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To present a case series of retinal detachments associated with the use of pilocarpine for presbyopia.Multicenter case series of 3 eyes from 2 patients.Patient 1, a 47-year-old man, presented with flashes and floaters in both eyes. The patient had started pilocarpine 1.25% drops 1 month prior for presbyopia in both eyes. He noted the onset of flashes and floaters 3 days after he initiated the drops. A dilated examination revealed an inferotemporal retinal detachment in the right eye with an associated retinal tear inferotemporally. The left eye demonstrated a retinal detachment in the superior quadrant with an associated horseshoe tear at 12 o'clock. Patient 2, a 46-year-old man, presented 5 weeks after initiating topical pilocarpine 1.25% drops for presbyopia. He noted a nasal visual field defect in his left eye that progressed to include his central vision. A dilated examination revealed a superior retinal detachment from 11 to 3 o'clock with subretinal fluid extending into the macula.Pilocarpine and other miotics have long been suspected to be associated with an increased risk of retinal detachment. Prior to prescribing pilocarpine for presbyopia, physicians should inform patients of this potential adverse event and consider that these patients undergo a screening dilated examination, particularly if they are myopic, to determine if they are at higher risk for retinal detachment. Before the initiation of therapy, patients should be appropriately informed regarding symptoms of retinal tears or detachment, which include flashes, floaters, and visual field loss.

There is evidence that glycemic fluctuations trigger vascular-mediated dysfunction in both the retina and the striatopallidal regions in patients with diabetes. The latter is associated with a variety of hyperkinetic disorders that are rare but disabling and potentially preventable. We conducted a systematic review of the potential association between diabetic retinopathy and the risk and prognosis of hyperkinetic disorders in patients with diabetes. We identified a total of 461 articles and 147 were eligible for review. Nine out of 147 articles (6.12%) reported 13 patients with information on diabetic retinopathy. Glycemic fluctuations were present at onset in 10 patients (77%) and retinopathy was present in nine of them (69.23%). The degree of retinopathy was reported in four patients. Two had severe, bilateral proliferative retinopathy, one had moderate-to-severe non-proliferative retinopathy and one had non-proliferative retinopathy. In the nine patients with retinopathy, hyperkinesia persisted, required higher doses of dopamine receptor antagonists or deep brain stimulation. Retinopathy was absent in four cases (30.77%). In these patients, hyperkinesia resolved spontaneously or with lower doses of dopamine receptor antagonists. Diabetic retinopathy could be an indirect marker of striatopallidal microangiopathy in patients with diabetes. The severity of retinopathy may be associated with increased risk or worse prognosis for patients who develop hyperkinetic disorders of the diabetic striatopathy spectrum. Early detection of retinopathy could identify patients in which avoiding glycemic fluctuations may prevent the development of striatopathy and hyperkinetic disorders.

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

Purpose “Cell therapy” is becoming increasingly available to the public via online direct-to-consumer advertisement within the United States (U.S.). The current study investigates the scope of “cell therapy” clinics across the U.S. that advertise and offer “cell therapy” for ocular conditions based on information provided on their websites. Design Cross-sectional study. Participants The study included companies that are U.S.-based, participate in direct-to-consumer online marketing, have websites that can be data-mined with content analysis, and advertise therapy for ocular conditions. Methods Using a systematic, extensive keyword-based Internet search, content analysis of company websites was utilized to identify, document, and analyze U.S. businesses marketing “cell therapy” for ocular conditions as of September 16, 2017. Main Outcome Measures Clinic locations, source of stem cells used, route of administration, marketed ocular conditions, and cost of treatment. Results Forty companies with 76 clinics use “cell therapy” to treat ocular conditions. California (23), Florida (12), and Illinois (10) contain the most clinics. All 40 companies specified sources of cells, which included autologous adipose-derived stem cells (35; 67%), autologous bone marrow–derived stem cells (8; 15%), amniotic stem cells (2; 4%), peripheral blood–derived stem cells (2; 4%), umbilical cord blood stem cells (2; 4%), allogenic bone marrow–derived stem cells (1; 2%), placental stem cells (1; 2%), and xenocells (1; 2%). The most commonly marketed ocular conditions included macular degeneration (35), optic neuritis (18), retinitis pigmentosa (17), and diabetic retinopathy (16). The most common routes of administration were intravenous (22) and “unspecified” (12); however, other companies listed more ocular-specific routes such as intravitreal injections (2), retrobulbar injections (2), eye injections (2), retrofundal injection (1), sub-Tenon injection (1), intraocular injection with vitrectomy (1), and eye drops (1). The cost of advertised “cell therapy” ranged from $4000 to $10 500. Conclusions “Cell therapy” for ocular conditions is readily available via direct-to-consumer marketing strategies across the United States. The “cells” are harvested from numerous sources and administered through different methods for multiple ocular conditions at these “cell therapy” clinics. Limited data for these treatments necessitates advocating caution to physicians and patients about treatments offered at commercial “cell therapy” clinics.

Toxic anterior segment syndrome is a surgical complication characterized by a noninfectious anterior chamber inflammatory reaction having multiple etiologies. The clinical signs (prominent limbus-to-limbus corneal edema, anterior chamber inflammation) and symptoms (decreased visual acuity, discomfort) generally occur within the first 12-48 hours after intraocular surgery. Most patients achieve good clinical and visual outcomes when there is a prompt clinical diagnosis and adequate treatment. We review the literature on toxic anterior segment syndrome, emphasizing its etiology, pathophysiology, and clinical and surgical management, as well as prognosis and sequelae. Our goal is to reduce the frequency of toxic anterior segment syndrome by highlighting the importance of prevention, early recognition, and distinguishing toxic anterior segment syndrome from infectious endophthalmitis.

