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Abstract Purpose To report the clinical characteristics, antibiotic susceptibilities, and review the literature of Burkholderia cepacia complex (BCC) associated endophthalmitis. Study design Retrospective, observational case series. Methods Clinical and microbiology records were reviewed for patients evaluated at the Bascom Palmer Eye Institute and diagnosed wisth culture-confirmed endophthalmitis due to BCC. Antibiotic susceptibility profiles were generated using standard microbiologic protocols via an automated VITEK system. Results Endophthalmitis associated with BCC was diagnosed in three patients. Infection occurred in the setting of post-penetrating keratoplasty (PKP), glaucoma filtering surgery, and suspected trauma. All isolates demonstrated in vitro susceptibility to ceftazidime and meropenem. Presenting visual acuity (VA) ranged from hand motion to light perception. Initial treatment strategies included intravitreal ceftazidime (2.25 mg/0.1 mL) and vancomycin (1.0 mg/0.1 mL) injections with fortified topical antibiotics in 2 patients, and surgical debridement of a corneoscleral melt with patch graft along with both topical fortified antibiotics oral antibiotics in the third patient. In all 3 patients, there was no VA improvement at last follow-up, as 2 eyes ultimately underwent enucleation and 1 eye exhibited phthisis bulbi at last follow-up. BCC related endophthalmitis was reviewed among 13 reports. Treatment outcomes were generally poor and antibiotic resistance was common. These BCC isolates cases demonstrated broad resistance patterns, with susceptibilities to ceftazidime (58%), ciprofloxacin (53%), and gentamicin (33%). Conclusions Endophthalmitis caused by B. cepacia is a rare clinical entity with generally poor visual outcomes despite prompt treatment with appropriate antibiotics.

We present 2 cases of sutureless 25-gauge pars plana vitrectomy and fluid-gas exchange, in which incorrect gas concentrations likely led to elevated intraocular pressures and retrobulbar gas. Combined removal of orbital gas with anterior orbitotomy and pars plana vitrectomy was performed in the first case to address expanding intraocular and retrobulbar gas resulting from a suspected error in gas dilution. Vitreous and orbital gas removal by needling was effective in the second case. In patients with elevated intraocular pressure and orbital gas accumulation after vitrectomy, combined intraocular and orbital decompressions were effective in optimizing clinical outcomes. There is no consensus regarding the best management of orbital gas after vitrectomy. We propose that a multidisciplinary technique should be considered, when available.

Endophthalmitis is a rare but vision-threatening infection characterized by marked inflammation of intraocular fluids and tissues, uncommonly seen following surgery and intravitreal injection. Antimicrobials are used worldwide in the prophylaxis and treatment of bacterial and fungal infections of the eye and are standard treatment in the preoperative and postoperative care of surgical patients. However, antimicrobials are reported to be overprescribed in many parts of the world, which contributes to antimicrobial resistance (AMR). AMR complicates the prophylaxis and treatment of endophthalmitis. This article examines the prevalence and mechanisms of AMR in ocular microorganisms, emphasizing the importance of understanding AMR patterns for tailored treatments. It also explores prophylaxis and management strategies for endophthalmitis, with a discussion on the use of intracameral antibiotic administration. The use of prophylactic intracameral antibiotics during cataract surgery is common in many parts of the world but is still controversial in some locations, especially in the US. Finally, it highlights the role of stewardship in ophthalmology and its benefits in the treatment of endophthalmitis.

Abstract Purpose Bilateral endogenous Candida endophthalmitis (ECE) treatment usually involves administering systemic and intravitreal antifungal medications. In advanced cases with vitreous seeding, pars plana vitrectomy (PPV) is considered. The use of focal endolaser treatment to chorioretinal lesions has not been reported. We present a case of bilateral recurrent ECE treated with PPV and endolaser to elevated focal lesions. Case A 45-year-old diabetic male presented with decreased visual acuity in both eyes (20/50 right eye, 20/150 left eye) and was found to have bilateral ECE with moderate vitritis and chorioretinal lesions. The initial treatment consisted of multiple intravitreal voriconazole injections to both eyes as well as systemic antifungal therapy. Resolution of ECE occurred after three months, but one year later despite therapy recurred bilaterally. Patient underwent PPV with endolaser to the elevated chorioretinal lesions in both eyes. One year later, his vision improved to 20/40 in both eyes, focal lesions were flat and resolved along with the ECE. Conclusion Advanced or recurrent ECE that is refractive to intravitreal antifungal therapy may be treated with PPV. Endolaser therapy to the chorioretinal lesions is an additional local option that can resolve the activity of ECE.

Purpose: Swept-source optical coherence tomography angiography (SS-OCTA) was used to detect the presence of macular neovascularization (MNV) in eyes with exudative central serous chorioretinopathy (CSCR). Observations: Case 1 is a 73-year-old man using prednisolone drops with 20/40 vision and a retinal pigment epithelial detachment (PED) associated with subretinal fluid (SRF) and no clinical signs of age-related macular degeneration (AMD) in his left eye. Three months after presentation he underwent SS-OCTA imaging that revealed MNV. He received a series of intravitreal anti-vascular endothelial growth factor (VEGF) injections and SS-OCTA imaging showed a decrease in the MNV lesion size with resolution of the SRF. VA improved to 20/25. Case 2 is a 65-year-old man with recent oral steroid use, presenting with 20/20 vision, a PED, SRF, and no evidence of AMD. SS-OCTA imaging at presentation revealed MNV, which worsened on interval SS-OCTA imaging after the patient deferred treatment. Intravitreal anti-VEGF therapy was then performed with resolution of the SRF and VA improved to 20/15. A total of six cases of type 1 MNV were diagnosed with CSCR. Most were men with a history of steroid or testosterone use and were treated with good response. Conclusions and importance: SS-OCTA imaging provides a convenient non-invasive strategy for identifying CSCR eyes with MNV without the need for dye-based angiography.

