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Purpose: Complications associated with intravitreal anti-VEGF therapies are reported inconsistently in the literature, thus limiting an accurate evaluation and comparison of safety between studies. This study aimed to develop a standardized classification system for anti-VEGF ocular complications using the Delphi consensus process., Design: Systematic review and Delphi consensus process., Participants: Twenty-five international retinal specialists participated in the Delphi consensus survey., Methods: A systematic literature search was conducted to identify complications of intravitreal anti-VEGF agent administration based on randomized controlled trials (RCTs) of anti-VEGF therapy. A comprehensive list of complications was derived from these studies, and this list was subjected to iterative Delphi consensus surveys involving international retinal specialists who voted on inclusion, exclusion, rephrasing, and addition of complications. Furthermore, surveys determined specifiers for the selected complications. This iterative process helped to refine the final classification system., Main Outcome Measures: The proportion of retinal specialists who choose to include or exclude complications associated with anti-VEGF administration., Results: After screening 18 229 articles, 130 complications were categorized from 145 included RCTs. Participant consensus via the Delphi method resulted in the inclusion of 91 complications (70%) after 3 rounds. After incorporating further modifications made based on participant suggestions, such as rewording certain phrases and combining similar terms, 24 redundant complications were removed, leaving a total of 67 complications (52%) in the final list. A total of 14 complications (11%) met exclusion thresholds and were eliminated by participants across both rounds. All other remaining complications not meeting inclusion or exclusion thresholds also were excluded from the final classification system after the Delphi process terminated. In addition, 47 of 75 proposed complication specifiers (63%) were included based on participant agreement., Conclusions: Using the Delphi consensus process, a comprehensive, standardized classification system consisting of 67 ocular complications and 47 unique specifiers was established for intravitreal anti-VEGF agents in clinical trials. The adoption of this system in future trials could improve consistency and quality of adverse event reporting, potentially facilitating more accurate risk-benefit analyses., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Social determinants of health (SDH) play a crucial role in shaping health outcomes. Few studies have explored the impact of SDH in ocular oncology, looking at differences in disease presentation, treatment choices, and outcomes based on race, ethnicity, socioeconomic status (SES), and insurance status. Retinoblastoma exhibits disparities in survival, with lower-income countries experiencing substantially lower rates compared to high-income countries. In the U.S., racial and SES disparities exist, impacting treatment choices and outcomes in children with retinoblastoma. Disparities in treatment modalities based on race and SES have been reported in uveal melanoma, with non-White and economically disadvantaged patients more likely to undergo primary enucleation. Ocular surface squamous neoplasia (OSSN) exhibits racial and socioeconomic disparities in treatment outcomes. Black patients with OSSN face higher mortality, independent of tumor size, eye laterality, or tumor behavior. Given the rarity, there is no data on disparities in vitreoretinal lymphoma management. When using primary central nervous system lymphoma as a surrogate, management and survival outcomes vary based on factors such as race, socioeconomic status, and insurance status. This article aims to review current literature on disparities in ocular oncology, highlighting the need for granular data to better understand existing gaps in care within ocular oncology., (Copyright © 2024 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate the association between insurance status and uveal melanoma (UM) care., Methods: We utilized the National Cancer Database to identify patients diagnosed with UM from 2004 to 2017. We examined the associations between patient sociodemographic characteristics, specifically insurance status, and UM care., Results: Of 7677 patients, 50% had private, 41% Medicare, 4% Medicaid, 3% other government, and 3% no insurance. Most initially received brachytherapy (66%), followed by enucleation/resection (19%) and other treatment (15%). Compared to private, Medicaid and no insurance were associated with higher odds of late-stage disease presentation ( p  < .05). Patients with Medicare, Medicaid, and no insurance had higher odds of enucleation/resection and lower odds of brachytherapy versus enucleation/resection ( p  < .05 for all). Medicaid and no insurance were associated with lower odds of other treatment versus enucleation/resection ( p  < .05)., Conclusions: Access barriers to UM care may exist based on insurance status and may be associated with later-stage presentation and more radical treatment.

Purpose: To report 2 cases of presumed retinal hamartoma (RH) in pediatric patients with genetically-confirmed familial adenomatous polyposis (FAP), both evaluated by optical coherence tomography (OCT) and one evaluated with optical coherence tomography angiography (OCTA)., Observations: A six-year-old girl presented with occasional blurry vision in the left eye. OCT showed a foveal hyperreflective lesion with disruption of photoreceptors and retinal pigment epithelium (RPE). A nine-year-old female with a past medical history of FAP presented with progressively decreasing vision and floaters in the right eye for the past 6 months. OCT showed a well-demarcated hyperreflective ovoid lesion in the fovea. OCTA revealed no flow signal within the lesion, as well as a second smaller hyperreflective lesion temporal to the fovea. Both patients were diagnosed with presumed retinal hamartoma in the setting of FAP., Conclusions and Importance: Presumed RH can occur in genetically-confirmed, pediatric FAP. On OCTA imaging, these lesions show no intrinsic vascularity. Evaluation with OCT and knowledge of foveal changes in these patients can help identify underlying systemic disease., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Disclosures and Conflicts of Interest: Serena Shah, Francisco Lopez-Font, Davina Malek, Jason Fan, Natasha Ferreira Santos da Cruz, and Catherin Negron have no conflicts of interest to disclosure. Basil K. Williams Jr. is a consultant for Alcon, Allergan, Alimera, Astellas, Castle Biosciences, EyePoint Pharmaceuticals, Genentech, Immunocore, and Regeneron and he has stock options with Lumata Health. Audina M. Berrocal is a consultant for Alcon, Allergan, Zeiss, Dutch Ophthalmic Research Center, Novartis, ProQR, and Oculus., (© 2024 The Authors. Published by Elsevier Inc.)

