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Purpose: To describe delayed detection of pericentral hydroxychloroquine (HCQ) toxicity. Methods: 67-year-old Dominican woman with rheumatoid arthritis on HCQ presented for examination. Results: Spectral-domain optical coherence tomography (SD-OCT) demonstrated bilateral cystoid macular edema with parafoveal attenuation of the external limiting membrane (ELM) and the ellipsoid zone (EZ). ELM and EZ disruption was present in inferior macula. While subtle superior defects were present on 10-2 visual fields, superior pericentral defects were noted on 24-2 testing. Hyperautofluorescence along inferior arcades corresponded to SD-OCT and visual fields. Examination 2 years prior demonstrated nonspecific points of depression on 10-2 visual fields and normal central SD-OCT findings. EZ and ELM disruption was present in the perifoveal inferior macula. Conclusions: Early pericentral distribution of HCQ toxicity is not limited to Asian patients. Detecting pericentral HCQ toxicity involves reviewing entire macular cube on OCT. When OCT changes are suspected on parafoveal OCT B-scans, visual field testing with 24-2 may be more sensitive than 10-2.

Purpose: We evaluated the relationship between dosing frequency of intravitreal antivascular endothelial growth factor (anti-VEGF) agents and visual acuity (VA) outcomes over 2 years in eyes with macular edema (ME) secondary to central retinal vein occlusion (CRVO) in the US routine clinical practice setting. Methods: This retrospective analysis assessed electronic medical records of eyes with ME secondary to CRVO that received their first anti-VEGF injection January 1, 2012, to May 31, 2016, and were followed for 1 year or more in the US-based Vestrum Health Treatment and Outcomes database. Eyes were divided into 2 injection frequency subcohorts (≤6 or ≥7 injections/year). Results: Overall, 851 (34.6%) of 2458 eyes with ME secondary to CRVO received 6 or fewer injections, and 1607 (65.4%) received 7 or more injections through 1 year. The mean number of injections in patients receiving 6 or fewer injections and 7 or more injections was 4.7 and 8.8, respectively, and baseline mean VA was 35 and 37 letters, respectively. At year 1, mean letter gain from baseline was less in eyes receiving 6 or fewer injections vs in those receiving 7 or more injections (7.0 vs 12.2, P < .001). Mean VA at year 2 was 50 letters in eyes receiving 6 or fewer injections (n = 50) and 55 letters in eyes receiving 7 or more injections (n = 157). Conclusions: In routine clinical practice, more frequent dosing with anti-VEGF agents was associated with greater visual benefits in eyes with ME secondary to CRVO.

Posterior pigment dispersion is a rare ophthalmic finding that has been reported in patients undergoing retinectomy with silicone oil placement and in patients who underwent significant anterior segment manipulation and vitrectomy. The pigment release is believed to occur from retinal pigment epithelium (RPE) cells in the former and the posterior iris in the latter. The exact timing of this pre-retinal pigment deposition is unknown but typically is mild and occurs over several months. A rapid progression of diffuse preretinal pigmentation is uncommon and may be suggestive of persistent RPE release from an open break or continued iris trauma with posterior pigment release. This report describes a case of profound posterior pigment deposition more than 4 months after retinectomy and oil in a patient with a persistently open retinectomy edge with anterior retinal detachment. The rapidity of pigment deposition was the clue to recognizing this subtle anterior detachment under silicone oil. [ Ophthalmic Surg Lasers Imaging Retina . 2021;52:47–49.]

Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.

PURPOSE: The purpose of this study was to compare intravitreal ziv-aflibercept (IVZ) monotherapy to intravitreal bevacizumab (IVB) monotherapy in patients with exudative age-related macular degeneration (eAMD). MATERIALS AND METHODS: Patients with treatment-naive eAMD treated with pro re nata (PRN) monotherapy of IVZ (1.25 mg/0.05 ml) or IVB (1.25 mg/0.05 ml) with a minimum follow-up of 12 months were retrospectively analyzed. Study outcomes included change in best-corrected visual acuity (BCVA), central macular thickness, mean number of injections, and total medication cost in both the groups at 12 months. RESULTS: Forty-seven eyes (IVZ, 18/47 [38.3%] and IVB, 29/47 [61.7%]) from 47 treatment-naive patients were included. The change in BCVA for patients receiving IVZ was from 0.61 ± 0.33 logarithm of the minimum angle of resolution (Snellen 20/81; range: 20/38–20/174) to 0.45 ± 0.31 (Snellen 20/56; range: 20/27–20/115) at 1 year (P = 0.02). The total number of injections needed to achieve the resolution of intraretinal or subretinal fluid was 2.6 ± 1.4 and 3.5 ± 1.3 for IVZ and IVB, respectively (P = 0.029). Direct medication cost of IVZ and IVB in our cohort on PRN basis was an average of US$78 (2.6 × US$30) and US$175 (3.5 × US$50), respectively, through 1 year. CONCLUSION: IVZ-PRN monotherapy resulted in improved visual acuity, reduced treatment burden, and reduced direct medication cost in comparison to IVB-PRN monotherapy through 1 year.