Kocuria is an anaerobic, Gram-positive bacterium, which has been rarely reported to cause endophthalmitis following cataract surgery, intravitreal injections, penetrating ocular trauma, and also secondary to endogenous sources. Visual prognosis is often guarded, with no previous cases reporting a final visual acuity better than 20/60. We describe a young female patient who developed culture-proven Kocuria kristinae endophthalmitis associated with a traumatic scleral rupture. Visual acuity at 2 months of follow-up improved from light perception to 20/50 after treatment with intravitreal antimicrobial therapy and pars plana vitrectomy.

We report a case of endophthalmitis occurring secondary to a retained cilium in a clear corneal wound after cataract surgery. A 67-year-old female presented to an ophthalmology emergency room with light perception vision in the right eye 5 days after routine cataract surgery. Examination of the right eye demonstrated decreased vision, conjunctival injection, a corneal endoplaque, and anterior chamber fibrin. Additionally, a cilium was visible in the clear corneal incision. A vitreous aspiration and injection of antibiotics and steroid were performed, and the patient underwent a vitrectomy the next day. Intraoperative cultures and culture of the cilium grew Staphylococcus epidermidis. One year after vitrectomy, the patient’s vision recovered to 20/25 in the operated eye. In conclusion, a retained cilium in a clear corneal wound related to cataract surgery, though rare, may result in endophthalmitis. The surgical field should be cleared of cilia on the ocular surface prior to surgery. Proper draping and use of povidone-iodine antisepsis are essential in reducing the risk of endophthalmitis.

Agrobacterium radiobacter is a Gram-negative bacillus and a rare cause of endophthalmitis. An 85-year-male presented with late-onset endophthalmitis associated with exposure of an inferonasal Baerveldt tube. The patient was initially treated with anterior chamber paracentesis and intravitreal antibiotics. Aqueous humor culture revealed A. radiobacter resistant to cefazolin, ceftazidime, amikacin, tobramycin, and trimethoprim-sulfamethoxazole. Subsequently, the patient underwent explantation of the glaucoma drainage implant (GDI). After initial improvement, the patient had clinical worsening and was diagnosed with recurrence. Subsequent treatment involved explantation of the second GDI in addition to pars plana vitrectomy with silicone oil infusion, intraocular lens removal, and administration of intravitreal antibiotics. Visual acuity improved but remained at count fingers at 2 weeks. This is the first reported patient with A. radiobacter endophthalmitis associated with an exposed GDI. This report illustrates the resistant nature of this organism in addition to the efficacy of silicone oil administration and intraocular prosthesis explantation.

We report the clinical features, treatment strategies and outcomes in a series of patients with infectious endophthalmitis after cataract surgery caused by Cutibacterium acnes (C. acnes), formerly known as Propionibacterium acnes (P. acnes). This retrospective case series includes six eyes of six patients with chronic postoperative endophthalmitis caused by culture-proven C. acnesfrom December 2010 to July 2019 at a University referral center. All patients underwent prior cataract extraction with intraocular lens (CE/IOL) implantation. The mean time between cataract surgery and the microbiologic diagnosis of endophthalmitis was 7.4 ± 5.2 months (range 1.5–17 months). The average time from obtaining the specimen to culture positivity was 7.7 ± 4.4 days (range 3–15 days). Three eyes (50%) presented with hypopyon and three eyes (50%) presented with prominent keratic precipitates without hypopyon. Presenting visual acuity ranged from 20/25 to 2/200. Initial treatments included intravitreal antibiotics alone (n = 2), pars plana vitrectomy (PPV) with partial capsulectomy and intravitreal antibiotics (n = 3), and pars plana vitrectomy with IOL removal and intravitreal antibiotics (n = 1). Follow-up treatments included IOL removal (n = 2), intravitreal antibiotics (n = 1), and topical antibiotics (n = 1). The best-corrected visual acuity at last follow-up was 20/70 or better in all patients. In a literature review, the clinical features and treatment outcomes for all case series of delayed-onset postoperative endophthalmitis caused by C. acnes(n = 120) are listed. A definitive cure (the absence of recurrent inflammation) was achieved in 100% of patients that underwent IOL removal, in 77% of those that underwent PPV/partial capsulectomy and intravitreal antibiotics, and in 18% of cases treated with intravitreal antibiotics alone. Endophthalmitis after CE/IOL caused by C. acnesis characterized by slowly progressive intraocular inflammation and has a protracted course from surgery to microbiologic diagnosis. Visual outcomes are generally favorable, but IOL explantation may be necessary for definitive cure.

Abstract Purpose To demonstrate antibiotic susceptibility and genomic virulence factor profiles of Pseudomonas aeruginosa isolates from patients with culture-confirmed endophthalmitis. Methods Clinical isolates from patients diagnosed with pseudomonas endophthalmitis were included. Laboratory antibiotic susceptibility testing and whole genome sequencing was performed on all isolates. Results In the current study, 8 patients had vitreous culture-confirmed endophthalmitis due to P. aeruginosa. All isolates were multi-drug resistant but sensitive to ceftazidime and each fluoroquinolone tested. Whole genome sequencing revealed a total of 179 unique genes. The most common type of virulence genes included those involved in adherence and the secretion system. Seven of 8 (88%) isolates were of the cytoinvasive phenotype (exoST) and no isolates contained exoU. Conclusions P. aeruginosa associated endophthalmitis is often multi-drug resistant and demonstrates a variety of virulence factors with those involved in adherence and the secretion system being the most common.