Introduction: A retrospective review of patients treated for retinoblastoma who developed a non-pineoblastoma second primary malignant neoplasm (SPMN) was performed., Methods: The demographics, clinical features and treatments for retinoblastoma, pathologic types of non-pineoblastoma second primary malignant neoplasm (SPMN), intervals between the retinoblastoma diagnosis and treatment and diagnosis of non-pineoblastoma SPMN, treatment provided for the SPMN, and the survival outcomes of the patients were evaluated., Results: Of 550 patients treated initially for retinoblastoma, this series used the 15 (2.7) that developed a non-pineoblastoma SPMN, 14 of which (93.3%) had been treated for bilateral retinoblastoma. All patients had carried a germline mutations in the  RB1  gene. The median time from retinoblastoma diagnosis to SPMN diagnosis was 19.0 years (extremes 3.4 and 39.4 years). Six of the fifteen patients died during the follow-up of their SPMN. The median interval between initial retinoblastoma diagnosis and death in the 6 patients who died of their SPMN was 18.8 years (extremes 6.2 and 34.6 years) and between diagnosis of the SPMN and death was 1.2 years (extremes 0.25 and 4 years)., Discussion: Of the patients who had been treated with External Beam Radiotherapy (EBRT), 13 developed a SPMN within the previously irradiated field., Competing Interests: Maura Di Nicola consults for EyePoint Pharmaceuticals and reports personal fees from SpringWorks Therapeutics, outside the submitted work. Basil K Williams Jr consults for Alcon, Allergan/Abbvie, Alimera, Astellas, Castle Biosciences, EyePoint Pharmaceuticals, Genentech/Roche, Immunocore, and Regeneron; owns stock options of Lumata Health. Malcolm T Wiseman Jr, Jared J Ebert, James J Augsburger, Zelia M Correa, and James I Geller declare that they have no conflicts of interest in this work., (© 2024 Wiseman Jr et al.)

Purpose: To report the clinical features and outcomes in eyes that underwent vitreoretinal surgery for complications of concurrent sickle cell retinopathy and diabetic retinopathy., Methods: Retrospective, consecutive case series of all eyes that underwent vitreoretinal surgery for complications secondary to concurrent sickle cell retinopathy and diabetic retinopathy between January 01, 2014, and December 31, 2021., Results: The study included 20 eyes of 14 patients. Indications for surgery included tractional retinal detachment in 12 eyes (60%), combined tractional retinal detachment/rhegmatogenous retinal detachment in 6 eyes (30%), and vitreous hemorrhage in 2 eyes (10%). Pars plana vitrectomy was performed in all eyes. One eye received a scleral buckle at the same time as pars plana vitrectomy. There was no change in mean best-corrected visual acuity at the last follow-up examination (1.5 [20/678]) when compared with mean preoperative best-corrected visual acuity (1.6 [20/762], P = 0.83). Preoperative best-corrected visual acuity correlated with postoperative best-corrected visual acuity at the last follow-up examination in eyes with retinal detachment (r = 0.49, P = 0.04). Single operation anatomic success was achieved in 11 of 17 eyes (65%) with retinal detachment., Conclusion: Functional and anatomic outcomes after surgery in eyes with concurrent sickle cell retinopathy and diabetic retinopathy are relatively poor.

Purpose of Review: The purpose of this review is to evaluate the current state of eco-sustainability in ophthalmology, highlighting key practices, recent advancements, and areas requiring improvement. This review aims to provide ophthalmologists with a comprehensive overview of sustainable practices that can reduce environmental impact., Recent Findings: Recent studies have identified several areas within ophthalmology where sustainable practices can be implemented including multidose eyedrops, adjusting surgical packs, making package inserts available electronically, and reusing surgical instruments. Moreover, there is an increasing emphasis on waste reduction both in the surgical and clinical setting, by decreasing the use of unnecessary materials and implementing more efficient use of recycling programs. Telemedicine has also emerged as a sustainable option, reducing the carbon footprint associated with patient travel. Despite these advancements, significant challenges remain, particularly in balancing the cost and accessibility of sustainable options with traditional practices., Summary: Eco-sustainability in ophthalmology is gaining momentum as the medical community aims to reduce its environmental impact. While progress has been made, further efforts are required to overcome financial and logistical barriers to widespread implementation. Continued research, education, and policy development are essential to advancing eco-sustainable practices, ensuring that environmental considerations become an integral part of ophthalmic care., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In the past few decades, the primary management for uveal melanoma has evolved from enucleation to eye-preserving treatments. However, despite achieving a high rate of local tumour control, complications following eye-preserving treatments still occur and are partly responsible for functional loss and secondary enucleation., Methods: A literature review by a broad international panel., Results: We summarised the current literature on utilizing vitreoretinal (VR) surgery for managing the complications of uveal melanoma. We also provided insights from the authors' personal experience and practical recommendations for clinical care., Conclusions: With the advancement of VR instruments and surgical techniques and the combination of VR and ocular oncology knowledge ("Onco-VR"), it is now possible to manage or even prevent complications such as vitreous haemorrhage, retinal detachment, and toxic tumour syndrome.