PURPOSE: Nonproliferative (NPDR) and proliferative diabetic retinopathy (PDR) without diabetic macular edema (DME) affect millions of individuals living with diabetes throughout the world. There is increasing data on various management strategies for such patients, but there is limited consensus on how the data should be adopted into clinical practice. METHODS: This literature review and editorial presents and synthesizes the current evidence for various management paradigms for NPDR and PDR without DME. RESULTS: Retina specialists are an integral member of the diabetes management team, and should encourage patients on the importance of glycemic and cardiovascular optimization for both systemic and retinopathy risk factor reduction. The diabetic retinopathy severity scale (DRSS) is now an approvable endpoint for clinical trials in the United States, therefore becoming more clinically relevant. For PDR without DME, the Diabetic Retinopathy Study (DRS) and the Early Treatment Diabetic Retinopathy Study (ETDRS) established the standard of care with panretinal photocoagulation (PRP). Laser parameters have since evolved to include less intense and earlier intervention. Studies have recently demonstrated that anti-vascular endothelial growth factor (VEGF) treatment of PDR is effective at regressing neovascularization and improving DRSS levels in many patients. Further evidence is required to determine optimal treatment frequency, duration, and retreatment criteria, in the real world. There are concerns for adverse events in patients being lost to follow up during anti-VEGF treatment. For NPDR without DME, the standard of care has been a wait-and-watch approach. Data within the DRS and the ETDRS suggest that PRP for severe NPDR can be an option for select patients as well. Multiple clinical trials have now demonstrated that anti-VEGF treatment can improve the DRSS score in NPDR. Further studies are required to assess whether this positively affects long-term visual outcomes, and whether the benefits outweigh the risks in the real world for routine use. CONCLUSIONS: There is cumulative evidence demonstrating the efficacy of various treatment options for NPDR and PDR without DME. Currently, patients would most likely benefit from thoughtful management strategies that are tailored to the individual patient.

Purpose To determine which spectral domain optical coherence tomography biomarkers of idiopathic macular hole (MH) correlate with the postoperative best-corrected visual acuity (BCVA) in anatomically closed MH. Methods Retrospective analysis of spectral domain optical coherence tomography scans of 44 patients presenting with MH followed for a mean of 17 months. Widths of MH aperture, base, and ellipsoid zone disruption were calculated from presenting foveal spectral domain optical coherence tomography B-scans. Macular hole base area and ellipsoid zone disruption area were calculated through the custom in-house software. Results Poorer postoperative BCVA correlated with increased preoperative choroidal hypertransmission (r = 0.503, P = 0.0005), minimum diameter (r = 0.491, P = 0.0007), and base diameter (r = 0.319, P = 0.0348), but not with preoperative ellipsoid zone width (r = 0.199, P = 0.2001). Applying en-face analysis, the BCVA correlated weakly with preoperative ellipsoid zone loss area (r = 0.380, P = 0.013), but not with preoperative MH base area (r = 0.253, P = 0.1058). Conclusion Increased MH minimum diameter, base diameter, base area, and choroidal hypertransmission are correlated with a poorer postoperative BCVA. Ellipsoid zone loss measurements were not consistently correlated with a BCVA. Choroidal hypertransmission width may be an easy-to-visualize predictive imaging biomarker in MH surgery.

Artificial intelligence (AI) is a growing area that relies on the heavy use of diagnostic imaging within the field of retina to offer exciting advancements in diagnostic capability to better understand and manage retinal conditions such as diabetic retinopathy, diabetic macular edema, age-related macular degeneration, and retinopathy of prematurity. However, there are discrepancies between the findings of these AI programs and their referral recommendations compared with evidence-based referral patterns, such as Preferred Practice Patterns by the American Academy of Ophthalmology. The overall focus of this task force report is to first describe the work in AI being completed in the management of retinal conditions. This report also discusses the guidelines of the Preferred Practice Pattern and how they can be used in the emerging field of AI.

Retinal vein occlusion (RVO) is the second most common cause of vision loss from retinal vascular diseases in adults in the United States. Visual loss arises as a result of a host of factors, including macular ischemia and macular edema. Primary antivascular endothelial growth factor therapy is the current standard of care, with level I evidence demonstrating sustained visual gains up to 2 years after treatment in both branch and central RVO. Prompt antivascular endothelial growth factor therapy is important because delays in treatment yield lesser visual gains. Steroid therapy also improves visual outcomes in RVO but with higher rates of adverse effects, including cataract formation and ocular hypertension. Although the treatment burden can be high, these drugs have collectively revolutionized treatment outcomes in this disease state, providing improved visual outcomes over previous laser therapies.

A 73-year-old woman presented with 3 years of monocular visual distortion and progressive binocular diplopia. She was found to have a comitant left hypertropia due to an epiretinal membrane causing inferior foveal drag. Displacement of the fovea from an epiretinal membrane is a likely under-recognized cause ocular cause of a comitant binocular diplopia.

A retrospective case series comparing inner retinal hyper-reflectivity, as represented by optical intensity ratio, and visual acuities at baseline and one month as prognostic values for twelve month visual acuity after central retinal vein occlusion.