Abstract Background The optimal management of patients with endophthalmitis is challenging and includes both intravitreal and, in some cases, systemic antimicrobials. Systemic antimicrobials may be administered either intravenously or orally. In this article we review systemic antimicrobial options currently available for the treatment of types of endophthalmitis and the role of systemic antimicrobials (antibiotics and antifungals) in these treatments. Review While systemic antimicrobials are not universally utilized in the management of endophthalmitis, they may be helpful in some circumstances. The blood–retinal barrier affects the penetration of systemic medications into the posterior segment of the eye differently; for example, moxifloxacin and imipenem cross the blood–retinal barrier relatively easily while vancomycin and amikacin do not. However, inflammation, including endophthalmitis, may disrupt the blood–retinal barrier, enhancing the penetration of systemic agents into the eye. Conclusion Systemic antimicrobials may be particularly beneficial in patients with certain types of endophthalmitis; as such, they are standard treatment in the management of endogenous endophthalmitis (fungal and bacterial) and also widely used for prophylaxis and treatment of open-globe injuries. Although systemic antimicrobials are used in some patients with acute-onset postoperative endophthalmitis following cataract surgery, the literature generally does not support this practice. It is noted that there are currently no randomized clinical trials demonstrating a benefit of systemic antibiotics for any category of endophthalmitis.

Abstract Background To assess the in-vitro efficacy of delafloxacin, a new fourth generation fluoroquinolone, against Staphylococcus vitreous isolates from patients with clinically diagnosed endophthalmitis. This is the first investigation of delafloxacin in ocular tissues. Methods Intravitreal isolates of culture-proven S. aureus and S. epidermidis were identified between 2014 and 2018. Minimum inhibitor concentrations (MIC) were determined using ETEST strips. The antibiotic susceptibilities were tested against a panel of drugs including glycopeptides such as vancomycin, as well as traditional and newer fluoroquinolones (levofloxacin, moxifloxacin, and delafloxacin). Results Of 45 total isolates identified between 2014 and 2018, 13% (6) were methicillin-resistant S. aureus (MRSA), 9% (4) were methicillin-sensitive S. aureus (MSSA), 53% (24) were methicillin-resistant S. epidermidis (MRSE), and 24% (11) were methicillin-sensitive S. epidermidis (MSSE). Among the fluoroquinolones, resistance rates were 61% for levofloxacin, 50% for moxifloxacin, and 12% for delafloxacin. Inter-class comparisons between delafloxacin and the two other fluoroquinolones demonstrated higher Gram-positive susceptibility to delafloxacin (p

Agrobacterium (Rhizobium) radiobacter is a gram-negative bacillus rarely implicated in ocular disease. A 79-year-old male who performed extensive yardwork following intravitreal injection with aflibercept for diabetic macular edema developed endophthalmitis caused by Agrobacterium radiobacter on post-injection day 7. The patient was treated with vitreous tap and intravitreal injection of vancomycin and ceftazidime with clearance of the infection and restoration of his baseline visual acuity at 20/80.

Purpose: To report two cases of laser-induced choroidal neovascularization (CNV) using swept source optical coherence tomography (SS-OCTA) imaging in patients with proliferative diabetic retinopathy. Observations: Two patients developed CNV adjacent to laser scars, and these neovascular lesions were detected on SS-OCTA imaging. Historically, both patients had subretinal fluid associated with these lesions. Visual acuity for both patients was 20/25 in the affected eyes. Both patients were observed over multiple years with stable CNV and visual acuity. Conclusions and importance: SS-OCTA was able to detect laser-induced CNV in a rapid and non-invasive manner. When there is no foveal involvement and excellent visual acuity, we recommend close observation since the CNV may not progress.

Purpose: To report two patients with transient decreased vision and associated paracentral acute middle maculopathy (PAMM) lesions identified with multi-modal imaging, including what we believe to be the first documented patient of PAMM associated with iron deficiency anemia. Observations: Case 1 is a 56-year-old man who experienced transient blurred vision one week following cardiac ablation for atrial fibrillation. Symptoms resolved by the time of presentation and visual acuity was 20/20 in each eye. Ocular examination was unremarkable aside from subtle discoloration within the papillomacular bundle in the right eye. Spectral domain optical coherence tomography (SD-OCT) revealed thickening of the middle retinal layers with a corresponding area of hyporeflectivity on the en face infrared image. This area of hyporeflectivity was confirmed on “structural” SD-OCT angiography, although no flow voids were identified. Fluorescein angiography was normal. Case 2 is a 25-year-old man with no past medical history who noted decreased central vision in his right eye upon awakening. Visual acuity was light perception in the right eye and 20/20 in the left eye. Posterior segment examination in the right eye showed tortuous retinal vessels and subtle pallor involving the superior part of the macula. SD-OCT showed thickening of the middle retinal layers of the superior macula with a corresponding area of hyporeflectivity on the en face infrared image. Systemic work-up was completed and identified severe iron deficiency anemia as the most likely inciting factor. In both cases, visual acuity was 20/20 in each eye at follow-up. Conclusions: Small arterial occlusions of the retina remain difficult to diagnose and may represent a sequela of systemic disease. Multi-modal imaging is helpful in equivocal cases with subtle clinical findings. Importance: The present case report illustrates the utility of multi-modal imaging in diagnosing transient ischemic events of the retina, and reports what we believe to be the first association of PAMM with iron deficiency anemia.

