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Sarah C Miller,1 Prajna Meeralakshmi,2 Michael J Fliotsos,3 Grant A Justin,4 Yoshihiro Yonekawa,5 Ariel Chen,1 Annette K Hoskin,6,7 Richard J Blanch,8– 10 Kara M Cavuoto,11 Rebecca Low,12 Ximin Li,1,13 Matthew Gardiner,14 TY Alvin Liu,1 Ankoor S Shah,14 James D Auran,15 Rupesh Agrawal,12,16– 18 Fasika A Woreta1 On behalf of The International Globe and Adnexal Trauma Epidemiology Study (IGATES)1Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Aravind Eye Hospital, Madurai, India; 3Department of Ophthalmology, Yale New Haven Hospital, New Haven, CT, USA; 4Vitreoretinal Surgery Service, Duke Eye Center, Durham, NC, USA; 5Wills Eye Hospital, Mid Atlantic Retina, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA; 6Save Sight Institute, University of Sydney, Sydney, Australia; 7Lions Eye Institute, University of Western Australia, Perth, Australia; 8Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, England; 9University Hospitals Birmingham, NHS Foundation Trust, Birmingham, England; 10Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, England; 11Bascom Palmer Eye Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA; 12Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, Singapore; 13Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 14Massachusetts Eye and Ear Infirmary, Boston, MA, USA; 15Columbia University Irving Medical Center, New York City, NY, USA; 16Singapore Eye Research Institute, Singapore; 17Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; 18Duke NUS Medical School, SingaporeCorrespondence: Fasika A Woreta, The Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21205, USA, Tel +410-961-2868, Fax +410-614-9632, Email fworeta1@jhmi.edu Rupesh Agrawal, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore Eye Research Institute, Lee Kong Chian School of Medicine, Nanyang Technological University, Duke NUS Medical School, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore, Tel +6563571000, Email Rupesh_agrawal@ttsh.com.sgPurpose: Hyphema is a sequela of ocular trauma and can be associated with significant morbidity. Management of this condition is variable and can depend on individual institutional guidelines. We aimed to summarize current practices in hyphema management across ophthalmological institutions worldwide.Methods: A cross-sectional online survey was conducted across North America, Asia, South America, Africa, Europe, and Australia from August 2020 to January 2021. The survey assessed the existing practices in the management of hyphema at each institution.Results: For layered hyphema, topical steroids were routinely administered by 34 (of 36 respondents, 94.4%) institutions, of which prednisolone was the preferred choice (n = 32, 88.9%). Topical cycloplegics were used at 34 (94.4%) institutions. No institution reported routine use of antifibrinolytics. Head elevation was the most deployed procedure to promote hyphema reabsorption (n = 31, 86.3%), followed by partial bed rest (n = 21, 58.3%). The majority of institutions (n = 25, 69.4%) did not routinely pursue admission for hyphema patients, although 75.0% of institutions (n = 27) scheduled follow-up visits within 48 hours of presentation. Additionally, few institutions performed routine sickle cell trait testing for patients presenting with hyphema (n = 6, 16.7%). The decision to perform anterior chamber washout varied and was often based on intraocular pressure and the speed of hyphema resolution.Conclusion: Unanimity of international institutions on hyphema management is lacking. As it stands, many current interventions have unconvincing evidence supporting their use. Evidence-based guidelines would be beneficial in guiding decision-making on hyphema management. Additionally, areas of consensus can be used as foundations for future standard of care investigations.Keywords: current practices, hyphema, trauma, sickle cell, anterior segment