Recurrent episodes of neurological dysfunction and white matter lesions in a young adult raise suspicion for multiple sclerosis (MS). However, occlusive retinopathy, hearing loss and absence of CSF oligoclonal bands are atypical for MS and should make the clinician consider an alternative diagnosis. We describe a man with hearing loss, visual signs and symptoms, and an accumulating burden of brain lesions, who was treated for a clinical diagnosis of MS for nearly two decades. Genetic testing revealed a unifying diagnosis.

Purpose The purpose was to establish the position of the fovea centralis to the optic nerve via en-face, near-infrared spectral domain optical coherence tomography (NIR-OCT) in healthy patients. This may shed light on physiological variability and be used for studying subtle cases of foveal ectopia in macular pathology and after retinal detachment. Methods SD-OCT data of 890 healthy eyes were retrospectively analyzed. Exclusion criteria included axial myopia causing tilting of the optic disc, peripapillary atrophy >1/3 the width of the disc, macular images excluding greater than half of the optic disc, and patients unable to maintain vertical head positioning. Two independent reviewers measured the horizontal and vertical distance from the fovea to the optic disc center and optic disc diameter via cross-sectional and en-face scanning laser ophthalmoloscopy OCT imaging. Results 890 eyes were included in the study. The right and left eyes differed in the horizontal distance from the fovea to the disc center (4359 vs. 4248 µm, P < 0.001) and vertical distance from the fovea to the disc center (464 µm vs. 647, P < 0.001). This corresponded to a smaller angle between the right and left eyes (6.07° vs. 8.67°, P < 0.001). Older age was associated with a larger horizontal (P = 0.008) and vertical distance (0.025). These differences persisted after correcting for axial length in the 487 patients with axial-length data. Conclusions This study compares the position of the fovea centralis among individuals without macular pathology on a micron level basis. The significant variability between right and left eyes indicates that contralateral eye evaluation cannot be reliably used. Rather, true foveal ectopia requires assessments of preoperative and postoperative NIR-OCT scans. This finding is relevant to retinal detachment cases and evaluation of subtle foveal ectopia. Translational Relevance This finding is relevant to retinal detachment cases and evaluation of subtle foveal ectopia.

PURPOSE. To evaluate the depth and pattern of retinal hemorrhage in acute central retinal vein occlusion (CRVO) and to correlate these with visual and anatomic outcomes. METHODS. Retinal hemorrhages were evaluated with color fundus photography and fluorescein angiography at baseline and follow-up. Snellen visual acuity (VA), central foveal thickness (CFT), extent of retinal ischemia, and development of neovascularization were analyzed. RESULTS. 108 eyes from 108 patients were evaluated. Mean age was 63.6 ± 16.1 years with a predilection for the right eye (73.1%). Average follow-up was 17.2 ± 19.2 months. Mean VA at baseline was 20/126 and 20/80 at final follow-up. Baseline (P = 0.005) and final VA (P = 0.02) in eyes with perivascular nerve fiber layer (NFL) hemorrhages were significantly worse than in eyes with deep hemorrhages alone. Baseline CFT was greater in the group with perivascular hemorrhages (826 ± 394 μm) compared to the group with deep hemorrhages alone (455 ± 273 μm, P < 0.001). The 10 disc areas of retinal ischemia was more common in patients with perivascular (80.0%) and peripapillary (31.3%) versus deep hemorrhages alone (16.1%, P < 0.001). Neovascularization of the iris was more common, although this differrence was not significant, in the groups with peripapillary (14.3%) and perivascular (2.0%) NFL versus deep hemorrhages alone (0.0%). CONCLUSIONS. NFL retinal hemorrhages at baseline correlate with more severe forms of CRVO, with greater macular edema, poorer visual outcomes, and greater risk of ischemia and neovascularization. This may be related to the organization of the retinal capillary plexus. The depth and pattern of distribution of retinal hemorrhages in CRVO may provide an easily identifiable early biomarker of CRVO prognosis.

Purpose To report a retinal pigment epithelium (RPE) tumor with exudative maculopathy, originating from an atypical RPE lesion presumed to represent congenital hypertrophy of the RPE or RPE hyperplasia. Methods Multimodal imaging including fundus autofluorescence, optical coherence tomography, fluorescein angiography, and optical coherence tomography angiography. Results A 76-year-old West African man noted visual acuity reduction to count fingers in the right eye and 20/400 in the left eye. Features of chronic glaucoma were noted. In addition, there was a fairly well-circumscribed darkly pigmented RPE lesion in the paramacular region in the right eye, measuring 4 mm in diameter and flat and consistent with atypical congenital hypertrophy of the RPE or RPE hyperplasia. On the posterior margin of this mass was an RPE tumor, presumed to represent RPE adenoma, producing exudative maculopathy and cystoid macular edema. Multimodal imaging was used to distinguish the RPE tumor from macular neovascularization. A similar atypical congenital hypertrophy of the RPE without retinopathy measuring 3.5mm in diameter was noted in the temporal macular region in the left eye. After six monthly doses of intravitreal bevacizumab (1.25 mg/0.05 mL) in the right eye, the maculopathy resolved and the RPE mass showed partial involution with visual acuity return to baseline 20/200. Conclusion Congenital hypertrophy of the RPE and RPE hyperplasia can produce RPE adenoma with related exudative maculopathy. In this case, the maculopathy responded to bevacizumab.

