nonfacility setting. Cost utility was calculated based on the preserved visual utility and estimated life years remaining. Sensitivity analyses were performed to evaluate the impact of the model’s assumptions. Results: The modeled cost per quality-adjusted life year (QALY) of treatment for PDR with baseline DME for 5 years of utility in the facility (nonfacility) setting was $280,919 ($203,444) in the PRP group and $452,387 ($339,319) in the IVR group. The estimated lifetime cost per QALY in the facility (nonfacility) setting was calculated as $84,761 ($50,077) in the PRP group and $314,483 ($230,301) in the IVR group. The cost per QALY of IVR for the first 5 years of treatment was 1.6 to 1.7 times that of PRP, whereas lifetime cost per QALY was 3.7 to 4.6 times higher. When considering all patients regardless of baseline DME status, lifetime cost per QALY of PRP was 8% to 13% higher, whereas IVR was only 1% higher compared with the cost per QALY without baseline DME. Conclusions: When considering the subset of patients with PDR and baseline DME, PRP maintains a more favorable cost utility compared with IVR. This augments previous reports that PRP has a more favorable cost utility than IVR for PDR without DME, given the marginal visual benefit of IVR.

To compare thickness and reflectance of retinal layer findings in patients with idiopathic epiretinal membranes (ERMs) before and after surgery with those of normal controls.Retrospective study.Patients with ERMs before and after surgery and healthy controls.Spectral-domain (SD) OCT imaging of eyes with ERMs before and after surgery and of healthy eyes were analyzed for morphologic appearance and using a customized algorithm to measure retinal layer reflectance and thickness. Findings were correlated with visual acuity outcomes.Retinal layer thickness and reflectance.Thirty-four ERM and 12 healthy eyes were identified. Mean preoperative best-corrected visual acuity (BCVA) improved from 0.53±0.31 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/68) to 0.41±0.25 logMAR (Snellen equivalent, 20/51) after surgery (P = 0.030). Differences in reflectance and thickness of retinal layers were identified among the preoperative ERM, postoperative ERM, and healthy eyes. High preoperative reflectance of the internal limiting membrane (ILM) to outer plexiform layer (OPL) was correlated with better postoperative BCVA (r = -0.451; P = 0.007). A larger improvement in BCVA was correlated with preoperative thick measurements of the outer nuclear layer (r = 0.514; P = 0.002), high reflectance of the group of layers from the ILM to the OPL (r = 0.426; P = 0.012), and low reflectance of the photoreceptor layer (r = -0.453; P = 0.007). Using linear regression analysis, better postoperative BCVA was associated with better preoperative vision (standardized regression coefficient, 0.553; P = 0.001) and high reflectance of the group of layers from the ILM to OPL (standardized regression coefficient, -0.526; P = 0.001). A larger improvement in BCVA was associated with worse preoperative BCVA (standardized regression coefficient, -0.539; P0.001) and high reflectance of the group of layers from the ILM to OPL (standardized regression coefficient, -0.428; P = 0.001).Quantitative differences in reflectance and thickness among preoperative, postoperative, and normal SD OCT imaging allow assessment of retina layer changes secondary to ERMs. High reflectance of the ILM to OPL correlated with and was associated with better postoperative BCVA and improvement in BCVA.

A cost-utility analysis of methotrexate (MTX) versus mycophenolate mofetil (MMF) for noninfectious intermediate, posterior, and panuveitis using data from the FAST Uveitis Trial showed MTX to have a lower cost/QALY, but both are cost-effective.

Purpose The purpose of this study was to determine if it is possible for the macula to remain attached if a bullous retinal detachment blocks the examiner's view to the macula. Methods A mathematical analysis compared the arc length of the attached retina versus the length of a detached retina necessary to obscure the macula (hang over the visual axis). The shape (oblate ellipsoid) and dimensions of the retina were based on a published study. The complete path of the hanging retina was calculated as a static catenary so as to depict the lowest possible position ("worst case scenario"). Results The measured and calculated angle between the fovea and ora serrata was 105 degrees. When considering a catenary shape of the hanging retina, the macula could, mathematically, still be attached despite the retina hanging down 1.03 mm below the visual axis for an emmetropic eye. The maximal distance calculated was 1.095 mm for a -12 diopter (D) myopic eye. Conclusions If the macular center cannot be viewed due to a bullous superior retinal detachment hanging into the examiner's view, it is unlikely but possible that the macula remains attached. If the view is obscured by at least 1 mm below the fovea, it is not mathematically possible for the fovea to be attached. Translational relevance The status of the macula being detached is subject to mathematical constraints, which, explored herein, offer a higher certainty of clinical decision making that could inform management for better clinical results.