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 report the ocular and adnexal injuries sustained by patients with Thomas A. Swift’s electric rifles (TASER; TASER International, Scottsdale, AZ), review the literature, and discuss the management of this complex trauma. Design Multicenter, retrospective case series and literature review. Participants Seventeen eyes of 16 patients (5 eyes of 5 patients treated at 3 institutions, and 12 eyes of 11 previously reported cases). Methods The clinical data of 17 eyes were pooled. Spearman’s correlation coefficient was used to assess the association between the extent of TASER injury and patient outcomes. Main Outcome Measures Extent of TASER injury (zone of injury, penetrating vs. perforating) and association with patient outcomes (visual acuity [VA] and retinal detachment [RD]). Results In our cohort, 4 patients were transported by law enforcement and 1 was transferred from a community hospital. Four patients were taken to the operating room for TASER removal and globe repair; 1 patient underwent removal in the emergency room. Of 17 pooled cases, 12 (71%) involved open-globe injury. Of these, there was a high rate of zone 3 injuries (100%; n = 12) and a high incidence of RD (73%; 8 of 11, eviscerated eye excluded). Among patients with closed-globe injury (n = 5), 1 patient demonstrated exudative RD and 1 patient demonstrated retinal dialysis with RD. Of 10 patients with RD, 1 (10%) achieved resolution with monitoring (exudative RD); 1 (10%) underwent cryopexy and pneumatic retinopexy; 3 (30%) underwent vitrectomy, and 5 (50%) with poor prognosis did not undergo vitreoretinal surgery. In the 3 patients who underwent vitrectomy, all 3 (100%) demonstrated redetachment resulting from proliferative vitreoretinopathy and required additional surgery. Visual acuity on presentation was significantly correlated with final VA (ρ = 0.783; P = 0.02). Men (94%) were more likely than women (6%) to sustain TASER trauma. Median age was 26 years. There was a 50% rate of loss to follow-up. Conclusions Thomas A. Swift’s electric rifle injuries to the eyes or ocular adnexa represent complex trauma. Zone 3 injuries are common. The visual prognosis is guarded, and eyes may require multiple surgeries to preserve vision. Patients are at high risk for loss to follow-up by way of incarceration.

The Branch Vein Occlusion Study is a multi-center, randomized, controlled clinical trial designed to answer several questions regarding the management of complications of branch vein occlusion. This report discusses the question, "Is argon laser photocoagulation useful in improving visual acuity in eyes with branch vein occlusion and macular edema reducing vision to 20/40 or worse?" One hundred thirty-nine eligible eyes were assigned randomly to either a treated or an untreated control group. Comparing treated patients to control patients (mean follow-up 3.1 years for all study eyes), the gain of at least two lines of visual acuity from baseline maintained for two consecutive visits was significantly greater in treated eyes (P = .00049, logrank test). Because of this improvement in visual acuity with argon laser photocoagulation of macular edema from branch vein occlusion, we recommend laser photocoagulation for patients with macular edema associated with branch vein occlusion who meet the eligibility criteria of this study.

Purpose To report the clinical features, antibiotic susceptibility profiles, treatment, and visual acuity (VA) outcomes of endophthalmitis caused by Corynebacterium species. Design Retrospective case series. Participants Patients with endophthalmitis caused by Corynebacterium species. Methods Microbiology database records were retrospectively reviewed for all patients with endophthalmitis caused by Corynebacterium species from January 1, 1990, to December 31, 2012, at a large university referral center. The corresponding clinical records were then reviewed to evaluate endophthalmitis clinical features and treatment outcomes. Main Outcome Measures Presenting clinical features, visual acuity outcomes, and antibiotic susceptibility patterns. Results For the 10 patients identified, clinical settings included post–cataract surgery (n = 6), post–penetrating keratoplasty (n = 2), and posttrabeculectomy (n = 2). The mean time from surgical procedure to presentation with endophthalmitis was 6.8 months (range: 1 day to 28 months). All isolates were susceptible to vancomycin. Presenting VA ranged from 7/200 to no light perception. Initial treatment strategies were vitreous tap and intravitreal antibiotic injection (n = 5) and pars plana vitrectomy with intravitreal antibiotic injection (n = 5). VA outcomes were ≥20/60 in 5 of 10 patients (50%) and ≤20/400 in 5 of 10 patients (50%). Conclusions The most common clinical setting was post–cataract surgery. All isolates were susceptible to vancomycin. Despite prompt treatment with appropriate antibiotics, visual outcomes varied.

Purpose To present the management options for vitreomacular traction (VMT) and to recommend an individualized approach to treatment selection. Design Presented at the American Academy of Ophthalmology Annual Meeting, 2016, Chicago, October 15, 2016 (The Charles Schepens Lecture). Participants None. Methods Review of published literature and clinical trials. Main Outcome Measures Visual and anatomic outcomes of various treatment options for VMT were reviewed. Results The management options for VMT include pars plana vitrectomy, pneumatic vitreolysis, enzymatic vitreolysis, and observation. The surgical management using pars plana vitrectomy offers the most effective approach for VMT, but there are inherent risks and cost issues. Pneumatic vitreolysis is reported to be cost-effective and may be an anatomically successful nonsurgical option for management. Enzymatic vitreolysis with intravitreal ocriplasmin is another nonsurgical option, but both short- and long-term side effects may occur. Observation in selected patients can be associated with stable visual outcomes during long-term follow-up. Conclusions The final management decision should be individualized for specific patients depending on the patient's clinical findings, potential risks, probable benefits, and costs of each option.