Purpose To report a case of bilateral toxic corneal and conjunctival epitheliopathy secondary to administration of filter paper impregnated with lysergic acid diethylamide (LSD) in the inferior conjunctival fornices. Methods This is a single case report of an 18-year-old man who presented to the emergency department with acute, bilateral eye pain and redness of 24 hours. The patient admitted to placing folded strips of blotting paper impregnated with LSD into the inferior fornices of his eyes the previous night. Results The patient was found to have localized bilateral corneal and conjunctival abrasions with underlying subconjunctival hemorrhage. Conjunctival abrasion was "kissing," involving the bulbar and palpebral conjunctiva, corresponding to the presumed location of the filter paper. There was no corneal stromal opacification. He was lost to follow up within 1 week of initial presentation but stated that his symptoms improved. Conclusions To the best of our knowledge, this is the first reported case of bilateral hemorrhagic conjunctival abrasion and corneal abrasion secondary to LSD. "Kissing" conjunctival lesions, which have been previously reported with heroin use, should raise suspicion for drug abuse.

Purpose: To describe a case of endogenous endophthalmitis from Streptococcus dysgalactiae subspecies equisimilis in the setting of an aortic valve abscessMethods: Retrospective case report....

A black teenager presented with long-standing vision loss in his right eye. Clinical exam revealed increased conjunctival vascularity and total exudative retinal detachment of the right eye. Ultrasound imaging demonstrated a choroidal mass with moderate-to-high reflectivity consistent with a choroidal hemangioma. A closer external examination demonstrated a subtle reddish hue of the eyelids and cheek, consistent with a nevus flammeus. MRI of the brain revealed a T2 enhancing vascular mass. Collectively, these findings were consistent with Sturge-Weber Syndrome. This case highlights the need for a high degree of suspicion for Sturge-Weber Syndrome in dark-skinned individuals that can otherwise mask the nevus flammeus. Physical exam findings and radiographic evidence can be used to guide the diagnosis. [ Ophthalmic Surg Lasers Imaging Retina . 2019;50:183–186.]

Dog bites result in a diverse range of injuries and complications in the periocular region, particularly in school aged children. It is therefore incumbent on the oculoplastic surgeon to be well versed in both acute and long-term management. The intent of this review is to provide a systematic evaluation of the epidemiology, principles of dog bite wound care, and specific considerations related to common patterns of ophthalmic injury. Review of clinical literature from 1976 to 2014. The majority of periocular injuries result from seemingly benign interactions between young children and familiar dogs. Aggressive saline lavage combined with selective debridement of devitalized tissue is essential. High-risk wounds and vulnerable patient groups may benefit from preventive antibiotic coverage as well as appropriate rabies and tetanus prophylaxis. While the nuances of surgical repair are variable given the heterogeneity of presentation, systematic examination and an algorithm-driven approach underlie the optimal management of these complex injuries.

Neovascular age-related macular degeneration (NVAMD) is one of the leading causes of blindness. Over the last decade, the treatment of NVAMD has been revolutionized by the development of intravitreal anti-vascular endothelial growth factor (VEGF) therapies. Several anti-VEGF medications are used for the treatment of NVAMD. The safety and tolerability of these medications deserve review given the high prevalence of NVAMD and the significant utilization of these medications. Numerous large randomized clinical trials have not shown any definitive differential safety relative to ocular or systemic safety of these medications. Intravitreal anti-VEGF therapy does appear to impact systemic VEGF levels, but the implications of these changes remain unclear. One unique safety concern relates drug compounding and the potential risks of contamination, specifically for bevacizumab. Continued surveillance for systemic safety concerns, particularly for rare events, is merited. Overall, these medications are well tolerated and effective in the treatment of NVAMD.

This review will seek to answer if advances in ophthalmic imaging and evolution of treatment modalities have shed further light on the epidemiology, pathophysiology, diagnosis, and acute management of acute CRAO.Imaging characteristics of acute CRAO have been further characterized with the use of fluorescein angiography, optical coherence tomography (OCT), OCT-angiography, and indocyanine-green angiography. Layer segmentation of OCT imaging has found inner retinal layer hyper-reflectivity to be a common finding in acute CRAO. Non-invasive therapies, fibrinolytic delivery, and surgical interventions for acute CRAO have been further evaluated as potential management tools.A large body of literature reports very inconsistent treatment success with a wide variety of modalities. Currently, there is no clear evidence supporting the use of fibrinolytics in acute CRAO. Large, multicenter, randomized control trials are necessary to elucidate the role of the various acute treatment options in the management of CRAO.

To describe a case of posterior scleritis with serous choroidal detachment that occurred as an acute complication of herpes zoster ophthalmicus (HZO).Retrospective case report.A 75-year-old female presented with 3 days of painful, decreased vision in her left eye 1 week after being diagnosed with HZO. She had unilateral crusted vesicular lesions in the V1 dermatomal distribution and corneal pseudodendrites. Funduscopic examination demonstrated a large choroidal detachment in her left eye. B-scan ultrasonography revealed unilaterally thickened sclera consistent with posterior scleritis. She was treated with oral prednisone and a 2-week course of intravenous acyclovir. Two weeks after the initiation of treatment, her vision had improved and she demonstrated complete resolution of her pseudodendrites, posterior scleritis, and choroidal detachment.Prompt recognition and treatment of this unique combination of clinical manifestations of HZO resulted in significant improvement in vision and resolution of the scleritis and choroidal detachment.