Background and Objective: Retinal gliovascular proliferation (RGVP) is a benign lesion of the retina that can arise idiopathically or secondary to another disease entity. This study describes the clinical features, treatment, and outcomes of six patients with secondary RGVP associated with irradiated, regressed retinoblastoma, and distinguishes it from late local relapse of retinoblastoma., Patients and Methods: In a retrospective review of available clinical records of 550 patients evaluated for retinoblastoma in a single ocular oncology practice between 1975 and 2022, seven eyes of six patients were identified as having secondary RGVP overlying a treated and regressed retinoblastoma. The clinical features, treatment, and outcomes are described., Results: The median age at RGVP diagnosis was 20 years. All RGVPs were associated with a completely regressed retinoblastoma and in proximity to a calcific tumor residue or chorioretinal atrophy that remained after external beam radiotherapy (six eyes) or plaque brachytherapy (one eye). Lesions were measured between 2.8 to 12 mm in largest basal diameter and 1.3 to 4.4 mm in thickness and described as globular, raised areas with focal retinal telangiectasis often associated with overlying subretinal fluid or hemorrhage. Median time between initial retinoblastoma treatment and detection of RGVP was 20 years. Treatment was decided based on evidence of lesion growth and most often consisted of laser photocoagulation and intravitreal anti-VEGF injection. Through available follow-up of the treated lesions, all exhibited at least partial regression, while two untreated lesions remained stable, reassuring us against late local relapse of retinoblastoma., Conclusions: Secondary RGVP develops occasionally in association with regressed previously irradiated retinoblastoma. This lesion must be distinguished from late local relapse of active retinoblastoma. [ Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.] .

Purpose: To report the clinical presentation and outcomes in patients who underwent surgery for proliferative sickle cell retinopathy (PSCR)., Design: Retrospective, consecutive case series., Subjects: All patients who underwent vitreoretinal surgery for complications secondary to PSCR between January 1, 2014, and December 31, 2021, at a university referral center., Methods: Retrospective consecutive case series., Main Outcome Measures: Best-corrected visual acuity (BCVA), single operation anatomic success rate., Results: The study included 65 eyes of 61 patients. Disease distribution included 24 (44.4%) eyes with hemoglobin SC disease, 14 (25.9%) with hemoglobin SS disease, 13 (24.1%) with sickle cell trait, and 3 (5.6%) with sickle cell-β thalassemia. Preoperative transfusion was not performed in any study patients. Regional anesthesia with monitored anesthesia care (RA-MAC) was utilized in 58 (89.2%) eyes and general anesthesia in 7 (10.8%). In eyes that underwent surgery for retinal detachment (RD; N = 52) the rate of single operation anatomic success was 72.4% with combined scleral buckling/pars plana vitrectomy (SB/PPV; N = 29) compared with 47.8% with PPV alone (N = 23; P = 0.07). Mean BCVA at the last follow-up examination was 1.27 (20/372) in the SB/PPV group and 1.05 (20/226) in the PPV group (P = 0.48). In all SB cases, an encircling band was utilized and there were no known cases of anterior segment ischemia. All eyes that had surgery for vitreous hemorrhage (N = 13) underwent PPV with endolaser and mean BCVA improved from 1.67 (20/944) preoperatively to 0.45 (20/56) at last follow-up examination (P < 0.001). Mean preoperative BCVA, indication for surgery, single operation success rate, and mean BCVA at last follow-up examination did not differ based on sickle cell disease type (P > 0.05)., Conclusions: In patients with RD, SB/PPV achieved slightly higher rates of single operation anatomic success compared with PPV alone. Visual acuity outcomes were similar in the 2 groups. The majority of patients received RA-MAC anesthesia and preoperative transfusions were not performed. There were no cases of postoperative anterior segment ischemia. Hemoglobin SC disease was the most common disease type in the current study and surgical outcomes did not differ between sickle cell disease types., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the case of a woman who developed rapid progression of a choroidal melanoma after 19 years of observation of a previously treated choroidal nevus., Methods: A 71-year-old woman with a 22-year history of a choroidal nevus was observed for 19 years after undergoing transpupillary thermotherapy for a localized, macula-involving, exudative, retinal detachment. Five months after her most recent stable examination, she presented for routine follow-up., Results: The lesion was noted to have increased thickness with the development of lipofuscin and subretinal fluid, suggestive of malignant transformation. In the 1 month between diagnosis and treatment with iodine-125 plaque brachytherapy, the lesion continued to expand, requiring a radiation dose adjustment., Conclusion: Choroidal nevus transformation into melanoma has been well-documented, highlighting the need for routine follow-up. Treatment within 1 month is typically sufficient for appropriate management. Occasionally, melanomas may grow substantially between diagnosis and treatment, suggesting that repeat measurement may be necessary in rare instances to ensure appropriate radiation treatment.