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 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 Venous air embolism (VAE) during pars plana vitrectomy (PPV) can occur owing to improper positioning of the infusion cannula in the suprachoroidal space and may lead to sudden compromise of cardiac circulation and death. This was an in vivo demonstration of fatal VAE during PPV to show that air can travel from the suprachoroidal space into the central circulation. Design Experimental in vivo surgical study on porcine eyes. Methods Experimental PPV under general anesthesia was performed on porcine eyes (Yorkshire species) at a University Surgical Training & Education Center. Infusion cannulas were placed into the suprachoroidal space and fluid–air exchange (FAE) was started with sequential increases in infusion air pressure. Vital signs of porcine animals were continuously monitored and recorded in real time during the PPV, including end-tidal carbon dioxide (ETCO 2 ), oxygen saturation (SaO 2 ), intra-arterial blood pressure, electrocardiography (EKG), and transesophageal echocardiography (TEE). Results Intracardiac air was detected on TEE less than 30 seconds after increasing air infusion pressure to 60 mm Hg. ETCO 2 declined precipitously, followed by hypotension and EKG changes. Oxygen desaturation was a late phenomenon. The animal died within 7 minutes of VAE. During autopsy, the heart was open under water and air escaped from the right ventricle. Conclusion This in vivo porcine model confirms that during the FAE in PPV, pressurized air from an infusion cannula malpositioned in the suprachoroidal space can transit through the eye to the central circulation, resulting in fatal VAE.

Purpose To report the clinical features, antibiotic susceptibilities and treatment outcomes in patients with endophthalmitis caused by nontuberculous mycobacterium. Design Noncomparative, consecutive case series. Methods Retrospective chart review between December 1990 and June 2014. Results In the 19 study patients, the clinical setting of endophthalmitis included post–cataract surgery (7/19, 36.8%), post–glaucoma implant (6/19, 31.6%), post–intravitreal injection (2/19, 10.5%), endogenous endophthalmitis (2/19, 10.5%), post–pars plana vitrectomy (1/19, 5.3%), and post–scleral buckle exposure (1/19, 5.3%). Chronic recurrent or persisting ocular inflammation was present in 15 of 19 patients (78.9%). The species isolated were Mycobacterium chelonae in 14 patients (73.7%), M fortuitum in 3 patients (15.8%), M triplex in 1 patient (5.3%), and M avium intracellulare in 1 patient (5.3%). Antibiotic susceptibilities to tested isolates were the following: amikacin (14/16; 87.5%) and clarithromycin (12/16, 75.0%). Intravitreal injections of amikacin (0.4 mg/0.1 mL) were given in 14 of 19 patients (73.7%) with an average of 7 injections per patient (range, 1–24 injections). Intraocular lens removal was performed for 6 of 7 patients (85.7%) with post–cataract surgery endophthalmitis. All the patients with glaucoma implant (6/6, 100%) underwent implant removal. At last follow-up, 6 of 19 patients (31.6%) had best-corrected visual acuity of 20/400 or better. Conclusion Endophthalmitis caused by nontuberculous mycobacterium often included chronic recurrent or persistent intraocular inflammation and frequently required removal of ocular device (intraocular lens, glaucoma implant, or scleral buckle). The majority of the isolates were susceptible to amikacin and clarithromycin. Visual outcomes in these patients even after treatment were generally poor.

Purpose To evaluate the in vitro efficacy of rose bengal– and riboflavin-mediated photodynamic therapy for inhibition of methicillin-resistant Staphylococcus aureus (MRSA) isolates. Design Experimental study. Methods Two different multidrug-resistant, clinical MRSA isolates were grown on nutrient agar, prepared in suspension, and adjusted to concentrations of 1.5 × 10 4 colony-forming units per milliliter. Bacterial suspensions were mixed with rose bengal, riboflavin, or water according to experimental group. Tested in triplicate, groups included: Group I, MRSA control; Group II, MRSA with 0.1% rose bengal; Group III, MRSA with 0.03% rose bengal; and Group IV, MRSA with 0.1% riboflavin. All experimental groups were exposed to 3 lighting conditions: dark, ambient room light for 30 minutes, and 5.4 J/cm 2 with either green light-emitting diode (LED) or ultraviolet-A (UV-A) irradiation. Plates were photographed at 72 hours and custom software measured bacterial growth inhibition. Results Complete growth inhibition of both MRSA strains was demonstrated (1) for both rose bengal concentrations under ambient and green LED irradiation, and (2) for the 0.1% rose bengal in the dark. The 0.03% rose bengal in dark conditions showed complete inhibition of strain 2 but incomplete inhibition of strain 1. Riboflavin showed almost complete inhibition with UV-A irradiation but demonstrated minimal inhibition for both strains in dark and ambient light conditions. Conclusions Rose bengal– and riboflavin-mediated photodynamic therapy demonstrated complete growth inhibition in vitro of 2 multidrug-resistant MRSA strains. Rose bengal was also effective in dark and ambient conditions. These results may have implications for in vivo therapy.