Purpose: To present a previously unreported cause of bacterial endophthalmitis manifesting as delayed post-traumatic endophthalmitis ultimately responsive to total capsulectomy. Case Report: A patient presented with chronic endophthalmitis that occurred after ocular trauma with organic material and Oerskovia turbata was eventually isolated. After a prolonged treatment course, including two pars plana vitrectomies and total capsulectomy, the patient achieved 20/80 visual acuity at 1-year follow-up. Conclusion: This is the first reported patient with endophthalmitis due to O. turbata, a Gram-positive bacillus found in soil that rarely causes human infection. The infection had a delayed presentation despite early prophylactic antibiotics and was ultimately eliminated with total capsulectomy. Removal of lens and lens capsule may be necessary in the management of post-traumatic endophthalmitis unresponsive to more conservative therapy, particularly in cases involving atypical organisms and lens capsule violation.

Abstract We report localized opacification of a sclera-fixated Akreos® hydrophilic acrylic intraocular lens after successful repair of rhegmatogenous retinal detachment with silicone oil tamponade in a nondiabetic patient. No intraoperative lens opacification during air–fluid exchange or lens dislocation was encountered. Granular opacities within the optic were noted at 5 months after surgery, and did not relent to scrubbing with a vitrector during oil removal. Akreos lens opacification under silicone oil is not well documented in the literature. Surgeons must be aware of this potential complication, which is known to occur with various types of hydrophilic acrylic lenses after exposure to air or gas.

Purpose: To describe an immunosuppressed patient who developed acute-onset postoperative endophthalmitis caused by a moxifloxacin-resistant strain of Staphylococcus epidermidis after cataract surgery despite the use of intracameral moxifloxacin. Observations: A 76-year old woman with a history of birdshot chorioretinopathy controlled on systemic immunosuppression underwent uneventful cataract surgery in her right eye. Compounded intracameral moxifloxacin 0.2 cc of 1mg/0.1mL (Edge Pharmacy, Syracuse, NY) was injected intraoperatively as prophylaxis, and the patient was placed on a standard regimen of trimethoprim-polymyxin b (10000-0.1unit/mL) and prednisolone acetate 1% postoperatively. Four days later, the patient experienced a sudden decrease in vision in the right eye. Anterior chamber inflammation, vitritis, and vasculitis were seen in the operated eye. The patient underwent a vitreous tap and intravitreal injections of vancomycin (1mg/0.1mL), ceftazidime (2.25mg/0.1mL), and dexamethasone (0.4mg/0.1mL). Cultures grew Staphylococcus epidermidis, resistant to moxifloxacin (MIC ≥8mg/L). The inflammation resolved over two months. Eight months later, the patient underwent uncomplicated cataract surgery in the left eye. Intracameral antibiotics were not used, however her systemic immunosuppressive therapy was held for several weeks perioperatively. One year after the initial surgeries, the patient had an uncorrected visual acuity of 20/20 in each eye. Conclusions and Importance: S. epidermidis, the most common cause of postoperative endophthalmitis, is increasingly resistant to fluoroquinolones. Adequate concentrations of intracameral antibiotics need to be achieved in order to exceed minimal inhibitory concentration values of the targeted pathogen. Although intracameral moxifloxacin has been reported to decrease the rate of endophthalmitis after cataract surgery, it does not eliminate the risk. Keywords: Endophthalmitis, Post-surgical infection, Moxifloxacin, Intracameral antibiotic

Purpose: To describe the clinical course and microbial properties of the first two reported cases of nutritionally variant Streptococci (Granulicatella adiacens and Abiotrophia defectiva) endophthalmitis following intravitreal anti-vascular endothelial growth factor injection (IVI). Observations: A 74 year-old female developed Granulicatella adiacens endophthalmitis following IVI. The patient underwent a pars plana vitrectomy and visual acuity recovered to 20/30 in six weeks. Similarly, an 88 year-old male developed Abiotrophia defectiva endophthalmitis after IVI. After a pars plana vitrectomy, the visual acuity recovered to 20/60 at five weeks. Conclusions and Importance: Endophthalmitis due to Streptococcus species has traditionally resulted in uniformly poor visual outcomes. However, nutritionally variant Streptococci, now reclassified as Granulicatella and Abiotrophia species, appear to have a less aggressive clinical course and better visual acuity outcomes. To the authors’ knowledge, these are the first reports of nutritionally variant Streptococci following IVI related endophthalmitis.

Purpose: To report an unusual case of endogenous panophthalmitis involving Candida auris and describe its clinical and histopathological features. Findings: A 30 year-old man with history of human immunodeficiency virus, polysubstance abuse, syphilis, and recently treated pneumonia presented with polymicrobial endogenous panophthalmitis. Two separate ocular specimens confirmed simultaneous Pseudomonas aeruginosa and Candida auris involvement. Histopathological analysis demonstrated fulminant polymorphonuclear infiltration of all ocular tissue layers. Despite aggressive management including two intravitreal injections and enucleation, the patient died, ultimately after receiving care at four neighboring urban medical centers. Conclusions and importance: Candida auris has been a recently and increasingly described pathogen leading to mortality in metropolitan hospitals worldwide. To the authors’ knowledge, Candida auris has not previously been reported with endophthalmitis or panophthalmitis. Future cases may be expected with the reported rise in Candida auris. A high suspicion of its contribution to panophthalmitis could be warranted early in the evaluation and management of profoundly immunocompromised patients, particularly those who have had sequential care at multiple neighboring metropolitan hospitals.

