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Improvements in retinal imaging have recently elucidated structural patterns in the development of macular edema, particularly involving the inner nuclear layer. Here, the authors describe two cases of isolated inner nuclear layer cystic changes in the phakic fellow eye of patients with pseudophakic cystoid macular edema. Both cases improved with treatment of their fellow eye and resolution of contralateral macular edema. The authors hypothesize potential pathomechanisms for this likely common but under-recognized phenomenon. [ Ophthalmic Surg Lasers Imaging Retina . 2019;50:522–524.]

Ocular histoplasmosis syndrome (OHS) is a chorioretinal disorder with a distinct fundus appearance that is commonly found in regions endemic for Histoplasma capsulatum. Choroidal neovascularization (CNV) secondary to OHS is considered one of the principal causes of central vision loss among young adults in endemic areas. Although there is no consensus regarding its pathogenesis, evidence points to Histoplasma capsulatum as the most probable etiology. Once considered an intractable hemorrhagic maculopathy, CNVs are now treatable. Extrafoveal CNVs are successfully treated with laser photocoagulation. Subfoveal and juxtafoveal CNVs are managed with anti-vascular endothelial growth factor therapy, photodynamic therapy, or a combination of both. Modern imaging technologies such as spectral-domain optical coherence tomography have improved our diagnostic abilities, making it easier to monitor disease activity and CNV regression. We review the epidemiology, pathogenesis, clinical manifestations, differential diagnosis, and current treatment of this disease.

To review current literature on Coats disease and provide a structured framework for differentiating challenging clinical features in Coats disease patients.We critically reappraise historical and current literature and present clinical methods for developing a thorough differential diagnosis and management strategy for Coats disease.Coats disease is a sporadic, usually unilateral condition typically occurring in young males. When untreated, this disorder can lead to total exudative retinal detachment and secondary glaucoma.Anti-VEGF agents are currently a treatment option in combination with ablative therapy of telangiectatic vessels. Anti-VEGF agents appear particularly useful for patients with extensive areas of exudative retinal detachment, and are an effective treatment option for total retinal detachment.

To describe the structural characteristics of retinal angiomatous proliferation and chorioretinal anastomosis in childhood Coats disease and redefine the previously described macular fibrosis.Prospective observational case series of consecutive patients with Coats disease examined over a 1-year study period. Multimodal imaging, including color fundus photography, wide-field fluorescein angiography, and spectral domain optical coherence tomography, was used to identify the features of macular retinal angiomatous proliferation and chorioretinal anastomosis.Retinal angiomatous proliferation and chorioretinal anastomosis were present in 5 of 21 patients with Coats disease (24%). The lesions appeared as well demarcated, nodular retinal pigment epithelial detachments surrounded by exudate, with retinal vessels continuous with the underlying choroidal neovascularization.Retinal angiomatous proliferation and chorioretinal anastomoses are features observed in a number of children (24% in the present series) with Coats disease and macular involvement. This lesion represents a distinct macular variant of Coats disease that underlies at least a proportion (all in the present series) of the previously described "macular fibrosis" and "subretinal mounds."

BACKGROUND To compare the spectral-domain optical coherence tomography morphologic features and visual characteristics of a series of patients with epimacular membrane with and without a history of retinal breaks. METHODS Prospective, comparative case series of patients with epimacular membrane. All patients were evaluated with spectral-domain optical coherence tomography and detailed peripheral retinal examination. Symptomatic patients were treated with pars plana vitrectomy and epimacular membrane removal based on standard visual criteria. RESULTS Macular proliferative vitreoretinopathy was present in 21 of 50 patients (42%). Approximately 18 of 21 patients had a previous retinal break, 5 of which were untreated before the initial examination. No retinal breaks were observed in the idiopathic group. Macular proliferative vitreoretinopathy was highly associated with a history of retinal breaks (P < 0.001). Presenting visual acuity was significantly worse (mean, 0.86 ± 0.44) for macular proliferative vitreoretinopathy than for the idiopathic group (mean, 0.44 ± 0.36). CONCLUSION Epimacular membrane occurring in the context of previous retinal breaks or macular proliferative vitreoretinopathy has a characteristic morphologic feature in spectral-domain optical coherence tomography. Surgical removal typically results in significant visual improvement.