To report the clinical settings, bacterial isolates, antibiotic sensitivities, and visual acuity outcomes of patients with persistently positive vitreous cultures after intravitreal antibiotics.Consecutive, noncomparative case series.setting: Tertiary care center.Thirty-six eyes of 36 patients with exogenous endophthalmitis with the same bacterial organism identified on at least 2 consecutive vitreous cultures from 1981 to 2015.Vitreous cultures with intravitreal injections of antibiotics and pars plana vitrectomies with intravitreal antibiotics.Bacterial isolates, antibiotic sensitivities, visual outcomes.Thirty-six eyes of 36 patients met the study criteria. The mean follow-up was 26.5 months. The most common clinical settings were after cataract extraction (18/36, 50%) and glaucoma surgery (11/36, 31%). The mean initial visual acuity was 2.16 ± 0.77 logMAR (Snellen equivalent ≈20/2900), and there was no statistically significant change at the final evaluation (2.08 ± 0.97 logMAR, ≈20/1900, P = .72). The most common bacteria were Staphylococcus (11/36, 31%) and Streptococcus (9/36, 25%). Gram-positive bacteria were sensitive to vancomycin (27/27, 100%); gram-negative bacteria were sensitive to amikacin (5/5, 100%). The antibiotic sensitivities were the same on repeat cultures in 34 of 36 patients (94%). The initial treatment was a vitreous culture and intravitreal injection of antibiotics in 28 of 36 patients (78%). The vision at the last follow-up was 20/200 or better in 12 patients (33%) and no light perception in 11 of 36 patients (31%).The most commonly identified organisms were gram-positive bacteria. There was good concordance in the antibiotic sensitivities between initial and subsequent cultures. Patients with persistently vitreous culture-positive endophthalmitis had poor visual outcomes.

BackgroundAge-related macular degeneration (AMD) is a leading cause of visual loss among the elderly. A key cell type involved in AMD, the retinal pigment epithelium, expresses a G protein–coupled receptor that, in response to its ligand, L-DOPA, up-regulates pigment epithelia–derived factor, while down-regulating vascular endothelial growth factor. In this study we investigated the potential relationship between L-DOPA and AMD.MethodsWe used retrospective analysis to compare the incidence of AMD between patients taking vs not taking L-DOPA. We analyzed 2 separate cohorts of patients with extensive medical records from the Marshfield Clinic (approximately 17,000 and approximately 20,000) and the Truven MarketScan outpatient and databases (approximately 87 million) patients. We used International Classification of Diseases, 9th Revision codes to identify AMD diagnoses and L-DOPA prescriptions to determine the relative risk of developing AMD and age of onset with or without an L-DOPA prescription.ResultsIn the retrospective analysis of patients without an L-DOPA prescription, AMD age of onset was 71.2, 71.3, and 71.3 in 3 independent retrospective cohorts. Age-related macular degeneration occurred significantly later in patients with an L-DOPA prescription, 79.4 in all cohorts. The odds ratio of developing AMD was also significantly negatively correlated by L-DOPA (odds ratio 0.78; confidence interval, 0.76-0.80; P

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 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 To evaluate the current practices in anesthesia for vitreoretinal surgery in a variety of practice locations and types. Design Cross-Sectional Survey Based Study Participants 2,638 retinal specialists from academic and private practices. Methods Participants were questioned in detail regarding their preferences for topical, regional, or general anesthesia for a variety of case types. Main Outcome Measures Utilization of local or general anesthesia, providers of anesthesia, and selection of anesthesia for vitreoretinal procedures and open globe injuries. Results The cumulative response rate was 23% (597/2,638). Of the 556 respondents who regularly perform surgery, regional anesthesia was more commonly administered by ophthalmologists than anesthesiologists. Intraconal anesthesia was used in 319/555 (57%) of cases and was more commonly used in the United States (US) than non-US where extraconal and sub-Tenon’s anesthesia were more common (p Conclusion Regional anesthesia with MAC is the most common method for vitreoretinal procedures, but GA is still a common option especially for scleral buckling and trauma.

Purpose To report the histopathologic findings of a series of patients from an outbreak of Streptococcal endophthalmitis after intravitreal injection of bevacizumab prepared by a single compounding pharmacy. Design Case series. Participants Seven surgical specimens (5 enucleated globes and 2 evisceration specimens) from 7 patients with endophthalmitis after intravitreal injection of bevacizumab. Methods Retrospective case series, including clinical data and histopathologic specimens examined by light microscopy. Main Outcome Measures Review of clinical data included baseline visual acuity, clinical intervention, and time elapsed from injection to loss of globe. Histopathologic specimens were reviewed for pathologic changes at all tissue levels. Results Seven of 12 total patients (4 women, 3 men; mean age, 77.7 years) from an outbreak of Streptococcus mitis/oralis endophthalmitis after bevacizumab injection ultimately sustained loss of the affected globe, with an average of 139.1 days elapsed between injection and globe loss. Mean time from injection to presentation was 2.86 days (range, 1–6), and all patients were initially treated with vitreous tap and injection. Although histologic review of surgical specimens disclosed a wide range of pathologic tissue changes, recurring patterns of tissue damage were evident. All 5 enucleated globes displayed retinal detachment, fibrous proliferation with cyclitic membrane formation, rubeosis iridis, and secondary angle closure. All 7 specimens displayed persistent choroidal inflammation, in 1 case 208 days after injection. Six of 7 specimens had foci of retinal necrosis. Although vitreous cultures were positive in all cases, no organisms were identified by light microscopy in any of the 7 specimens. Conclusions S. mitis/oralis endophthalmitis is a devastating complication of intravitreal injection with bevacizumab with a high rate of globe loss (7 of 12 patients, 58.3%) and a wide variety of severe pathologic tissue changes. Although no organisms were identified in the examined tissues, persistent inflammation was present in all cases, and fibrous proliferation resulted in cyclitic membrane formation and retinal detachment in all enucleated globes. These findings suggest that potential globe-salvaging interventions must address a pattern of changes involving persistent, chronic inflammation and fibrovascular proliferation as key components.