A patient underwent cataract surgery with prophylactic intracameral vancomycin (Vancocin; Pfizer, New York City, NY) in each eye, 2 weeks apart. Four weeks after, the patient presented with a mild bilateral hemorrhagic occlusive retinal vasculitis (HORV). A systemic work-up was negative for syphilis, toxoplasmosis, Bartonella , tuberculosis, and sarcoidosis. The patient was treated with oral steroids and one intravitreal steroid injection in the left eye. Ten months after presentation, the patient's vasculitis was quiescent. Although the literature describes primarily severe forms of HORV, the authors' case describes bilateral, mild HORV and highlights the potential underreporting of these cases in the literature. [ Ophthalmic Surg Lasers Imaging Retina . 2018;49:369–373.]

Purpose To evaluate the changes of vascular endothelial growth factor (VEGF) plasma levels after intravitreal injections of aflibercept or ranibizumab in patients with exudative age-related macular degeneration (AMD). Methods Thirty-eight patients with exudative AMD were included in this randomised, prospective study. Nineteen patients were randomised to treatment with intravitreal aflibercept (2.0 mg) and 19 to intravitreal ranibizumab (0.5 mg). The concentration of VEGF was measured by ELISA just before the injection, after 7 days and 1 month. Twenty-two age- and sex-matched healthy patients without chorioretinal diseases served as control. Results The median baseline plasma VEGF concentration was 61.0 pg/ml in the control group, 43.0 pg/ml in the aflibercept group and 59.0 pg/ml in the ranibizumab group (p = 0.127). Seven days after intravitreal injection of aflibercept plasma levels were significantly reduced to values below the minimum detectable dose (MDD) in 17 of 19 patients (89.5%) resulting in a median VEGF concentration of

A 61-year-old man presented with a 2.5 cm fungating skin lesion above the right medial canthus, accompanied by fluctuance and subtle inferotemporal globe displacement. The tumor had erupted 2 months previously and grown rapidly. Computed tomography (CT) revealed a 4.2 × 2.8 × 2.1 cm exophytic mass of the right orbit, superimposed on chronic dacryocystitis. Incisional biopsy disclosed faulty epithelial maturation sequence with possible basement membrane invasion. The patient underwent wide excision with medial maxillectomy, inferior turbinectomy, ethmoidectomy, and partial rhinectomy. The orbital floor was then reconstructed; a paramedian forehead flap and myocutaneous cheek advancement flap were used to fill cutaneous defects. All surgical margins were negative on both frozen and permanent sections. Definitive histopathology was consistent with transitional cell type papillary carcinoma of the lacrimal sac. Adjuvant radiotherapy was recommended, but the patient has declined further treatment. He remains recurrence-free at one year.

The majority of Coats’ disease cases are diagnosed in the first decade of life, though cases with symptom onset and first diagnosis in adulthood are well documented. While the cases diagnosed in childhood and adulthood share many of the characteristic features that define Coats’ disease, adult cases have been shown to present with less severe disease manifestations and an increased incidence of macroaneurysms with perianeurysmal hemorrhage. We present two cases of Coats’ disease diagnosed in adulthood that demonstrate prominent arteriolar macroaneurysms with perianeurysmal hemorrhages and contribute to an understanding of the adult Coats’ phenotype.

Bull’s-Eye Maculopathy Associated with Hydroxychloroquine A 60-year-old woman receiving long-term hydroxychloroquine presented to the eye clinic after noticing central blind spots in her visual fields. Retinal examination showed a bull’s-eye pattern of hypopigmentation.

A 79-year-old man presented with a symptomatic, full-thickness macular hole with concurrent vitreomacular traction (VMT), stage 2. The patient was treated with a single injection of ocriplasmin. Within 1 week, the macular hole had closed, but there was persistence of vitreomacular traction. Two months after injection, the VMT released with sustained closure of the macular hole. The temporal course of macular hole closure antecedent to VMA release runs contrary to our current understanding of macular hole closure and warrants further research to decipher the mechanism by which ocriplasmin achieves its intended effect. [ Ophthalmic Surg Lasers Imaging Retina . 2015;46:677–679.]

A 6-month-old boy presented with a unilateral motility deficit of the right eye in all fields of gaze. Neuroimaging revealed unilateral enlargement of the medial, lateral, and inferior rectus muscles with sparing of the tendons. An evaluation for thyroid eye disease, idiopathic orbital inflammation, myositis, inflammatory and neoplastic infiltration of the muscle, vascular anomalies, and metastatic neuroblastoma was unrevealing. Biopsy of the muscle revealed normal architecture with an absence of inflammation, infiltration, or fibrosis. A review of the literature reveals the exceptionally rare nature of this finding. While the authors cannot rule out an atypical case of congenital euthyroid eye disease, this constellation of findings is not consistent with thyroid eye disease and may represent previously described cases of idiopathic enlargement of the extraocular muscles.