Kumiko Kato,1 Maki Takeuchi,1 Yuka Yonekawa,1 Yuzen Kashima,1 Koji Hirano,2 Mineo Kondo1 1Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Japan; 2Department of Ophthalmology, Fujita Health University Bantane Hospital, Nagoya, JapanCorrespondence: Kumiko KatoDepartment of Ophthalmology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, JapanTel +81-59-231-5027Fax +81-59-231-3036Email k-kato@clin.medic.mie-u.ac.jpPurpose: To report our findings in three cases of an inflamed conjunctival nevus whose size and degree of pigmentation were reduced by topical antiallergic and immunosuppressive ophthalmic solutions.Methods: Observational case series. Three patients with inflamed conjunctival nevus were examined by slit-lamp biomicroscopy, and the findings before and after the treatments were compared.Results: All three patients had a slightly pigmented and edematous conjunctival tumor at the corneal limbal area. The tumors were hyperemic, and papillae and follicles were present on the superior conjunctiva in all patients. All of the patients had an allergic predisposition. The antiallergic treatment not only resolved the hyperemia and edema of the palpebral conjunctiva, but also reduced the tumor size. In one case, the topical antiallergic agent alone led to a reduction of the tumor size. A combination of topical antiallergic agent and topical immunosuppressant was effective in reducing the tumor size and degree of pigmentation in the other two patients.Conclusion: The hyperemia and pigmentation in eyes with inflamed conjunctival nevus can be resolved by topical antiallergic agent and topical immunosuppressant without resection of the tumor.Keywords: inflamed juvenile conjunctival nevus, epinastine, tacrolimus

Devasis N Reddy,1 Yoshihiro Yonekawa,1–4 Benjamin J Thomas,1,2,5 Eric D Nudleman,6 George A Williams1,2 1Oakland University William Beaumont School of Medicine, Rochester, MI, 2Associated Retinal Consultants, William Beaumont Hospital, Royal Oak, MI, 3Massachusetts Eye and Ear Infirmary, Boston, MA, 4Boston Children’s Hospital, Harvard Medical School, Boston, MA, 5Florida Retina Institute, Jacksonville, FL, 6Shiley Eye Institute, University of California San Diego School of Medicine, San Diego, CA, USA Purpose: The aim of the study was to present the long-term anatomical and visual outcomes of retinal detachment repair in patients with Stickler syndrome.Patients and methods: This study is a retrospective, interventional, consecutive case series of patients with Stickler syndrome undergoing retinal reattachment surgery from 2009 to 2014 at the Associated Retinal Consultants, William Beaumont Hospital.Results: Sixteen eyes from 13 patients were identified. Patients underwent a mean of 3.1 surgical interventions (range: 1–13) with a mean postoperative follow-up of 94 months (range: 5–313 months). Twelve eyes (75%) developed proliferative vitreoretinopathy. Retinal reattachment was achieved in 100% of eyes, with ten eyes (63%) requiring silicone oil tamponade at final follow-up. Mean preoperative visual acuity (VA) was 20/914, which improved to 20/796 at final follow-up (P=0.81). There was a significant correlation between presenting and final VA (P

Benjamin J Thomas, Yoshihiro Yonekawa, Jeremy D Wolfe, Tarek S Hassan Department of Vitreoretinal Surgery, William Beaumont Hospital, Royal Oak, MI, USA Objective: To compare the effects of intravitreal ranibizumab (RZB) or dexamethasone (DEX) intravitreal implant in cases of recalcitrant diabetic macular edema (DME).Methods: Retrospective, interventional study examining patients with symmetric bilateral, center-involved DME recalcitrant to treatment with RZB, who received DEX in one eye while the contralateral eye continued to receive RZB every 4–5 weeks for a study period of 3 months.Results: Eleven patients (22 eyes) were included: mean logarithm of the minimal angle of resolution (logMAR) visual acuity (VA) for the DEX arm improved from 0.415 (standard deviation [SD] ±0.16) to 0.261 (SD ±0.18) at final evaluation, and mean central macular thickness (CMT) improved from 461 µm (SD ±156) to 356 µm (SD ±110; net decrease: 105 µm, P=0.01). Mean logMAR VA for the RZB arm improved from 0.394 (SD ±0.31) to 0.269 (SD ±0.19) at final evaluation. Mean CMT improved from 421 µm (SD ±147) to 373 µm (SD ±129; net decrease: 48 µm, P=0.26).Conclusion: A subset of recalcitrant DME patients demonstrated significant CMT reduction and VA improvement after a single DEX injection. Keywords: aflibercept, bevacizumab, central macular thickness, macular edema, dexamethasone implant, diabetic macular edema, diabetic retinopathy, ranibizumab