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

Purpose To report the 1-year clinical outcomes of an outbreak of Streptococcus endophthalmitis after intravitreal injection of bevacizumab, including visual acuity outcomes, microbiological testing, and compound pharmacy investigations by the Food and Drug Administration (FDA). Design Retrospective consecutive case series. Participants Twelve eyes of 12 patients who developed endophthalmitis after receiving intravitreal bevacizumab prepared by a single compounding pharmacy. Methods Medical records of patients were reviewed; phenotypic and DNA analyses were performed on microbes cultured from patients and from unused syringes. An inspection report by the FDA based on site visits to the pharmacy that prepared the bevacizumab syringes was summarized. Main Outcome Measures Visual acuity, interventions received, time to intervention, microbiological consistency, and FDA inspection findings. Results Between July 5 and 8, 2011, 12 patients developed endophthalmitis after intravitreal bevacizumab from syringes prepared by a single compounding pharmacy. All patients received initial vitreous tap and injection, and 8 patients (67%) subsequently underwent pars plana vitrectomy (PPV). After 12 months follow-up, outcomes have been poor. Seven patients (58%) required evisceration or enucleation, and only 1 patient regained pre-injection visual acuity. Molecular testing using real-time polymerase chain reaction, partial sequencing of the groEL gene, and multilocus sequencing of 7 housekeeping genes confirmed the presence of a common strain of Streptococcus mitis/oralis in vitreous specimens and 7 unused syringes prepared by the compounding pharmacy at the same time. An FDA investigation of the compounding pharmacy noted deviations from standard sterile technique, inconsistent documentation, and inadequate testing of equipment required for safe preparation of medications. Conclusions In this outbreak of endophthalmitis, outcomes have been generally poor, and PPV did not improve visual results at 1-year follow-up. Molecular testing confirmed a common strain of S. mitis/oralis . Contamination seems to have occurred at the compounding pharmacy, where numerous problems in sterile technique were noted by public health investigators. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

A systematic review of the literature on the diagnosis and management of traumatic intraocular foreign bodies (IOFBs) is presented together with a schematic "flight plan" to assist in clinical decision making when confronted with an IOFB. Several large retrospective series of IOFB have been published recently, with relevant observations regarding prognostic factors, endophthalmitis and retinal detachment incidence, timing of surgical intervention, and preventative measures. Eye trauma and IOFB, in particular, remain poorly suited to prospective study because of their variability. With few exceptions, retrospective observational series represent the strongest clinical evidence to guide our approach to IOFB. Synthesis of the available literature into a general guideline for management of IOFB would be helpful considering the typically hectic first few hours after such a patient presents to the ophthalmologist.

Diabetic macular edema (DME) is the leading cause of vision loss in the working-age population in developed countries. Management has traditionally consisted of focal/grid macular laser, according to the guidelines established by the Early Treatment of Diabetic Retinopathy Study. More recent prospective clinical trials examining the effect of intravitreal ranibizumab in the treatment of DME—most notably, READ-2, RESOLVE, RESTORE, RISE/RIDE, and DRCR.net protocol I—have demonstrated improved visual outcomes with pharmacologic targeting of vascular endothelial growth factor. Similar treatment benefits have also been noted in clinical trials evaluating intravitreal bevacizumab and aflibercept (BOLT and DA VINCI, respectively). Intravitreal steroids, particularly in refractory cases, continue to have a limited role in the management of DME. In patients with symptomatic visual loss, the treatment paradigm for DME has shifted toward intravitreal pharmacotherapeutics, principally anti–vascular endothelial growth factor therapy, and this review examines the clinical trials leading to this change.

Purpose To describe the incidence, microbiology, associated factors, and clinical outcomes of patients with infectious keratitis progressing to endophthalmitis. Design Nonrandomized, retrospective, consecutive case series. Participants All patients treated for culture-proven keratitis and endophthalmitis between January 1, 1995 and December 31, 2009, at the Bascom Palmer Eye Institute. Methods Ocular microbiology and medical records were reviewed on all patients with positive corneal and intraocular cultures over the period of the study. Univariate analysis was performed to obtain P values described in the study. Main Outcome Measures Microbial isolates, treatment strategies, and visual acuity (VA) outcomes. Results A total of 9934 corneal cultures were performed for suspected infectious keratitis. Only 49 eyes (0.5%) progressed to culture-proven endophthalmitis. Fungi (n = 26) were the most common responsible organism followed by gram-positive bacteria (n = 13) and gram-negative bacteria (n = 10). Topical steroid use (37/49 [76%]) was the most common associated factor identified in the current study, followed by previous surgery (30/49 [61%]), corneal perforation (17/49 [35%]), dry eye (15/49 [31%]), relative immune compromise (10/49 [20%]), organic matter trauma (9/49 [18%]), and contact lens wear (3/49 [6%]). There were 27 patients in whom a primary infectious keratitis developed into endophthalmitis, and 22 patients in whom an infectious keratitis adjacent to a previous surgical wound progressed into endophthalmitis. Patients in the primary keratitis group were more likely to be male (22/27 [81%] vs 8/22 [36%]; P = 0.001), have history of organic matter trauma (8/27 [30%] vs 1/22 [5%]); P = 0.030), and have fungal etiology (21/27 [78%] vs 5/22 [23%]; P P = 0.024). A VA of ≥20/50 was achieved in 7 of 49 patients (14%), but was Conclusions Progression of infectious keratitis to endophthalmitis is relatively uncommon. The current study suggests that patients at higher risk for progression to endophthalmitis include patients using topical corticosteroids, patients with fungal keratitis, patients with corneal perforation, and patients with infectious keratitis developing adjacent to a previous surgical wound. Patients with sequential keratitis and endophthalmitis have generally poor visual outcomes. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

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.