BACKGROUND AND OBJECTIVE: To describe the clinical features, management, and immediate outcomes of patients with subretinal abscesses secondary to methicillin-resistant Staphylococcus aureus (MRSA) endogenous endophthalmitis. PATIENTS AND METHODS: Eleven eyes of seven patients were identified by retrospective chart review. Demographics, initial presentation, examination findings, imaging, cultures, treatments, and short-term outcomes were reviewed. RESULTS: Eleven eyes of seven patients presented with subretinal abscesses secondary to MRSA endogenous endophthalmitis. Four had history of recurrent MRSA infections or active soft-tissue ulceration. Six underwent vitreous tap for culture without growth. Three had positive blood cultures for MRSA. Six received empiric therapy with intravenous vancomycin, one received oral trimethoprim-sulfamethoxazole, and six received intravitreal vancomycin. Consolidation of abscesses was seen within days of initial treatment. Visual outcomes were contingent on abscess location and time to initial treatment. CONCLUSION: Prompt diagnosis and systemic antibiotic therapy is paramount in the treatment of this rare presentation. [ Ophthalmic Surg Lasers Imaging Retina . 2017;48:134–142.]

Background The aim is to compare the therapeutic effects of three antivascular endothelial growth factor (VEGF) drugs (bevacizumab, aflibercept and ranibizumab) on fibrovascular pigment epithelial detachments (fvPEDs) in age-related macular degeneration (AMD). Methods This was a retrospective, comparative, consecutive case series of 88 unique eyes with fvPEDs in neovascular AMD treated with anti-VEGF monotherapy for a minimum of 6 months. All eyes were treatment naive. Diagnosis was confirmed retrospectively by fluorescein angiography and spectral-domain optical coherence tomography. Exclusion criteria included serous/drusenoid PEDs or patients who switched anti-VEGF. Mean follow-up across all therapies was 313.9±85.3 days. Results Average age of all patients was 80.6 years. Baseline maximum subfoveal PED height was 326.8±185.1 μm, 394.5±238.6 μm and 258.0±145.3 μm for bevacizumab, aflibercept and ranibizumab, respectively (p=0.05). All patients had subretinal fluid, intraretinal fluid or a combination of the two at an initial presentation. Central retinal thickness decreased at all time points compared with baseline across all three anti-VEGF therapies. Subfoveal PED height decreased in patients treated with aflibercept at all time points and decreased in patients treated with bevacizumab at 1-month, 3-month and 6-month time points. Aflibercept reduced PED height more than bevacizumab at 1-month and 12-month follow-ups (p=0.02 and p=0.03, respectively) and ranibizumab at 1-month and 6-month follow-ups (p=0.03 and p=0.02, respectively). No differences in best-corrected visual acuity were appreciated at any time point between drugs. Conclusions There was a significant reduction in subfoveal PED height for aflibercept and bevacizumab compared with baseline. A direct comparison of drugs demonstrated a beneficial reduction of PED height, albeit inconsistently, favouring aflibercept. There were no differences in visual acuity across the groups at any time point.

To compare retinal layer volumes using spectral-domain optical coherence tomography between eyes with hydroxychloroquine (HCQ) toxicity and control eyes.Using a previously validated algorithm, volumetric analysis from the macular cube scan of the ganglion cell layer, inner plexiform layer, inner nuclear layer, and outer retina (outer plexiform layer to retinal pigment epithelium) layers were compared in three sets of patients: patients with a clinical diagnosis of HCQ toxicity, age-matched patients taking HCQ but not manifesting overt toxicity, and age-matched control patients.There were 14 patients in each group. The ganglion cell layer (P = 0.01), inner plexiform layer (P = 0.004), inner nuclear layer (P0.001), and outer plexiform layer to retinal pigment epithelium (P0.001) volumes were significantly reduced in HCQ toxicity eyes relative to the HCQ exposure eyes. There were no significant inner and outer retinal volume differences between the HCQ exposure group and group with no HCQ use (P0.05 for all layers). Increasing disease severity correlated with increasing volume loss in the inner retina (2.27 mm in early disease vs. 1.78 mm in advanced retinopathy, P = 0.02).Hydroxychloroquine toxicity seems to result in both outer and inner retinal volumetric thinning compared with age-matched control patients and patients taking HCQ but not manifesting toxicity.

Purpose To report a brimonidone-induced allergic reaction that mimicked a limbal form of vernal keratoconjunctivitis in the setting of background ocular surface toxicity. Patients and methods A 78-year-old male with a history of primary open angle glaucoma presented with symptoms of unilateral blurry vision, irritation, and redness shortly after starting brimonidine exclusively in the right eye. Examination revealed injected palpebral and bulbar conjunctiva, diffuse punctate epithelial erosion and discrete, non-staining corneal limbal infiltrates superiorly. Results Given the unilateral presentation, the patient was diagnosed with an allergic limbal keratoconjunctivitis secondary to bromonidine. Shortly after discontinuing the brimonidine, there was full resolution of the corneal limbal infiltrates. The punctate epithelial erosions and tear film abnormalities remained. Conclusion Direct medication allergy and ocular surface disease are two distinct entities that often co-exist. Distinguishing between the two entities, sometimes by trial and error, is critical in the management of these patients.