Purpose: The purpose of this article was to describe 3 cases of chronic central serous chorioretinopathy (CSCR) in the pediatric patient population., Methods: Retrospective case series., Results: The authors report three pediatric patients with CSCR. All patients initially presented after failed vision screens or during routine office examinations. All patients presented with macula-involving subretinal fluid (SRF) and multimodal imaging features consistent with CSCR. At the last follow-up, one patient had minimal residual SRF, one patient had a small recurrence of SRF, and one patient had persistent SRF., Conclusion: Although CSCR classically occurs in adults, it can be seen in pediatric patients. Given the rarity of this condition in the pediatric population, CSCR may go undetected and underreported, with diagnosis resulting from failed vision screens.

Purpose of Review: Diabetic retinopathy (DR) is a leading cause of visual impairment, and the increasing prevalence of diabetes and obesity will impact rates of visual impairment moving forward. Our review aims to synthesize the current body of evidence regarding the impact of lifestyle interventions, such as weight loss, bariatric surgery, and novel antidiabetic drugs, on DR., Recent Findings: Literature review revealed insufficient evidence regarding the impact of weight loss on DR. Preoperative DR patients undergoing bariatric surgery were found to have similar short-term chances of improvement or worsening DR. Progression of DR with glucagon-like peptide 1 receptor agonists treatments appears unrelated to specific drugs and was also observed with traditional antidiabetic medications., Summary: Rapidly correcting HbA1c levels (≥2%) can paradoxically lead to early worsening DR. Patients considering weight loss, bariatric surgery, and novel antidiabetic drugs should be aware of the potential for DR progression, but they should not be discouraged, as achieving glycemic control is essential for reducing long-term morbidity and mortality from other diabetes-related complications. It is advisable to conduct a baseline retinal examination before treatment and continue monitoring during therapy. Further research is needed to understand the long-term effects of these treatments on DR., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Physician-patient concordance in sex and race is associated with improved patient outcomes. Studies have explored diversity among ophthalmology residents and faculty, but to our knowledge, not among ophthalmology fellows., Objective: To assess diversity by sex and race and ethnicity among fellowship applicants in ophthalmology subspecialties and compare match rates by applicants' sex and underrepresented in medicine (URiM) status., Design, Setting, and Participants: This cohort study examined ophthalmology subspecialty fellowship data from the 2021 San Francisco Match., Main Outcomes and Measures: Applicant characteristics were stratified by sex and URiM status and compared using χ2, Mann-Whitney U, and median tests. For applicants who matched, the percentages of female and URiM applicants were compared among the ophthalmic subspecialties. A multivariable logistic regression model was used to assess the association of applicant characteristics with their match outcomes., Results: Included in the sample were 537 candidates who applied for an ophthalmology fellowship using the 2021 San Francisco Match; 224 applicants (42.6%) were female, and 60 applicants (12.9%) had URiM status. Females and males had similar match rates (70.5% [n = 158] and 69.2% [n = 209], respectively; P = .74), but females had a higher median (IQR) US Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge (CK) score (248 [240-258] vs 245 [234-254]; P = .01). The pediatric ophthalmology subspecialty had the highest percentage of female matched applicants (67.5%; 27 of 40 matched applicants), while the retina subspecialty had the highest percentage of males (68.9%; 84 of 122 matched applicants). URiM applicants had lower match rates (55.0%, n = 33) than non-URiM applicants (72.2%, n = 293; P = .007). The URiM applicants had lower median (IQR) scores on the USMLE Step 1 (238 [227-247]) compared with Asian applicants (246 [235-254]) and White applicants (243 [231-252]; P = .04). Additionally, URIM applicants submitted fewer median (IQR) applications (10 [1-23]) than Asian (21 [8-37]) and White (17 [8-32]; P = .001) applicants and completed fewer interviews (median [IQR], 2 [0-11]) than Asian (median [IQR], 12 [3-18]) and White applicants (median [IQR], 8 [1-14]; P = .001). Among matched fellows in each subspecialty, URiM applicants comprised 13.9% (n = 11) in glaucoma, 10% (n = 4) in pediatric ophthalmology, 7.3% (n = 6) in cornea, and 6.6% (n = 8) in retina., Conclusions and Relevance: Ophthalmology subspecialty fellowship match rates were lower for URiM vs non-URiM applicants in 2021. Underrepresentation of females exists in the retina subspecialty, while racial and ethnic differences exist in all ophthalmology subspecialty fellowships examined. Monitoring trends in fellowship diversity over time should help inform where targeted efforts could improve diversity.