To compare macular choroidal thickness between cigarette smokers, those with a history of smoking, and nonsmokers in patients over 65 years of age with early-atrophic age-related macular degeneration (AMD) and normals.Prospective, consecutive, observational case series. Enhanced depth imaging spectral domain optical coherence tomography 12-line radial scans were performed and choroidal thickness manually quantified at 84 points in the central 3 mm of the macula. Data of normals, soft drusen alone, and soft drusen with additional features of early AMD were compared. A multivariate analysis of variance (MANOVA) model, controlling for age, was constructed to evaluate the effect of smoking history and AMD features on choroidal thickness.A history of smoking was significantly associated with a thinner choroid across all patients via logistic regression (P=0.004; O.R.=12.4). Mean macular choroidal thickness was thinner for smokers (148±63 μm) than for nonsmokers (181±65 μm) among all diagnosis categories (P=0.003). Subgroup analysis of patients with AMD features revealed a similar decreased choroidal thickness in smokers (121±41 μm) compared with nonsmokers (146±46 μm, P=0.006). Bivariate analysis revealed an association between increased pack-years of smoking and a thin choroid across all patients (P0.001) and among patients with features of early AMD (P0.001). Both the presence of features of macular degeneration (P0.001) and a history of smoking (P=0.024) were associated with decreased choroidal thickness in a MANOVA model.Chronic cigarette smoke exposure may be associated with decreased choroidal thickness. There may be an anatomic sequelae to chronic tobacco smoke exposure that underlies previously reported AMD risk.

Purpose To describe the clinical and histopathologic characteristics of inflammatory deposits occurring within intermediate duration postoperative perfluoro-n-octane (PFO) for inferior retinal detachment repair. Methods Prospective interventional case series of consecutive patients with inferior retinal detachment treated with intermediate duration postoperative vitreous cavity PFO endotamponade were analyzed by ophthalmoscopy for the presence of inflammation and white deposits. Ten consecutive samples developing white deposits were analyzed microscopically. Clinical variables were analyzed. Results One hundred and eighty-one eyes of 181 patients were included (mean age = 52.4 ± 14 years; mean follow-up = 29.7 ± 14 months). Fifty of 181 patients (28%) developed a characteristic foreign body response with abundant white deposits within indwelling PFO. Ten consecutive samples analyzed histologically contained abundant macrophages, the absence of additional inflammatory cells, and intracytoplasmic optically lucent inclusions. Foreign body response was associated with longer duration of PFO (P = 0.003). Perfluoro-n-octane foreign body response was not associated with age (P = 0.136), ethnicity (P = 0.101), visual outcome (P = 0.157), or persistent intraocular pressure elevation (P = 0.381). Conclusion A stereotypical foreign body response occurs in ∼ 30% of patients with postoperative vitreous cavity PFO and becomes clinically apparent at 7 days to 10 days after initial placement for rhegmatogenous retinal detachment repair. The response consists almost exclusively of macrophages and does not seem to be related to either long-term intraocular pressure elevation or visual outcome. The response may be related to the duration of indwelling PFO and may limit visualization of the retina during PFO removal.

BACKGROUND AND OBJECTIVE: Recent reports have demonstrated inner retinal changes after internal limiting membrane (ILM) peeling, but the mechanism responsible for these findings remains poorly understood. The purpose of this report is to establish a correlation between ILM removal and postoperative morphologic changes. PATIENTS AND METHODS: Prospective, observational case series of eight consecutive patients undergoing pars plana vitrectomy with ILM peeling for macular hole or epimacular membrane. Intraoperatively, all grasp sites were recorded and subsequently superimposed on postoperative infrared and spectral-domain optical coherence tomography (SD-OCT) images. Repeat examination and imaging were performed at regular postoperative intervals. RESULTS: Infrared fundus photography revealed well-defined, hyporeflective arcuate striations in all patients during the early postoperative period. These defects followed the course of axonal pathways from the grasp site to the optic nerve. SD-OCT images on all patients revealed early focal nerve fiber layer swelling directly corresponding to grasp sites, with eventual atrophy. CONCLUSION: A dynamic process takes place within the inner retina following surgical removal of ILM. Inadvertent surgical trauma induced by ILM forceps may be the mechanism responsible for nerve fiber layer morphologic changes after ILM peeling. [ Ophthalmic Surg Lasers Imaging Retina . 2014;45:45–49.]

Since its original description in 1908, Coats disease has been recognized as an idiopathic cause of severe vision loss with a remarkable diversity in clinical presentation and morphology. Key clinical and imaging variables are helpful in differentiating Coats disease from life-threatening malignancies, and proper management revolves around a thorough knowledge of the differential diagnosis. Despite significant advancement in scientific understanding of the disease process and clinical spectrum, the underlying etiology remains obscure, and both primary and secondary forms are recognized. With the development of anti-VEGF therapy, vitreoretinal specialists have a new, effective adjunct to the clinical management of exudates, macular edema, and serous retinal detachment. We highlight the history, diagnostic challenges, evolving clinical spectrum, and current management of Coats disease.