Purpose To investigate clinical settings, management, and visual outcomes of endophthalmitis caused by Bacillus species and to review in vitro effectiveness of antibiotics commonly used against Bacillus species. Design Retrospective, consecutive case series. Methods Record review of all patients with endophthalmitis caused by Bacillus species treated at Bascom Palmer Eye Institute between January 1, 1990 and July 1, 2007. Antibiotic sensitivities were conducted on 21 of 22 isolates. Results Twenty-two eyes of 22 patients met study inclusion criteria. Median follow-up was 18 months. Clinical settings included open globe injury (18 eyes), endogenous (two eyes), delayed-onset bleb-associated (one eye), and acute-onset postoperative (one eye). Twelve (67%) of 18 patients with open globe injuries had intraocular foreign bodies. Presenting visual acuity (VA) was hand movements or better in 13 (59%) patients. Initial treatment included pars plana vitrectomy and injection of antibiotics in 14 eyes (64%), vitreous tap and injection of antibiotics in seven eyes (32%), and evisceration in one eye (5%). Four (18%) patients received additional doses of intravitreal antibiotics; 16 (73%) underwent secondary surgical procedures. Eight (36%) patients achieved a final VA of 20/400 or better and four (18%) achieved a final VA of 20/60 or better. All patients received intraocular vancomycin and a cephalosporin or aminoglycoside. Systemic antibiotics were used in 18 (82%) patients. Fifteen (68%) isolates were Bacillus cereus. All isolates tested were sensitive to vancomycin, gentamicin, and five fluoroquinolones. Only three of 21 isolates were susceptible to penicillin and cephalosporins. Conclusions Endophthalmitis caused by Bacillus species often results in poor visual outcomes. In vitro antibiotic sensitivities indicate that vancomycin, aminoglycosides, and fluoroquinolones were effective against Bacillus isolates, whereas cephalosporins were relatively ineffective.

Purpose To report the clinical features, causative organisms, and visual acuity outcomes associated with endophthalmitis after clear corneal cataract surgery and to compare outcomes with those of the Endophthalmitis Vitrectomy Study (EVS). Design Retrospective consecutive case series. Participants The study included 73 eyes of 73 patients, mean age 76 years (range, 48–94 years), with endophthalmitis after clear corneal cataract surgery, including both referred and in-house patients. Methods The clinical and microbiology records were reviewed of all patients treated at a single medical center between January 1, 1996, and December 31, 2005, for clinically diagnosed, culture-positive endophthalmitis occurring within 6 weeks of clear corneal cataract surgery. Main Outcome Measures Presence of hypopyon, mean time to endophthalmitis diagnosis, organisms cultured, and presenting and final visual acuities. Results The mean time between cataract surgery and diagnosis of endophthalmitis was 13 days (median, 9 days; range, 1–39 days). Visual acuity at the time of diagnosis was Staphylococcus was isolated in 50 of 73 (68.4%) eyes. Other isolates included Staphylococcus aureus in 5/73 (6.8%) and Streptococcus species in 6 of 73 (8.2%). A visual acuity of ≥20/40 was achieved in 36 of 73 patients (49.3%) at final follow-up. Conclusions The features and outcomes of endophthalmitis associated with clear corneal cataract surgery are similar to those reported in the EVS, which are associated with scleral incisions, but time to diagnosis was later with clear corneal incisions.

Purpose To report the incidence, clinical settings, and visual acuity outcomes of acute-onset endophthalmitis after cataract surgery. Design Retrospective, observational case series. Methods Annual cataract surgery statistics were determined by review of electronic surgical records. The clinical and microbiologic records were reviewed of all patients with clinically diagnosed endophthalmitis within 6 weeks after cataract surgery at a single university-affiliated hospital between January 2000 and November 2004. main outcome measures : Operative technique, intraoperative complications, and visual acuity. Results The incidence of acute-onset endophthalmitis after cataract surgery was 0.04% (7/15,920) for cataract surgeries of all methods, 0.05% (6/11,462) for cataract surgery by clear cornea phacoemulsification, and 0.02% (1/4,458) for cataract surgery by methods other than clear cornea phacoemulsification (P = .681, Fisher’s exact test). Six of seven (86%) cases occurred in the right eye, and all cases were performed by right-handed surgeons through temporal incisions. Five of seven (71%) patients had relative immune compromise. Four of seven (57%) patients had an intraoperative complication: vitreous loss in three patients and iris prolapse in one patient. Two patients had topical placement of lidocaine 2% gel before povidone-iodine preparation. The visual acuity at final follow up was 20/25 or better in four patients and count fingers or worse in three patients. Conclusions The incidence of acute-onset endophthalmitis after temporal clear cornea incision phacoemulsification is low (0.05%). Potential risk factors for endophthalmitis may include intraoperative complications, relative immune compromise, application of lidocaine 2% gel before povidone-iodine preparation, and inferior incision location.