Purpose of Review: Diversity, equity and inclusion (DEI) initiatives in ophthalmology have received increased attention in recent years. This review will highlight disparities, barriers to workforce diversity, as well as current and future efforts to improve DEI in ophthalmology., Recent Findings: Racial, ethnic, socioeconomic and sex disparities exist in vision health and across many ophthalmology subspecialties. The pervasive disparities result from factors such as a lack of access to eye care. In addition, ophthalmology is one of the least diverse specialties at the resident and faculty level. The lack of diversity has also been documented in ophthalmology clinical trials, wherein participant demographics do not reflect the diversity of the U.S. population., Summary: Addressing social determinants of health including racism and discrimination is necessary to promote equity in vision health. Diversifying the workforce and expanding the representation of marginalized groups in clinical research are also paramount. Supporting existing programmes and creating new ones focusing on improving workforce diversity and reducing eye care disparities are essential to ensure equity in vision health for all Americans., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: A patient with choroidal lymphoma associated with a choroidal neovascular membrane (CNVM) is described., Methods: Observational case report., Results: A 70-year-old man was referred for evaluation of bilateral uveitis with concern for intraocular lymphoma. Fundoscopic examination was notable for vitreous opacities and diffuse yellow-white, creamy choroidal infiltrates in both eyes. In the left eye, areas of hemorrhage and intraretinal fluid in the macula consistent with a CNVM were noted. Multimodal imaging confirmed the diagnosis of bilateral choroidal lymphoma with a CNVM in the left eye. The patient subsequently underwent external beam radiation therapy. The CNVM was treated with intravitreal bevacizumab., Conclusion: This case highlights the rare finding of a patient with a CNVM associated with choroidal lymphoma. Recognition and treatment of concurrent disease processes in the setting of choroidal lymphoma is important to achieve maximum visual potential.

Purpose: To present the rare occurrence of choroidal melanoma in an adult patient with phakomatosis pigmentovascularis and an overlap of Sturge-Weber syndrome and Klippel-Trenaunay syndrome., Methods: Observational case report., Results: A 75-year-old White woman with nevus flammeus involving the left forehead, periorbital area, cheek, chin, upper limb, and trunk, along with hemihypertrophy of the left side of the face and left upper limb, presented for evaluation of an intraocular mass in the left eye. Anterior examination of the left eye showed diffuse episcleral and iris melanocytosis. Fundus examination of the left eye showed diffuse choroidal melanocytosis and an elevated choroidal lesion. B-scan ultrasonography demonstrated a hollow lesion, and the patient was diagnosed with choroidal melanoma in the left eye in the setting of phakomatosis pigmentovascularis with overlap of Sturge-Weber syndrome and Klippel-Trenaunay syndrome. Fine-needle aspiration biopsy confirmed the diagnosis, and Iodine 125 plaque radiotherapy was performed., Conclusion: Individuals with clinical features suggestive of phakomatosis pigmentovascularis, Sturge-Weber syndrome, or Klippel-Trenaunay syndrome should undergo a complete ophthalmological evaluation for the presence of ocular melanocytosis and uveal melanoma.

Aim: This study explored uveal melanoma patient experiences and regret following molecular prognostic testing using a 15-gene expression profile (GEP) test., Materials & Methods: A retrospective, cross-sectional survey study was conducted through an online questionnaire capturing patient-reported experiences with prognostic biopsy/molecular testing., Results: Of 177 respondents, 159 (90%) wanted prognostic information at diagnosis. Most 15-GEP-tested patients who shared their results (99%) reported gaining value from testing, as did patients tested with other methods. Patients who received prognostic testing experienced lower decision regret than those who opted out. Decision regret did not differ based on GEP class., Conclusion: Most uveal melanoma patients desire prognostic testing and gain value from the GEP, independent of a high- or low-risk result., (© 2022 The Authors.)

Purpose of Review: In the absence of long-term data of the effects of private equity in ophthalmology, this article reviews the role of private equity in other medical specialties as a guide to the future for ophthalmology., Recent Findings: Across an array of medical specialties, including anesthesiology, dermatology, emergency medicine, ophthalmology/optometry, radiology, and urology, medical practices are being consolidated into a few larger platform groups. Although there has been a short-term financial success for both private equity firms and senior medical practice partners, there exists broad skepticism from peer-reviewed publications and the national media., Summary: Although the impact of private equity on ophthalmology is largely speculative, ophthalmology may follow some of the trends observed in other medical specialties. These trends include increased volume of services, increased profits, improved payer mix, increased payment per patient visit, increased use of midlevel practitioners, decreased physician autonomy, and decreased physician salaries., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: B.K.W. is a consultant for Allergan, Castle Biosciences, and Genentech. The remaining authors declare that they have no conflicts of interest to disclose.