Aristomenis Thanos,1 Yoshihiro Yonekawa,1,2 Bozho Todorich,1 Darius M Moshfeghi,3 Michael T Trese1 1Associated Retinal Consultants, William Beaumont Hospital, Royal Oak, MI, 2Retina Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, 3Byers Eye Institute, Horngren Family Vitreoretinal Center, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA Abstract: Several studies have validated the role of telemedicine as a new powerful screening and diagnostic tool for retinal disorders, such as diabetic retinopathy and retinopathy of prematurity. With regard to retinopathy of prematurity, bedside examination with binocular indirect ophthalmoscopy has been the gold standard technique for screening, yet with several limitations. Herein, we review the current evidence that supports the role of telemedicine for the screening of infants with retinopathy of prematurity. Keywords: retinopathy of prematurity, screening, telemedicine

Eric Nudleman,1 Jeremy D Wolfe,2,3 Maria A Woodward,4 Yoshihiro Yonekawa,2,3 George A Williams,2,3 Tarek S Hassan2,3 1Department of Ophthalmology, Shiley Eye Center, University of California, San Diego, La Jolla, CA, 2Beaumont Eye Institute, Oakland University William Beaumont School of Medicine, 3Associated Retinal Consultants, Royal Oak, 4Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA Purpose: Antivascular endothelial growth factor injection is the mainstay of treating neovascular age-related macular degeneration (AMD). Previous studies have shown that switching treatment from ranibizumab to aflibercept led to an improvement in eyes with recalcitrant activity. Herein, we identify a unique subset of patients whose eyes with neovascular AMD were previously well controlled with ranibizumab injections were then worsened after being switched to aflibercept. Methods: This is a retrospective interventional case series. Eyes with neovascular AMD, previously well controlled with monthly injections of ranibizumab, which then developed worsening of subretinal fluid after being switched to aflibercept were included. Results: A total of 17 eyes were included. All eyes developed increased subretinal fluid when switched from ranibizumab to aflibercept. Fourteen patients were switched back to ranibizumab after a single injection of aflibercept and had subsequent rapid resolution of subretinal fluid. Three patients continued with monthly aflibercept injections for two subsequent months and demonstrated the persistence of the increased subretinal fluid until they were switched back to treatment with ranibizumab at which time the fluid resolved. No eye had persistent decline in visual acuity. Conclusion: Switching from intravitreal ranibizumab to aflibercept in eyes with well-controlled neovascular AMD may result in worsening in a subset of patients and resolves when therapy is switched back to ranibizumab. Keywords: anti-VEGF; intravitreal injection; macula; optical coherence tomography; retina

Yoshihiro Yonekawa, Ashkan M Abbey, Ankoor R Shah, Benjamin J Thomas, Antonio Capone Jr Associated Retinal Consultants, Department of Ophthalmology, William Beaumont Hospital, Royal Oak, MI, USA Abstract: Phototoxic maculopathy caused by endoillumination during macular surgery is uncommon. Previously identified risk factors have included intensity of the light source, proximity to the retinal surface, and length of exposure. In the era of indocyanine green (ICG)-assisted internal limiting membrane (ILM) peeling, the use of ICG, and the technique of ILM peeling may both contribute to subsequent phototoxic maculopathy. We present cases of routine chromovitrectomy who developed phototoxic maculopathy in the precise discrete distribution of the ILM rhexes, and discuss potential mechanisms and implications. Keywords: ILM peeling, indocyanine green, vitrectomy, ERM

Nudleman E, Wolfe JD, Woodward MA, Yonekawa Y, Williams GA, Hassan TS. Clinical Ophthalmology. 2016;10: 1053–1057.A units error was published on page 1055, column 2, as “3.1%”; the correct units are “μm” (3.1 μm).Read the original article.