Purpose: Multifocal retinal arterial occlusions and choroidal infarctions due to embolic triamcinolone acetonide (TA) administered during a septoplasty were imaged using swept source OCT angiography (SS-OCTA) to demonstrate the utility of this imaging modality for the diagnosis and longitudinal follow-up of retinal and choroidal vascular diseases. Observations: A 37-year-old man presented with vision loss in his left eye upon awakening from a left-sided septoplasty during which TA was injected. Examination of the left eye demonstrated retinal whitening in the macula, white material in the distal lumen of retinal arterioles, and multifocal hypopigmented choroidal lesions. SS-OCTA imaging showed the absence of detectable flow in areas of retinal and choroidal whitening. Corresponding B-scans demonstrated hyperreflective material, thought to be embolic TA, within the retinal vessels and inner choroid. Conclusions: Wide field SS-OCTA was sufficient for the diagnosis and longitudinal evaluation of retinal and choroidal occlusions without the need for dye-based angiography.

Central serous chorioretinopathy (CSCR) is an idiopathic maculopathy characterized by thickened choroid, retinal pigment epithelial detachment, and variable subretinal fluid. CSCR predominantly affects young men, with risk factors including corticosteroid use, the type A behavior pattern, and psychological stress. While usually self-limited with a good visual prognosis, recurrent and persistent CSCR can lead to outer retinal and/or retinal pigment epithelial atrophy, choroidal neovascularization, and visual loss. This article reviews current multimodal imaging and treatment options, which include observation, mineralocorticoid receptor antagonists, thermal laser photocoagulation, and off-label photodynamic therapy with verteporfin.

Purpose: To report two cases of central retinal artery occlusion (CRAO) associated with vitreoretinal surgery. Observations: Two patients underwent vitreoretinal surgery and were diagnosed with CRAO on postoperative day one. Both had received retrobulbar anesthetic blocks, followed by pars plana vitrectomy in one patient and scleral buckling in the other patient. Best-corrected visual acuity at last follow-up was 20/40 and 20/400. Conclusions/Importance: CRAO is a rare but serious adverse event after vitreoretinal surgery. The causative mechanism is not known in these patients.

Background: Lipemia retinalis is a rare but known complication of elevated serum triglycerides. This case describes the clinical course of a diabetic patient who presented with lipemia retinalis and macular edema, which responded to systemic and local treatments. Case Report: A 40-year-old female with a history of type II diabetes mellitus, hypertriglyceridemia, and pancreatitis presented with decreased vision in the left eye. She had peripapillary and macular edema, intraretinal hemorrhages, and prominent exudates in the setting of lipemia retinalis due to type IV hypertriglyceridemia. She was treated with serial intravitreal bevacizumab injections for macular edema and systemic lipid lowering therapy, and her visual acuity improved back to baseline. Conclusions: In the setting of lipemia retinalis and hypertriglyceridemia, the current patient developed macular edema and vision loss. The macular edema was treated with intravitreal injections of bevacizumab, and the patient experienced a rapid recovery of visual acuity.

Purpose: To describe a patient with late post-operative endophthalmitis and clear cornea tunnel infection caused by Candida parapsilosis that was masquerading as chronic anterior uveitis. Observations: A 62-year old woman with history of uncomplicated cataract surgery 7 months prior and chronic postoperative anterior uveitis, presented with an endothelial plaque, hypopyon, and infiltrates in the capsular bag and within the clear corneal tunnel. Anterior chamber cultures identified C. parapsilosis and pathology of the endothelial plaque showed fungus. Anterior chamber washout, scraping of the endothelial plaque, serial intracameral and intravitreal injections with amphotericin B (10 mcg) failed to control the infection. Pars plana vitrectomy, removal of the intraocular lens and capsular bag, a corneal patch graft, and administration of intravitreal antifungal agents were performed. One year later the patient remains free of recurrence and her best-corrected vision is 20/25 with a rigid gas permeable contact lens. Conclusions: and Importance: Persistent intraocular and intracorneal inflammation after cataract surgery should raise suspicion of endophthalmitis caused by fungi non-responsive to topical and intravitreal antibiotics. Surgical intervention and removal of the nidus of infection, which is often the intraocular lens and capsular bag, may be necessary for a successful outcome. Keywords: Amphotericin B, Clear corneal tunnel infection, Fungal endophthalmitis, Intravitreal antifungals, Voriconazole

Purpose: To report the clinical settings, causative organisms, antimicrobial susceptibilities, and treatment outcomes of patients with endophthalmitis caused by gram-positive bacteria resistant to vancomycin. Methods: Retrospective case series of all patients with culture-proven endophthalmitis caused by gram-positive bacteria resistant to vancomycin between January 2010 and December 2016 in LV Prasad Eye Institute, Visakhapatnam, India. Results: The current study included 14 patients. The clinical settings were post-cataract surgery in 8/14 (57.1%) and open globe injury in 6/14 (42.8%). Primary intervention for all patients included tap and intravitreal antibiotic injection. During subsequent follow-up, pars plana vitrectomy was performed in 6 patients and one patient underwent penetrating keratoplasty. Mean number of intravitreal antibiotic injections performed were 3.4 per patient. The most common organisms isolated were coagulase-negative Staphylococci in 6/14 (42.8%), Staphylococcus aureus in 5/14 (35.7%), Streptococcus sp in 2/14 (14.2%) and Bacillus sp in 1/14 (7.14%). In addition to vancomycin, resistance to multiple drugs (three or more groups of antibiotics) was found in all 14 cases. Antimicrobial susceptibility results showed susceptibility to amikacin in 7/14 (50.0%), gatifloxacin in 6/14 (42.8%), moxifloxacin in 3/13 (23.0%), cefazoline in 5/14 (35.7%), cefuroxime in 3/14 (21.4%), ciprofloxacin in 2/14 (14.2%) and linezolid in 5/5 (100%). The mean duration of follow-up was 30.7 weeks (6 weeks–90 weeks). At last follow-up, visual acuity (VA) of 20/200 or better was recorded in 7/14 (50%) and VA