Subjects in diabetic macular edema clinical trials in the United States are disproportionately White and male, compared with the population undergoing treatment for diabetic macular edema., (Copyright © 2022 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the efficacy of photodynamic therapy (PDT) for management of retinal hemangioblastoma., Design: Retrospective case series., Participants: Seventeen patients with retinal hemangioblastoma treated with PDT., Methods: The medical records of 17 patients with retinal hemangioblastoma treated with PDT were reviewed, and treatment outcomes were assessed. Photodynamic therapy was performed with 6 mg/m 2 body surface area of verteporfin infused intravenously over 10 minutes activated by 50 J/cm 2 laser light at 689 nm for 83 or 166 seconds., Main Outcome Measures: Tumor control, subretinal and intraretinal fluid resolution, and visual outcome., Results: Eighteen retinal hemangioblastomas in 17 eyes were treated with PDT. Median patient age was 31 years (mean, 36 years; range, 7-66 years), and median follow-up was 51 months (mean, 61 months; range, 2-144 months). Genetic testing confirmed von Hippel-Lindau disease in 8 of 17 patients (47%). The tumors were unilateral in all patients and unifocal in most patients (n = 13/17 [76%]). The tumor median basal diameter was 3.5 mm (mean, 3.4 mm; range, 1.5-6.0 mm) and median thickness was 2.1 mm (mean, 2.3 mm; range, 1.0-5.0 mm). The tumor location was juxtapapillary in 9 of 18 cases (50%). Associated findings included subretinal fluid (n = 14/17 [82%]) and macular edema (n = 12/17 [71%]). The median number of PDT sessions was 1.5 (mean, 1.8; range, 1.0-4.0). Standard duration of PDT (83 seconds) was used in all cases except 2, in which double duration (166 seconds) was used. Outcomes revealed tumor control in 13 of 18 tumors (72%), partial or complete resolution of subretinal fluid in 10 of 14 eyes (71%), and partial or complete resolution of macular edema in 7 of 12 eyes (58%), and stable or improved visual acuity in 12 of 17 eyes (71%). Photodynamic therapy-related transient exudative response was noted in 4 of 17 eyes (24%)., Conclusions: Photodynamic therapy is an effective treatment for both juxtapapillary and peripheral retinal hemangioblastomas, providing satisfactory rates of tumor control and visual stabilization and improvement. Patients should be monitored for PDT-related transient exudative response., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

[ Ophthalmic Surg Lasers Imaging Retina. 2021;52:682-683.] .

Several neoplastic processes can involve the eye, either primarily or secondary to a systemic malignancy. The most common primary tumors of the eye include conjunctival and uveal melanoma, retinoblastoma, conjunctival and intraocular lymphoma, and ocular surface squamous neoplasia. Metastatic spread from systemic malignancies, especially of the breast and lung, also can involve the eye. A combination of ophthalmologic examination, ancillary testing, and cytologic/histopathologic evaluation leads to accurate diagnosis. Management consists of surgery, radiotherapy, chemotherapy, and immunotherapy delivered in various forms., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: To determine factors predictive of visual outcome in patients with circumscribed choroidal hemangioma treated with photodynamic therapy (PDT)., Design: Retrospective case series., Participants: Seventy-nine patients with circumscribed choroidal hemangioma treated with PDT., Methods: Patients with circumscribed choroidal hemangioma treated with PDT were identified, and factors predictive of final visual acuity were assessed., Main Outcome Measures: Factors predictive of final visual acuity of 20/40 or better versus 20/50 or worse., Results: Seventy-nine eyes of 79 patients with circumscribed choroidal hemangioma were treated with PDT. All tumors were unilateral and posterior to the equator. Mean largest basal diameter was 5.7 mm (range, 2.0-10.0 mm); mean thickness was 3.0 mm (range, 1.4-4.5 mm). A total of 116 PDT sessions were performed (mean, 1.5 sessions; range, 1.0-7.0 sessions). Standard duration PDT was used in most cases (83 seconds; n = 110/116 [95%]). Mean follow-up was 43 months. Of 79 patients, 49 (62%) demonstrated good visual acuity (≥20/40) and 30 (38%) showed intermediate to poor visual acuity (≤20/50) after PDT. A comparison (final visual acuity, good vs. intermediate to poor) revealed a statistically significant difference in baseline features of photopsia (100% vs. 0%; P = 0.04), initial visual acuity of 20/40 or better (77% vs. 23%; P < 0.001), mean tumor basal diameter (5.4 mm vs. 6.2 mm; P = 0.03), mean tumor thickness (2.9 mm vs. 3.2 mm; P = 0.01), cystoid macular edema (CME) involving the foveola (30% vs. 70%; P = 0.001), retinal edema overlying the lesion (39% vs. 61%; P = 0.003), retinoschisis involving the foveola (0% vs. 100%; P = 0.002), lack of CME regardless of foveola involvement at presentation (79% vs. 21%; P < 0.001), previous treatment (33% vs. 67%; P = 0.04), and CME progression after treatment (0% vs. 100%; P = 0.006). Partial or complete resolution of subretinal fluid was achieved in 93% of patients., Conclusions: In this comparative analysis, PDT was an effective treatment method for circumscribed choroidal hemangioma. Good final visual outcome (≥20/40) was correlated with good baseline visual acuity, smaller tumor size, lack of CME, and lack of treatment before PDT., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the clinical and imaging characteristics, pathologic features, and management options of retinal pigment epithelium (RPE) adenoma/adenocarcinoma., Design: Retrospective case series., Participants: Fifty-one patients with RPE adenoma/adenocarcinoma., Methods: Treatment options for the patients included observation, partial lamellar sclerouvectomy (PLSU), enucleation, and others., Main Outcome Measures: Factors related to visual acuity (VA) outcomes (>2 Snellen lines loss, poor final VA [≤20/200], good final vision [≥20/40]), tumor growth, and need for enucleation., Results: The mean patient age at diagnosis was 51 years, and the majority of patients were white (40/51, 78%) and female (34/51, 67%). Primary management included observation (29/51, 57%), PLSU (9/51, 18%), enucleation (4/51, 8%), or others (9/51, 18%). Outcomes revealed decreased VA (10/32, 31%), poor final VA (17/32, 53%), good final VA (11/32, 34%), tumor growth (12/25, 48%), and need for enucleation (7/51, 14%). By multivariable analysis, features predictive of decreased VA included increasing baseline tumor thickness (P = 0.01) and presence of vitreous hemorrhage (P = 0.05). Factors predictive of poor final VA included presence of exudative retinal detachment (P = 0.004), baseline VA 20/50 to 20/150 (P = 0.008), and baseline VA ≤20/200 (P = 0.01). Absence of feeding and/or draining vessel was predictive of good VA (P = 0.004). Tumor growth was associated with multiple treatments (P = 0.02). Increased tumor thickness (P = 0.03) and presence of exudative retinal detachment (P = 0.01) were predictive of enucleation., Conclusion: RPE adenoma/adenocarcinoma can simulate choroidal melanoma. Greater tumor thickness, vitreous hemorrhage, exudative retinal detachment, and poor baseline VA predict worse visual outcome and greater risk for enucleation., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