To compare visual and anatomic outcomes in eyes with type 2 idiopathic macular telangiectasia (Mactel) treated with either intravitreal bevacizumab (IVB), observation, or pars plana vitrectomy (PPV) with internal limiting membrane removal. Retrospective, consecutive, interventional case series of phakic patients with Mactel. Best-corrected Snellen visual acuity (BCVA) and complete ophthalmic exam was obtained prior to treatment and at subsequent 3-month intervals for a minimum of 6 months. Fluorescein angiographic and spectral-domain optical coherence tomography features were examined, and compared to BCVA at treatment initiation and follow-up. Fifty-six eyes of 28 patients were evaluated. Mean age was 65 ± 12 years, and mean follow-up was 24 ± 13 months. Patients were treated with either observation (n = 33), IVB (n = 15), or PPV (n = 8). Mean number of treatments for the IVB group was 2.5 ± 3.5 intravitreal injections. No significant differences in BCVA change were observed between treatment groups via one-way ANOVA (p = 0.49). Presence of inner retinal cysts was not correlated to BCVA (p > 0.05). Discontinuous outer nuclear layer was significantly related to worse initial and final vision, but not to BCVA change. IVB and PPV with ILM removal appear ineffective in improving visual outcome in eyes with non-proliferative Mactel. SD-OCT evidence of disrupted foveal outer nuclear layer is related to decreased BCVA, but not related to BCVA change following treatment.

BACKGROUND AND OBJECTIVE: To evaluate the association between temporal macular atrophy and the presence of neovascularization in eyes with sickle cell disease (SCD). PATIENTS AND METHODS: Retrospective, case-controlled study identifying 64 eyes from 38 consecutive patients with SCD. Dilated funduscopic examination and wide-field fluorescein angiography were used to identify the Goldberg stage of proliferative sickle cell retinopathy. Spectral-domain optical coherence tomography images were analyzed for the presence of temporal macular atrophy. The association between temporal macular atrophy and neovascularization was then evaluated. RESULTS: Temporal macular atrophy had a sensitivity of 27%, a specificity of 67%, a positive predictive value of 83%, and a negative predictive value of 13% for identifying neovascularization. CONCLUSION: Although the presence of temporal macular atrophy is not sensitive enough to be used as a screening test, if seen in a patient with SCD, the physician should be alerted to the strong possibility that peripheral neovascularization may be present. [ Ophthalmic Surg Lasers Imaging Retina . 2016;47:27–34.]

The purpose of this study was to describe the treatment of giant retinal tears (GRTs) with 25-gauge pars plana vitrectomy (PPV) and medium-term postoperative perfluoro-n-octane (MT-PFO).The study was a retrospective interventional case series of consecutive patients with GRTs treated with 25-gauge PPV and postoperative MT-PFO for a period of 2-3 weeks. A second, staged procedure was performed in all patients for PFO removal.Twenty-three eyes of 22 patients were studied, with a mean follow-up of 33.04 ± 19.74 months. Successful reattachment was achieved in 91.3 % of eyes (21/23) after MT-PFO. Retinal re-detachment occurred in five eyes, which was caused by proliferative vitreoretinopathy. Additional complications included cataract progression (n = 10), foreign body response (30.4 %, 7/23), and transient intraocular pressure (IOP) elevation (8/23, 34.8 %). Transient IOP elevation was associated with worse visual outcome (p = 0.01).MT-PFO was found to be an effective and safe technique for operative management of GRTs. In the majority of patients, retinas remained attached without further surgical intervention. Cataract progression, intraocular inflammation, and associated increased intraocular pressure are potential complications of MT-PFO.