Purpose: Proliferative vitreoretinopathy is a well-known cause of failure of retinal detachment surgery. The purpose of this case report is to illustrate the clinical occurrence and histopathology of a horizontal subretinal band (“clothesline” configuration) creating recurrent and persistent retinal detachment. Observations: A 67-year-old Hispanic female with diabetes type 2 and a history of retinal detachment surgery in the left eye (OS) presented with decreased vision OS. Best corrected visual acuity at this recent presentation was 20/80 OS. Clinical examination disclosed a recurrent inferior retinal detachment and a subretinal “clothesline” fibrotic band. Surgical removal of the subretinal band was performed. Histopathological evaluation of longitudinal and transverse sections of the band revealed a cable-like configuration composed predominantly of glial differentiation, RPE differentiation, and collagen, based on morphology and immunohistochemical staining. There was focal smooth muscle and neuroendocrine cell differentiation, as detected with smooth muscle actin (SMA) and S100 staining, respectively. Cross-sections demonstrated pigmented fibrocellular tissue with foci of cells staining positive for S100 and keratin peripherally around the tissue, suggestive of RPE differentiation. Scattered foci of SMA-positive cells suggested mild myoblastic differentiation. Conclusions and Importance: This case report presents further information on the structure and orientation of the cellular components of subretinal band proliferative vitreoretinopathy. Cells suggestive of Müller cell differentiation compose the central aspect of the band, alongside collagen fibers. RPE differentiation is variably present peripherally in the band, likely reflective of proliferating RPE encircling the subretinal fibrous tissue. A mild amount of myofibroblastic differentiation was present within the band of tissue, correlating with the clinical findings of subretinal tissue contraction and localized retinal detachment.

Purpose: To report the clinical features organisms and treatment outcomes in patients with endophthalmitis after penetrating keratoplasty (PK) Methods: Retrospective noncomparative case series. Results: Eleven eyes of 11 patients with culture positive endophthalmitis after PK were included. The time to diagnosis of endophthalmitis from last PK was less than 1 week in 3/11 (27%), between 1 and 4 weeks in 3/11 (27%), and greater than one month in 5/11 (46%) (range 2–924 days). The distribution of isolates included gram positive (GP) 9/11 (82%), gram negative (GN) 1/11 (9%), and fungal 1/11 (9%) species, respectively. Of GP bacteria tested, 9/9 (100%) were sensitive to Vancomycin. Of fungal isolates tested, none (0/1) were sensitive to Amphoteracin, Fluconazole, and/or Voriconazole. Among patients with rim culture data available, 1/7 (14%) donor rims were culture positive for Candida glabrata and 6/7 (86%) were culture negative. Patients were treated with primary tap and inject in 10/11 (91%) and primary vitrectomy in 1/11 (9%). VA of ≥5/200 was present in 2/11 (18%) at time of endophthalmitis diagnosis, and was recorded in 6/11 (55%) at last follow-up. Conclusions and Importance: Patients with endophthalmitis after PK presented at variable time points after surgery. Gram positive organisms were the most common isolate. VA outcomes after treatment were generally poor.

Purpose: To illustrate the progression of retrograde transsynaptic retinal degeneration using spectral-domain optical coherence tomography (SD-OCT). Observations: A 60 year-old man with a stroke was followed over a 17-month period using SD-OCT of the macula, ganglion cell layer (GCC), and retinal nerve fiber layer. Transsynaptic retinal degeneration progressed over this time. Conclusions and importance: Retrograde transsynaptic retinal degeneration may occur in patients with homonymous visual field loss caused by post-geniculate neurologic disease. This is best detected as homonymous thinning of the retina, corresponding to the pattern of visual field loss, using SD-OCT of the GCC and macula. The retinal changes occur at a variable time following the onset of neurologic disease.

Purpose: To describe the management of a giant retinal tear with retinal detachment in a patient with active toxoplasmosis retinochoroiditis. Results: While receiving systemic medications for toxoplasmosis, the patient underwent scleral buckling, pars plana vitrectomy, and C3F8 gas tamponade without removal of the lens. At last follow-up, best corrected visual acuity was 20/20 with an attached retina and the toxoplasmosis lesion was inactive. Conclusions: and Importance: Using modern surgical techniques, anatomic and clinical success is possible during active retinochoroiditis. Keywords: Giant retinal tear, Toxoplasmosis retinochoroiditis, Retinal detachment, Vitrectomy, Scleral buckle

Purpose: To describe a case of Multi-drug resistant Mycobacterium chelonae scleral buckle infection. Observations: A 56 year-old male with history of retinal detachment repair with scleral buckle 20 years prior presented with 8 months of intermittent pain and redness in the left eye. The patient was diagnosed with scleral buckle infection, the buckle was removed, and cultures revealed multi-drug resistant Mycobacterium chelonae. The postoperative course included orbital cellulitis treated with systemic linezolid, clarithromycin, and imipenem. All systemic antibiotics were discontinued on post-operative day 25, visual acuity improved to 20/25, the retina remained attached, and no recurrence occurred over 3 years of follow-up. Conclusions and importance: NTM infections are typically chronic and often require lengthy treatment. SB infection is rare, but often associated with biofilm and antibiotic resistance. In spite of removing the SB, anchoring sutures, sheath surrounding the buckle and associated biofilm, a prolonged course of systemic antibiotics may be necessary in some patients. Keywords: Non-tuberculous mycobacterium, Scleral buckle, Orbital cellulitis