A 34-year-old Caucasian woman with a past medical history of hypertension presented with acute floaters in the right eye (OD) for 1 week. Best-corrected visual acuity (VA) was 20/20 in both eyes. Fundus examination OD (Figure 1) revealed a retinal hemangioblastoma (RH) in the temporal midperiphery with a prominent feeding artery and draining vein. A retinal arterial microaneurysm (RAM) was noted within the feeding artery, and subretinal hemorrhage with a cuff of fluid was present. Fundus autofluorescence (Figure 2) showed hypoautofluorescence in the area of the RH, RAM, and subretinal hemorrhage. A hyperautofluorescent ring surrounding the hemorrhage suggested shallow subretinal fluid. Early phase fluorescein angiography (Figure 3) demonstrated appropriate arterial and venous filling and hyperfluorescence of the RH. The RAM appeared hyperfluorescent, whereas the subretinal hemorrhage blocked. There was no evidence of leakage on late images. Optical coherence tomography (OCT) (Figure 4) through the RAM revealed an inner retinal structure with a central lumen and hyperreflective border. Mild outer retinal exudation was also noted. Fovea was normal on OCT. Fundus examination of the left eye was normal. Genetic work-up was negative for von Hippel-Lindau disease. Treatment of the hemangioblastoma was offered, but the patient preferred observation. VA remained stable, and better systemic hypertension control was recommended. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:365-366.]., (Copyright 2020, SLACK Incorporated.)

Aim: To characterise combinations of multimodal imaging risk factors and predictive value for choroidal nevus transformation into melanoma., Methods: This is a retrospective review of multimodal imaging features for 3806 choroidal nevi from 1 January 2007 through 1 January 2017. Kaplan-Meier estimates and Cox regression analyses were used to calculate 5-year percentages of growth to melanoma and HR., Results: Using multimodal imaging, six risk factors predictive of choroidal nevus transformation into melanoma were identified, namely tumour thickness >2 mm, subretinal fluid, symptoms of visual acuity loss to 20/50 or worse, orange pigment, hollow acoustic density and tumour largest basal diameter >5 mm. Kaplan-Meier 5-year estimated tumour growth was found in 1% of nevi with no risk factors, 11% (range 9%-37%) with one factor, 22% (12%-68%) with two factors, 34% (21%-100%) with three factors, 51% (0%-100%) with four factors and 55% (0%-100%) with five factors. HR for growth was 0.1 with no factor, 2.1-7.8 with one factor, 1.8-12.1 with two factors, 4.0-24.4 with three factors, 4.6-170.0 with four factors and 12.0-595.0 with five factors. The highest HR with each combination of two, three, four or five risk factors always included symptoms of visual acuity loss and orange pigment., Conclusion: Six risk factors for choroidal nevus transformation into melanoma by multimodal imaging have been identified. Risk for transformation into melanoma is 1% when no factors are present, and approaches 100% with specific combinations of three or more risk factors. Understanding how combinations of factors influence risk of transformation into melanoma can guide counselling and treatment decisions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

A patient treated for retinoblastoma developed vitreous floaters 15 years later and was referred for recurrence with vitreous seeding. Clinical examination demonstrated a regressed scar and numerous calcified vitreous opacities with a "clear zone" on ultrasonography. The final diagnosis was asteroid hyalosis in an eye with regressed retinoblastoma. [J Pediatr Ophthalmol Strabismus. 2019;56:e41-e44.]., (Copyright 2019, SLACK Incorporated.)