Purpose To determine if inner retinal layer reflectivity in eyes with acute central retinal vein occlusion (CRVO) correlates with visual acuity at 12 months. Methods Macular optical coherence tomography (OCT) scans were obtained from 22 eyes of 22 patients with acute CRVO. Optical intensity ratios (OIRs), defined as the mean OCT reflectivity of the inner retinal layers normalized to the mean reflectivity of the RPE, were measured from the presenting and 1-month OCT image by both manual measurements of grayscale B-scans and custom algorithmic measurement of raw OCT volume data. OIRs were assessed for association with final visual outcome. Cohort subgroup division for analysis was determined statistically. Results Eyes with poorer final visual acuity (≥20/70) at 1 year were more likely to have a higher ganglion cell layer OIR than eyes with better final visual acuity (

Purpose: To report a case of an amelanotic irido-ciliary ring melanoma. Design: Interventional case report. Results: A 44-year-old male was followed for asymptomatic amelanotic iris nevus of the right eye that was noted to have a localized ciliary body mass with ring extension along the trabecular meshwork. Fine needle aspiration biopsy was consistent with malignant melanoma. The patient underwent enucleation and remains disease free at 9 years of follow-up. Histopathology revealed malignant melanoma involving the iris and ciliary body with a 360-degree extension along the trabecular meshwork. The tumor was composed of a mixture of spindled and epithelioid cells with scant pigmentation. Conclusions: Amelanotic irido-ciliary ring melanoma with growth along the trabecular meshwork is a rare form of uveal melanoma that could present as an inconspicuous amelanotic iris mass.

A 3-year-old boy presented with severe eye pain and nausea after colliding with a date palm tree branch. Examination under anesthesia revealed a self-sealed corneal laceration and traumatic cataract in his left eye. Cultures were taken and the patient received prophylactic subconjunctival, intravitreal, and systemic antibiotics because of the high risk of endophthalmitis. A thorn from the same tree grew Bacillus cereus . Examination after 2 weeks of the injury revealed a subretinal foreign body (a palm tree thorn), although there were no signs of endophthalmitis or retinal detachment. The patient underwent cataract extraction and laser demarcation of the subretinal foreign body, which was not removed. He was fitted for an aphakic contact lens. With alternate patching, his best-corrected visual acuity improved to 20/30.

BACKGROUND AND OBJECTIVE: To compare subfoveal choroidal thickness (CT) measurements in eyes with nonexudative age-related macular degeneration (AMD) in the presence or absence of reticular pseudodrusen (RPD). PATIENTS AND METHODS: Subfoveal CT measurements obtained from patients with AMD enrolled in the COMPLETE study (30 drusen-only eyes and 30 eyes with geographic atrophy [GA]) were compared with an age-distributed normal control group. Multimodal images were evaluated to detect the presence of RPD. RESULTS: After controlling for age and axial length, the mean CT was significantly thinner in the GA group with RPD (213.7 ± 53.1 µm) than in the GA group without RPD (335.3 ± 123.2 µm; P = .001). The mean CT in the GA group without RPD was not statistically different from the mean CT in the normal control group ( P = .076) or the drusen group without RPD ( P = .45). In eyes without RPD, there was a correlation between the increasing size of GA and a decrease in CT measurements. CONCLUSION: Subfoveal choroidal thinning in eyes with nonexudative AMD was associated with the presence of RPD. In the absence of RPD, CT only decreased as the size of GA increased. [ Ophthalmic Surg Lasers Imaging Retina . 2015;46:513–521.]

There are an estimated 18 million individuals in the United States afflicted with diabetes mellitus and approximately 4 % have diabetic macular edema (DME) [1]. This translates to about 700,000 individuals with DME [2]. The likelihood of DME development has been associated with longer duration of disease [3], poor glycemic control [4] and possibly, conversion to insulin therapy for type 2 diabetics [5]. The Diabetes Control and Complications Trial (DCCT) reported that just over one-fourth of patients with type 1 diabetes developed DME within 9 years of disease onset [6]. Patients with type 2 diabetes have a similarly high rate, with 28 % of individuals developing DME at 20 years after diagnosis [7].

BACKGROUND AND OBJECTIVE: To evaluate subfoveal choroidal thickness (CT) and the extent of outer retinal disruption in patients with macular telangiectasia type 2 (MacTel2) compared with healthy eyes. PATIENTS AND METHODS: In this prospective, observational, cohort study, 62 patients (62 eyes) with Mac-Tel2 and 130 healthy controls (130 eyes) underwent a complete ophthalmological examination, spectral-domain optical coherence tomography (SD-OCT) imaging, and axial length measurements. Patients in the study group also underwent color fundus photography, fundus autofluorescence, and fluorescein angiography. En face SD-OCT imaging was used to assess abnormalities involving the photoreceptor inner segment/outer segment/ellipsoid zone (IS/OS/EZ). RESULTS: After adjusting for age and axial length, the authors found that eyes with MacTel2 had a mean CT measurement that was greater than control eyes ( P = .007). There was a negative correlation between the visual acuity and the area of IS/OS/EZ damage ( P = .009), but no statistically significant correlation was seen between CT and the area of IS/OS/EZ damage. CONCLUSION: Eyes with MacTel2 were found to have thicker CT measurements than control eyes. While the extent of IS/OS/EZ disruption correlated with the loss of visual acuity, this damage did not correlate with CT measurements. [ Ophthalmic Surg Lasers Imaging Retina. 2015;46:162–170.]