Purpose: To report the Optical Coherence Tomography Angiography (OCTA) results as a novel non-invasive diagnostic modality which provides useful information regarding the status of blood flow in diabetic retinopathy. The current study is a long-term follow-up of eyes of patients with proliferative diabetic retinopathy managed with panretinal photocoagulation. Observations: Two patients with proliferative diabetic retinopathy (PDR) were treated with panretinal photocoagulation (PRP) in both eyes in the early 1980s. Fluorescein angiography performed at the baseline visit and follow-up Optical Coherence Tomography Angiography performed at 30 years after initial PRP treatment showed remarkable stability of the perifoveal capillary network. Visual acuity initially and at last follow-up remained 20/25 or better in these patients. Conclusions and importance: Fluorescein angiography and Optical Coherence Tomography Angiography demonstrated that the integrity of the perifoveal capillary network remained remarkably stable at 30 years. Similarly, the visual outcomes were stable inspite of advanced PDR at baseline.

Purpose: To report a series of patients with acute-onset bacterial endophthalmitis caused by culture proven Staphylococcus lugdunensis, and to characterize clinical outcomes and microbiologic susceptibilities of this organism. Observations: The study included six eyes of 6 patients. The etiologies included cataract surgery (3), open globe injury (2), and intravitreal injection (1). Isolates of S. lugdunensis demonstrated sensitivity to vancomycin in all cases reported. Three of 6 isolates of S. lugdunensis demonstrated resistance to oxacillin and 1 isolate demonstrated resistance to ciprofloxacin. Best-corrected visual acuity was ≥20/400 in 6/6 (100%) of eyes and ≥20/40 in 3/6 (50%) of cases. Conclusion and importance: Acute-onset endophthalmitis caused by S. lugdunensis is associated with variable visual outcomes. Vancomycin provides consistent coverage of acute-onset endophthalmitis cause by S. lugdunensis.

Macular hole can undergo spontaneous reopening and reclosure. This is a retrospective review of three patients who had spontaneous reopening and reclosure of previously spontaneously closed macular hole documented by optical coherence tomography. We report the first case of nivolumab-uveitis-associated macular hole formation. The authors hypothesize that cystoid macular edema (CME) might alter the integrity of foveal tissues or conversely the orientation of the macular hole edges and play a role in formation and resolution of a macular hole.

Purpose: To describe the importance of considering vaso-occlusive disease on the differential diagnosis of a patient presenting with amaurosis fugax (AF) and unilateral cotton wool spots (CWS). Observations: A 69-year-old female with history of obesity, hyperlipidemia and recent orthopedic surgery, presented with 3 days of worsening monocular AF and CWS in the right eye. She was diagnosed with antiphosphospholipid syndrome based on positive serologic testing for antiphosphatidylserine IgM, anticardiolipin IgM. The patient was treated with lipid lowering medication, long-term aspirin, and has followed a weightloss and physical therapy program under medical supervision. The CWS resolved and AF symptoms have not recurred. Conclusions and importance: Antiphospholipid syndrome can be considered in the differential diagnosis of patients presenting with AF, assymetric CWS, and/or rapid progression of symptoms.

Purpose: To report a novel clinical sign in patients with intraocular tuberculosis. The current study is an observational consecutive case series of patients diagnosed with intraocular tuberculosis managed at a tertiary eye care centre from June 1, 2012 to December 31, 2015. Observations: The diagnosis of intraocular tuberculosis was made in 6 patients based on ocular features suggestive of tuberculosis along with a positive tuberculin skin testing and chest X-ray consistent with tuberculosis. All patients presented with decreased visual acuity ranging from 20/25 to 20/400, anterior chamber reaction, vitritis, multifocal choroiditis and vasculitis. All patients had an area of active chorioretinitis within the zone of pre-existing chorioretinal atrophy, apart from various other signs suggestive of intraocular inflammation. All patients were started on anti-tubercular therapy for a period of 9 months alone or in combination with oral corticosteroids tapered over 3–4 months. A prompt response to the treatment with resolution of chorioretinitis within the chorioretinal atrophy occurred in all patients. In addition, there was resolution of vitritis and improvement in the visual acuity ranging from 20/20 to 20/40 at last follow-up. Conclusions and importance: and Importance: Active chorioretinitis within an area of chorioretinal atrophy is a novel clinical sign that may indicate intraocular tuberculosis.

Purpose: To report two patients with giant retinal tear (GRT) associated retinal detachment in the setting of baseball trauma. Observations: Two patients presented with retinal detachment associated with GRT following blunt trauma with a baseball. The first was a superotemporal GRT detachment treated with scleral buckling, pars plana vitrectomy, endolaser, and silicone oil injection. He subsequently underwent cataract surgery with silicone oil removal and at two year follow up the retina with attached with best-corrected visual acuity of 20/20. The second case was an inferotemporal GRT detachment treated initially with laser demarcation, however the tear progressed to a retinal detachment that was then treated with pars plana vitrectomy and lensectomy, endolaser, perfluoro-octane (PFO), and silicone oil injection. At the one year follow up, the retina was attached and the best-corrected visual acuity was 20/30. Conclusions and importance: GRTs are an uncommon cause of retinal detachment. While pars plana vitrectomy with tamponade is standard in GRT management, there is variability in the use of scleral buckling and PFO in these cases. This is in contrast to retinal dialysis where scleral buckle alone can yield favorable results. Though a baseball ocular trauma is common, retinal involvement is rare compared to other sports injuries such as those occurring with tennis, soccer and golf. Sports trauma remains an important cause of retinal injury and patients should be counseled on the need for eye protection.