Hemorrhagic occlusive retinal vasculitis (HORV) is a condition associated with intraocular vancomycin during surgical intervention, most frequently following bilateral sequential cataract surgery. Because of the high rate of ophthalmic vascular complications in this condition, gonioscopic evaluation for identification of neovascularization of the angle and iris is essential. Careful examination can reveal previously asymptomatic and unassociated lesions of the iris or ciliary body. We present the case of a 71-year-old female who was diagnosed with a ciliary body melanoma secondary to complete ophthalmic examination associated with HORV. She reported decreased vision to light perception in the left eye (OS) following sequential, bilateral cataract surgery. Fundus examination OS demonstrated diffuse retinal vasculitis, retinal ischemia, and extensive hemorrhage. Evaluation included inflammatory and coagulopathy laboratory evaluation, carotid ultrasonography and magnetic resonance imaging (MRI) of the brain and orbits, all of which proved unrevealing, except for an enhancing mass OS on MRI. Further evaluation revealed a pigmented mass with features of melanoma in the anterior chamber angle extending into the ciliary body. Fine needle aspiration biopsy revealed high risk cytogenetic characteristics, and plaque radiotherapy was successfully employed.

Purpose: To describe the clinical and imaging findings and treatment options in a series of patients with iris microhemangiomatosis., Design: Retrospective observational case series., Methods: Setting: Single institution., Study Population: Twenty-two eyes of 14 consecutive patients with iris microhemangiomatosis were reviewed., Observation Procedures: Clinical examination and slit-lamp photography were performed on every patient. Anterior segment optical coherence tomography (AS-OCT), anterior segment optical coherence tomography angiography (AS-OCTA), anterior segment intravenous fluorescein angiography (AS-IVFA), and ultrasound biomicroscopy were performed when possible., Main Outcome Measures: Clinical and imaging features and treatment strategies., Results: Twenty-two eyes of 14 patients with iris microhemangiomatosis were included in this series. Mean patient age was 70 years (range, 58-82 years), and all patients were white. The iris hemangiomatosis appeared as subtle, multifocal, ectatic vascular channels arranged circumferentially at the pupillary margin. Iris color was blue (n = 19 eyes) or green (n = 3 eyes), and the features were unilateral (n = 6 patients) or bilateral (n = 8 patients). Additional features included reduced visual acuity (n = 13 eyes), hyphema (n = 12 eyes), and glaucoma (n = 7 eyes). There was no history of ocular trauma or systemic vasculopathic conditions. AS-OCT documented the fine tuft at the pupillary margin, AS-OCTA showed vascular flow, and AS-IVFA demonstrated pupillary margin vascular lesions with mild staining. Observation was advised in 20 cases (91%), and argon laser photocoagulation was required for repetitive hyphema in 2 cases (9%)., Conclusion: Iris microhemangiomatosis is a rare ocular condition, often manifesting with spontaneous unilateral hyphema and/or secondary glaucoma. AS-IVFA confirms the diagnosis, and intervention with laser photocoagulation is necessary in only 9% of eyes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To report the visual outcomes and complications of scleral fixated intraocular lenses (IOLs) using Gore-Tex suture., Methods: The current study is a retrospective noncomparative case series including patients who underwent scleral fixation of IOL (Akreos AO60) using Gore-Tex suture from August 2015 to March 2017 at a university teaching center. Primary outcome measures were visual acuity and complications at last follow-up., Results: The current study included 49 eyes of 48 patients. Mean follow-up duration postsurgery was 6.9 months (range: 0.9-29.4 months). The indications for secondary IOL surgery were dislocated IOL in 16/49 (33%), subluxed IOL in 9/49 (18%), dislocated or subluxed crystalline lens in 9/49 (18%), traumatic cataract in 8/49 (16%), and complicated cataract surgery in 7/49 (14%). Mean best-corrected logMAR visual acuity improved from 1±0.7 (20/200 Snellen equivalent) preoperatively to 0.5±0.5 (20/63 Snellen equivalent) at last follow-up. There were no intraoperative complications noted. Early postoperative complications included significant persistent corneal edema (longer than 1 week) in 4/49 (8.2%), ocular hypertension (intraocular pressure ≥25 mmHg) in 8/49 (16.3%), hypotony (intraocular pressure ≤5 mmHg) in 6/49 (12.2%), cystoid macular edema 3/21 (6.1%), IOL tilt 2/49 (4.1%), hyphema in 2/49 (4.1%), and vitreous hemorrhage in 5/49 (4.8%). There was one case of recurrent retinal detachment. One patient presented with an erosion of the Gore-Tex suture through the conjunctiva resulting in a purulent scleritis 6 months after the initial surgery, and was managed with removal of the IOL, debridement, and cryotherapy. Forty-one of 49 patients completed 3-month follow-up, among which visual acuity improved, deteriorated, or remained same compared to baseline in 27/49 (55.1%), 8/49 (16.3%), and 6/49 (12.2%) eyes, respectively., Conclusion: In the current study, visual acuity outcomes were generally favorable. The complications were largely transient. Significant complications included a suture-related infection, which required removal of the IOL, and a recurrence of a retinal detachment., Competing Interests: Disclosure Dr Fortun works with DORC. He is the consultant for Alcon and DORC outside the submitted work. Dr Albini is the consultant for Beaver Visitec, Abbvie, Bausch and Lomb, Eleven Biotheraputetics, DORC, Allergan, Alcon, Santen, Clearside, UCB Corp, Genentech/Roche, outside the submitted work. Dr Flynn Jr reports grants from NIH Center, during the conduct of the study. The authors report no other conflicts of interest in this work.

Competing Interests: There are no conflicts of interest