Purpose To report clinical and optical coherence tomography (OCT) features in patients with idiopathic macular hole and extensive subretinal fluid (extending at least 1 disk diameter from the center of the hole). Design Retrospective, consecutive, noncomparative case series. Methods The case records of two patients with idiopathic macular holes with extensive subretinal fluid were reviewed. Results Both patients presented with reduced visual acuity (20/200 and 20/400). OCT demonstrated attachment of the posterior hyaloid to the inner retina, a full-thickness macular hole, cystoid macular edema (CME), and extensive subretinal fluid. After surgery, both patients achieved macular hole closure and improvement in visual acuity (20/60 and 20/30). Postoperatively, OCT showed a normal foveal contour, complete hole closure, and resolution of the CME and subretinal fluid. Conclusions In patients with macular hole and extensive subretinal fluid, improved visual acuity and hole closure can be achieved. Preoperative OCT in these patients demonstrates vitreoretinal interface abnormalities, CME, and extensive subretinal fluid. These changes resolve postoperatively.

Purpose To investigate the incidence, causative organisms, and visual acuity outcomes associated with endophthalmitis after pars plana vitrectomy. Design Retrospective, noncomparative, consecutive case series. Methods The medical records were reviewed of all patients who developed acute-onset postoperative endophthalmitis (within 6 weeks of surgery) after pars plana vitrectomy at Bascom Palmer Eye Institute between January 1, 1984 and December 31, 2003. Results During the 20-year study interval, the overall incidence rate of postvitrectomy endophthalmitis was 0.039% (6/15,326). Cultured organisms were Staphylococcus aureus (n = 3), Proteus mirabilus (n = 1), and Staphylococcus epidermidis / Pseudomonas aeruginosa (n = 1); one case was culture-negative. Visual acuity after treatment for endophthalmitis ranged from 2/200 to no light perception, with a final vision of light perception or no light perception in four of six (67%) eyes. Conclusion The incidence of endophthalmitis after pars plana vitrectomy is low but the visual acuity outcomes after treatment are generally poor.

Purpose To report macular hole formation among siblings within four families. Design Observational case series. Methods Four families were identified who had macular holes among siblings from within three multiphysician tertiary-care referral retina practices. Results In the first family, two sisters in their seventh decade developed Stage 2 macular holes requiring surgical intervention; two male siblings were unaffected. In a second family, three of four siblings were affected, including one brother with a Stage 4 macular hole, one sister with a Stage 3 macular hole, and a third sister with a lamellar macular hole. In a third family, two siblings (one man, one woman) developed macular holes within 1 year of each other. Three years later, the male sibling developed a macular hole in the fellow eye. In the last family, twin sisters developed macular holes (unilateral in one sister, bilateral in the other), and their deceased father may also have had bilateral macular holes. Conclusions The occurrence of macular holes in these four sets of siblings suggests a possible genetic component in the formation of macular holes in these individuals.

Purpose To investigate clinical settings, management strategies, antibiotic sensitivities, and visual acuity outcomes of endophthalmitis caused by Streptococcus pneumoniae . Design Retrospective, observational case series. Methods Records were reviewed of all patients with culture-positive endophthalmitis caused by Streptococcus pneumoniae treated at the Bascom Palmer Eye Institute between January 1, 1989 and December 31, 2003. MAIN OUTCOME MEASURES: Visual acuity and antibiotic sensitivities. Results Twenty-seven eyes of 27 patients met study inclusion criteria. The median follow-up was 7 months (range, 3 months to 10 years). Clinical settings included acute postoperative (10 eyes), corneal stitch abscess (5), corneal ulcer (3), bleb-associated (4), post-trauma (3), and endogenous (2). Eighteen cases (67%) were acute-onset (less than 3 weeks from event), with a median interval between event and presentation of endophthalmitis of 5 days (range, 1 day to 16 days). Nine cases (33%) were delayed-onset (median, 27 months; range, 3 to 121 months). Initial visual acuity was hand motions or better in 11 cases (41%). Initial therapeutic procedures included vitreous tap and injection of intravitreal antibiotics in 15 eyes (56%), pars plana vitrectomy and injection of intravitreal antibiotics in 10 eyes (37%), and evisceration in 2 eyes (7%). Seventeen (68%) of 25 eyes received intravitreal dexamethasone. Twelve patients (48%) received additional doses of intraocular antibiotics, and 11patients (44%) underwent secondary surgical intervention within one week of diagnosis. The Streptococcus pneumoniae isolates showed sensitivity patterns as follows: 27/27 vancomycin, 13/13 clindamycin, 6/6 cefazolin, 11/11 ciprofloxacin, 14/14 moxifloxacin, 24/26 (92%) ofloxacin, 12/14 (86%) levofloxacin, 13/14 (93%) gatifloxacin, and 1/13 (8%) gentamicin. The organism was sensitive to at least one antibiotic administered initially in all cases. Final visual acuity was 20/400 or better in 8/27 (30%) cases, but 10 eyes (37%) had a final vision of no light perception. Conclusion Despite prompt treatment with appropriate antibiotics, endophthalmitis caused by Streptococcus pneumoniae is associated with a poor visual prognosis.