Purpose: To describe the clinical course of a patient with a Boston Keratoprosthesis type I who developed a localized posterior pole retinal detachment secondary to a macular hole. Observations: A 73-year-old patient with a Boston Keratoprosthesis developed a localized posterior pole retinal detachment secondary to a macular hole. The retinal detachment was repaired with a 23-gauge pars plana vitrectomy, membrane peel, fluid-air exchange and 18% C3F8. Retinal reattachment was achieved but the macular hole remained open. Conclusions and importance: A posterior pole retinal detachment secondary to a macular hole can be repaired using standard techniques despite the limited view through a Boston Keratoprosthesis.

Low vision has been defined by best-corrected visual acuity worse than 20/40 in the better eye, substantial visual field loss, or substantial loss of contrast sensitivity that cannot be corrected by refraction, medical treatment, or surgery. In the United States, low vision is most commonly caused by age-related macular degeneration, glaucoma, and diabetic retinopathy. Most patients with low vision are elderly, although patients of all ages – including pediatric patients – may be affected. Low vision may decrease a patient’s quality of life substantially, leading to emotional distress and possibly depression. Low vision specialists aim to maximize the remaining vision of a patient by providing optical aids, orientation and mobility training, psychosocial support, and other methods of rehabilitation. Innovations in technology and devices offer additional options in low vision rehabilitation. Clinicians should consider referral to low vision specialists when a patient has difficulty with reading, mobility, driving, recognizing faces, or suffers from emotional distress due to low vision. Early referral may lead to improved outcomes.

Intravitreal injections of antivascular endothelial growth factor (anti-VEGF) agents have been reported to occasionally produce a therapeutic effect in the uninjected fellow eye. Here, three patients with bilateral neovascular age-related macular degeneration are presented. In all three patients, unilateral anti-VEGF injection resulted in bilateral reduction of macular thickness as measured by spectral domain optical coherence tomography.

A case of retinal arterial macroaneurysm (RAM) is presented with multimodal imaging, including commercially available optical coherence tomography angiography (OCT-A). Following treatment with intravitreal bevacizumab, reduction of flow signal through the RAM is documented. OCT-A provides useful information for the diagnosis and management of at least some patients with RAM, without the need for traditional fluorescein angiography.

Two illustrative cases of acute central retinal artery occlusion (CRAO) are presented with multimodal imaging, including fluorescein angiography (FA) and commercially available optical coherence tomography angiography (OCT-A). In both patients, retinal ischemia was imaged well using both FA and OCT-A, and the two imaging studies provided comparable pictures. OCT-A provides useful information for the diagnosis and management of patients with acute CRAO, without the need for dye injection.

Purpose. To report a case of bilateral choroidal neovascularization (CNV) in punctate inner choroidopathy (PIC) visualized utilizing optical coherence tomography angiography (OCT-A). Methods. Case report. Results. A 29-year-old woman presented with new visual symptoms in both eyes. Fundoscopic exam revealed bilateral multifocal, small, well-defined lesions consistent with PIC. Optical coherence tomography demonstrated subretinal fluid and retinal pigment epithelium detachments (RPEDs) in both eyes. OCT-A revealed bilateral abnormal increased flow within the RPEDs consistent with CNV. Fluorescein angiography confirmed the presence of bilateral CNV. Conclusion. CNV secondary to PIC may be identified using noninvasive optical coherence tomography angiography.

Purpose: To report management of inadvertent needle penetration during subtenons triamcinolone acetonide administration resulting in retinal detachment. Observations: A 71-year-old female with history of diabetes, hypothyroidism, and mild myopia underwent subtenons triamcinolone acetonide (TA) injection in the right eye for nodular scleritis. There was unexpected patient movement concurrent with the injection resulting in needle penetration, subretinal and intravitreal injection of TA, superotemporal retinal break, and macula-involving retinal detachment. The patient underwent partial subretinal TA removal, successful retinal detachment repair, and recovered 20/25 visual acuity. Conclusions and importance: In spite of prominent subretinal TA and retinal detachment, successful repair of retinal detachment and recovery of good visual acuity is possible. Keywords: Needle penetration, Retrobulbar injection, Peribulbar injection

Federico da Montefeltro (1422–1482), the Duke of Urbino, was a well-known historical figure during the Italian Renaissance. He is the subject of a famous painting by Piero della Francesca (1416–1492), which displays the Duke from the left and highlights his oddly shaped nose. The Duke is known to have lost his right eye due to an injury sustained during a jousting tournament, which is why the painting portrays him from the left. Some historians teach that the Duke subsequently underwent nasal surgery to remove tissue from the bridge of his nose in order to expand his visual field in an attempt to compensate for the lost eye. In theory, removal of a piece of the nose may have expanded the nasal visual field, especially the “eye motion visual field” that encompasses eye movements. In addition, removing part of the nose may have reduced some of the effects of ocular parallax. Finally, shifting of the visual egocenter may have occurred, although this seems likely unrelated to the proposed nasal surgery. Whether or not the Duke actually underwent the surgery cannot be proven, but it seems unlikely that this would have substantially improved his visual function.

Purpose: To present the reversal of a cilioretinal artery occlusion with the use of intra-arterial tissue plasminogen activator. Observations: A monocular 74 year old male presented with a cilioretinal artery occlusion. Treatment with intra-arterial tissue plasminogen activator 7 hours after the onset of symptoms led to a complete restoration of vision. Conclusions and importance: Early intervention with tissue plasminogen activator reversed acute onset loss of vision from cilioretinal artery occlusion.