BACKGROUND AND OBJECTIVE: To report outcomes of pneumatic retinopexy (PR) for retinal detachment (RD) occurring after prior scleral buckling surgery (SB) or pars plana vitrectomy (PPV). PATIENTS AND METHODS: Single-center study evaluating all patients treated between January 2000 and March 2013. RESULTS: Ten eyes underwent PR after prior SB. Nine of these 10 eyes had persistent subretinal fluid posterior to the buckle in the setting of an open break on the scleral buckle. The mean time to PR in these cases was 8.5 days after SB. PR achieved anatomic reattachment in eight of 10 eyes, but two of 10 eyes required additional PPV to achieve retinal reattachment. Seven eyes underwent PR after prior PPV. The average time to RD after PPV was 67 days (range: 15–232 days). The location of the break was superior in four eyes, horizontal in two, and inferior in one. Anatomic reattachment with PR alone occurred in four of seven eyes (57%). CONCLUSION: In the setting of recurrent RD after initial SB, pneumatic retinopexy was usually successful in the early postoperative course. In the setting of a new-onset RD after PPV, pneumatic retinopexy was a useful option, but recurrent RD was more common. [ Ophthalmic Surg Lasers Imaging Retina . 2014;45:409–413.]

After being exposed to an industrial Nd:YAG laser, an 11-year-old boy developed a full-thickness macular hole in the right eye with resultant visual acuity of 20/100. Five months after the initial injury, the vision was stable and the hole was still present. The patient underwent pars plana vitrectomy, internal limiting membrane peeling, and gas tamponade with prone positioning. Three months postoperatively, visual acuity improved to 20/25 with closure of the macular hole; however, there was a focal photoreceptor deficit. A review of the English-language literature identified 15 eyes with similar macular hole injuries after Nd:YAG exposure. Three eyes were surgically managed. While all holes were successfully closed, only two experienced visual improvement. [ Ophthalmic Surg Lasers Imaging Retina . 2013;44:e7–e10.]

BACKGROUND AND OBJECTIVE: To evaluate anatomic and clinical outcomes of pneumatic retinopexy for treatment of primary retinal detachment. PATIENTS AND METHODS: Noncomparative, single-center, consecutive, interventional case series evaluating all patients treated between 2000 and 2012. Patients with less than 1 month of follow-up or coexisting neovascular age-related macular degeneration, uveitis, endophthalmitis, or prior posterior segment surgery were excluded. RESULTS: Sixty-three eyes of 63 patients with primary retinal detachment treated with pneumatic retinopexy were included. Median follow-up was 10.3 months. Single-operation success (SOS), defined as anatomic reattachment with pneumatic retinopexy alone, occurred in 40 eyes (63%). The retina was successfully reattached in 21 of the other 23 eyes (91%) with one additional surgery. There was no difference in visual acuity outcomes between SOS and additional surgical intervention ( P = .85). New or missed breaks were identified in 19 of 63 eyes (30%). Postoperative subretinal fluid was observed in 22 of 63 eyes (35%) and persisted at last follow-up in two of 63 eyes (3%). At final follow-up, the retina was fully attached in 97% of eyes. CONCLUSION: Pneumatic retinopexy remains a reasonably successful option in the management of primary retinal detachment. No difference in best corrected visual acuity outcomes in eyes achieving SOS versus those requiring additional surgery was demonstrated. [ Ophthalmic Surg Lasers Imaging Retina . 2014;45:132–137.]

Purpose To compare visual acuity outcomes and adverse events in patients with retained lens fragments who underwent same-day versus later pars plana vitrectomy (PPV). Design Retrospective, interventional case series. Methods Single-center study evaluating all patients with retained lens fragments that underwent PPV over a 22-year period (1990 through 2011). Results The study included 569 eyes of 568 patients with a mean age of 74.6 years and a median follow-up of 8 months (range, 1 week to 100 months). One hundred seventeen patients (22%) underwent same-day vitrectomy, 131 patients (23%) underwent PPV within 1 week, and 321 patients (57%) underwent PPV more than 1 week later. Median time to vitrectomy in the same week group was 5 days, compared with 22 days in the delayed group. At the last examination, 61%, 63%, and 56% of patients undergoing PPV on the same day, within 1 week, and more than 1 week later, respectively, achieved best-corrected visual acuity (BCVA) of 20/40 or better ( P = .35), and 16%, 15%, and 21%, respectively, had BCVA of 20/200 or worse ( P = .29). There were no differences between groups when assessing cystoid macular edema ( P = .96), retinal detachment ( P = .096), elevated intraocular pressure ( P = .88), or suprachoroidal hemorrhage ( P = .26). Conclusions Patients undergoing same-day versus a later PPV (within 1 week or more than 1 week later) for retained lens fragments had similar visual acuity outcomes and complication rates. Although same-day surgery may be attractive logistically in many cases, our retrospective data suggest equivalent outcomes for surgical timing.