Purpose To investigate clinical features and visual acuity outcomes associated with endogenous endophthalmitis. Design Retrospective, observational case series. Methods Twenty-one eyes of 21 patients treated at Bascom Palmer Eye Institute for culture-proven endogenous endophthalmitis between 1996 and 2002 were reviewed. Results Patients were followed a mean of 3 months (range, 1 to 12 months). Fungal isolates occurred in 13 eyes (62%), gram-positive isolates in 7 (33%), and gram-negative isolates in 1 (5%). Twelve patients (57%) were hospitalized at the time of diagnosis and 6 patients (29%) died within 2 months of diagnosis. Initial treatment included tap and injection of intravitreal medication in 10 eyes (48%) and pars plana vitrectomy with injection of intravitreal medication in 11 eyes (52%). Final visual outcomes were obtainable for 18 eyes (two patients died within 10 days of diagnosis, and one patient was lost to follow-up). Eight (44%) of these 18 eyes achieved a visual acuity of 20/400 or better and 10 (56%) of 18 eyes achieved a visual acuity worse than 20/400, including 3 that were either enucleated or eviscerated. Three eyes with Aspergillus endophthalmitis had worse visual outcomes than eyes with either Candida ( P = .036) or bacterial endophthalmitis ( P = .024). Conclusions Compared with published series of postoperative or post-traumatic endophthalmitis, patients with endogenous endophthalmitis are more likely to have fungal isolates with a predominance of Candida albicans . Endogenous endophthalmitis is generally associated with high mortality and poor visual acuity outcomes, particularly when caused by more virulent species such as Aspergillus.

Purpose To review the literature and identify consistencies and inconsistencies in existing theories of pathogenesis and to consider some of their possible therapeutic implications. Design Presentation of clinical case material with a synthesis of ideas on macular holes. Methods The literature of macular hole surgery is reviewed pertinent to pathogenic theories. Clinical examples of evolving macular holes shown on ocular coherence tomography are presented to illustrate issues. Results The history of pathogenesis and macular holes is interesting in that, in many ways pathogenic theory has come full cycle. Initially, anteroposterior traction was thought to cause direct formation of a macular hole. Subsequently, degenerative and then tangential tractional etiologies were proposed. Current imaging studies have greatly advanced our understanding of anatomic features of full-thickness holes and early full-thickness hole conditions. These are most consistent with a focal anteroposterior traction mechanism, but some inconsistences in clinical cases suggest a role for degeneration of the inner retinal layers. Conclusions Degeneration of the inner retinal layers at the central fovea may predispose the eye to macular hole formation. What may otherwise be incidental tractional forces appear to initiate the hole. These tractional elements are oriented perpendicularly to the retinal surface, rather than tangentially. Further observations, especially with sequential observations from ocular coherence tomography, may yield further insights into the pathogenesis of macular holes as well as implications regarding the best repair techniques.

To report visual acuity and anatomical outcomes, as well as complications, of management of complex retinal detachment with proliferative vitreoretinopathy using pars plana vitrectomy and intraoperative perfluoro-n-octane (PFO), and to investigate clinical features associated with anatomical and visual acuity outcomes.Prospective, noncomparative, interventional multicenter study.The study included 555 patients (555 eyes) 15 months of age or older who underwent pars plana vitrectomy for complex retinal detachment associated with proliferative vitreoretinopathy with intraoperative PFO at 24 study sites between April 1994 and February 1996. Main outcome measures included visual acuity and rates of retinal reattachment, reoperation, retained PFO, corneal edema, elevated intraocular pressure ([IOP]25 mm Hg), hypotony (IOP5 mm Hg), and cataract. All outcome measures were assessed at 1 day, 1 week, 1 month, 3 months, and 6 months postoperatively and at the last examination.The study included 555 eyes of 555 patients followed up at a median of 5.6 months. Visual acuity of 20/200 or better was recorded in 51 (10%) patients preoperatively and 85 (24%) at 6 months postoperatively. Among the 465 eyes with both preoperative and final visual acuities available, postoperative visual acuity improved in 274 (60%) eyes, remained stable in 106 (23%), and worsened in 85 (18%) eyes. Six-month follow-up data were obtained for 356 (65%) eyes; the retina was attached in 279 (78%) eyes and retained PFO was noted in 20 (6%). Throughout follow-up, 238 of 555 (43%) eyes underwent reoperation for recurrent retinal detachment. At 6 months, corneal edema, elevated IOP, and hypotony were noted in 26 of 356 (7%), 6 of 356 (2%), and 48 of 356 (15%) eyes, respectively. Of the 114 phakic eyes without significant cataract preoperatively, 105 (92%) developed a significant cataract or underwent cataract surgery during study follow-up. Operative factors significantly (P.05) associated with recurrent retinal detachment include female gender, creation of a relaxing retinotomy, and the use of sulfur hexafluoride (SF(6)) gas tamponade, air tamponade, or no tamponade (compared with perfluoropropane [C(3)F(8)] or silicone oil tamponade). Factors significantly associated with final vision of 20/200 or better include first operation anatomic success, prior scleral buckling procedure, no diabetes mellitus, no prior vitrectomy, no silicone oil retinal tamponade, and no relaxing retinotomy. Cases that require relaxing retinotomy generally represent more severe cases of complex retinal detachment and, therefore, relaxing retinotomy is likely associated with a poorer visual outcome owing to the nature of the cases selected for this procedure.In the management of complex retinal detachment associated with proliferative vitreoretinopathy, pars plana vitrectomy and use of intraoperative PFO was associated with retinal reattachment and preserved visual acuity in most eyes.