To describe the relationship between pseudophakic cystoid macular edema (CME) progression and retinal structural changes observed by spectral-domain optical coherence tomography (SD-OCT) and fluorescein angiography. Retrospective, consecutive, longitudinal imaging analysis of patients with acute pseudophakic cystoid macular edema. Two observers at two study centers evaluated all images and categorized the macular structural features based on the retinal layer involved with cystic changes and/or subretinal fluid. A time series of the structural pattern and visual acuity was constructed for 1-month intervals over a 6-month study period. Thirty nine patients presented with CME. The mean time since cataract extraction was 48 ±38 days (range 5–71). CME included inner nuclear layer (INL) cystic changes, outer plexiform layer (OPL) cystic changes, and subretinal fluid. Isolated INL changes were observed in four phakic fellow eyes. Isolated OPL morphology was not observed, and additional inner layers remained uninvolved. Resolution occurred rapidly following administration of periocular glucocorticoids, and typically demonstrated a reverse structural pattern or delayed subretinal fluid resolution. Isolated subretinal fluid or a combined INL and subretinal fluid structure indicated CME resolution. Acute and recurrent pseudophakic CME involves a directional progression of the retinal layer involved with cystic changes and a clinical course. CME begins with INL cystic changes, progresses to combined INL and OPL morphology, and may continue to involve subretinal fluid. The inner nuclear layer is the most frequently involved layer, and isolated INL cysts may occur in phakic fellow eyes. A three-layer structure, the presence of OPL morphology, or isolated INL early in the postoperative period indicates disease activity.

PURPOSE To describe a method of 25-gauge pars plana vitrectomy (PPV) with posterior hyaloid scissor segmentation in a child with recurrent retinal detachment caused by vitreous traction under silicone oil. METHODS A two-port, 25-gauge PPV was performed under previously instilled silicone oil with retinotomy and internal drainage of subretinal fluid. RESULTS A 5-year-old monocular girl with familial exudative vitreoretinopathy presented with decreased vision and a recurrent retinal detachment 3 weeks after PPV and air-silicone exchange for rhegmatogenous retinal detachment. Ophthalmoscopy, fundus photography, and optical coherence tomography revealed persistent posterior hyaloid adherent to multiple retinal foci inducing a tractional detachment. The patient underwent two-port PPV revision with scissor segmentation of vitreous traction. Follow-up examination at 3 months revealed the absence of vitreous traction, an attached retina, and markedly improved vision. CONCLUSION Posterior vitreous sequestered under silicone oil inducing consecutive retinal detachment may be successfully managed with two-port interface PPV and scissor segmentation of vitreous traction.

PURPOSE To describe the spectral domain optical coherence tomography characteristics of retained subretinal perfluoro-n-octane (SR-PFO) after vitreoretinal surgery. METHODS Consecutive patients referred for retained SR-PFO after pars plana vitrectomy for retinal detachment were prospectively evaluated with spectral domain optical coherence tomography. The clinical findings, fundus autofluorescence, spectral domain optical coherence tomography images, and anatomical outcomes, were reviewed. RESULTS Three consecutive patients presented to the vitreoretinal service with history of retinal detachment and pervious vitrectomy with intraoperative PFO. Subretinal PFO bubbles were observed on clinical examination and imaging studies, including spectral domain optical coherence tomography. Case 1 had subfoveal PFO removal and developed a postoperative choroidal neovascular membrane. Case 2 had multiple foci of SR-PFO after giant retinal tear repair. Case 3 had superotemporal SR-PFO that remained stable for several years without migration or other associated pathology. CONCLUSION Subretinal PFO appears as a low-reflectance spherical mass, often with a pinpoint focus of hyperreflectance at the apex of the bubble. Optical coherence tomography details beneath subretinal PFO appear relatively hyperreflectant compared to adjacent tissue. Long-term observation revealed preferential absence of the outer retinal layers with no nerve fiber layer erosion, subretinal inflammatory precipitates, or proliferative vitreoretinopathy. Some evidence of retinal pigment epithelial disruption was observed but seemed to remain stable or improve with observation. The authors suggest management involving follow-up with close observation in SR-PFO unless present in the subfoveal region. Choroidal neovascular membrane can occur after SR-PFO removal and may be successfully managed with intravitreal bevacizumab.

PURPOSE To report the anatomical and visual outcomes in a series of patients with type 2 idiopathic macular telangiectasia (mactel) and cystic foveal changes treated with pars plana vitrectomy and internal limiting membrane removal. METHODS Five eyes of 3 patients with mactel were treated with 25-gauge sutureless transconjunctival pars plana vitrectomy and internal limiting membrane peeling. Complete clinical examination, including serial spectral-domain optical coherence tomography, was performed preoperatively and postoperatively. RESULTS Two of 5 eyes had stable vision at 2-year follow-up with continued evidence of foveal cystic spaces on spectral-domain optical coherence tomography. Two eyes experienced significant visual improvement despite continued evidence of foveal anatomical disruption. One eye experienced slight visual decline and full-thickness macular hole formation. CONCLUSION Surgical intervention involving pars plana vitrectomy with internal limiting membrane peeling may be a treatment option for select cases of mactel. Pars plana vitrectomy does not seem to alter the underlying disease process in mactel but may stabilize visual decline or lead to improved vision in some patients.

Purpose: To describe a case of hereditary hemorrhagic telangiectasia, presenting with multiple branch retinal artery occlusions, retinal ischemia, neovascularization, and vitreous hemorrhage after cerebral arteriovenous malformation embolization. Methods: The authors report a 7-year-old patient with decreased vision in his left eye after embolization of a pineal arteriovenous malformation secondary to hereditary hemorrhagic telangiectasia. Ophthalmic evaluation, fundus photography, fluorescein angiography, spectral domain optical coherence tomography, electroretinogram, examination under anesthesia, and pars plana vitrectomy (PPV) were performed. Results: Fundus examination of the left eye revealed extensive posterior segment ischemia, vascular tortuosity, and vitreous hemorrhage. Fluorescein angiography was remarkable for partial obstruction of retinal arteries, midperipheral nonperfusion, and associated leakage from multiple areas of neovascularization. Spectral domain optical coherence tomography was normal. Electroretinogram demonstrated decreased b-wave amplitude. The patient was subsequently treated with 25-gauge pars plana vitrectomy, panretinal endophotocoagulation, and intravitreal bevacizumab. Five weeks after surgery, best-corrected visual acuity had improved to 20/40, and examination showed resolution of vitreous hemorrhage and neovascularization. Conclusion: Retinal vascular abnormalities, posterior segment ischemia, and vitreous hemorrhage suggested a combination of retinal involvement of hereditary hemorrhagic telangiectasia complicated by nontarget embolization.

BACKGROUND AND OBJECTIVE: To describe a technique of 25-gauge pars plana lensectomy with primary posterior capsulotomy and sparing of the anterior lens capsule that is suitable for all lens densities. PATIENTS AND METHODS: The authors describe a technique they routinely employ for pars plana vitrectomy using primarily a 25-gauge, three-port approach with intraoperative lens density assessment and possible fragmatome use for dense lenses. An analysis of the ability to achieve surgical goals is provided. RESULTS: Surgical goals were achieved in all 68 cases performed during an 18-month period. Anterior lens capsule was consistently spared, and 25-gauge fluidics functioned well even in the presence of a fragmatome and single 20-gauge sclerotomy. CONCLUSION: 25-gauge pars plana lensectomy with vitrectomy with and without fragmatome incision is an efficacious technique for lensectomy. [ Ophthalmic Surg Lasers Imaging Retina . 2014;45:570–572.]

PURPOSE To compare macular choroidal thickness between patients older than 65 years with early atrophic age-related macular degeneration (AMD) and normals. METHODS This was a consecutive, cross-sectional observational study. Enhanced depth imaging spectral-domain optical coherence tomography using horizontal raster scanning at 12 locations throughout the macula was performed in one eye of consecutive patients presenting with large soft drusen alone, drusen with additional features of early AMD, or a normal fundus. Choroidal thickness was measured at 7 points for each raster scan in the central 3 mm of the macula (total 84 points per eye). In addition, a single subfoveolar measurement was obtained for each eye. RESULTS One hundred fifty eyes of 150 patients were included. There was no significant difference between mean refractive error for each diagnosis category via one-way ANOVA (P = 0.451). Mean macular choroidal thickness (CT) was 235 ± 49 μm (range, 125-334 μm; median 222 μm) for normals, 161 ± 39 μm (range, 89-260 μm; median = 158 μm) for the drusen group, and 115 ± 40 μm (range, 22-256 μm; median = 112 μm) for patients with AMD. Mean macular CT was significantly different via one-way ANOVA among all diagnosis categories (P < 0.001). CONCLUSIONS The presence of features of early AMD without geographic atrophy and/or soft drusen alone is associated with decreased mean macular CT in vivo compared to that in patients with no chorioretinal pathology. Using enhanced depth imaging, measurement of a single subfoveolar choroidal thickness is highly correlated to mean central macular CT.

Seven weeks after uneventful cataract extraction with intraocular lens (IOL) implantation, a 64-year-old man presented to his cataract surgeon with decreased vision and photophobia. The subacute presentation with anterior uveitis prompted initial therapy with topical and periocular glucocorticoids. One month later, the patient presented to the vitreoretinal service with counting fingers visual acuity, prominent anterior chamber reaction, a 2.5 mm hypopyon, and inflammatory deposits over the IOL. Cultures grew Rhizoctonia solani . The inflammation was successfully treated with pars plana vitrectomy, IOL explantation, and intravitreal voriconazole. Rhizoctonia should be included in the differential diagnosis of subacute exogenous endophthalmitis, especially in the context of fibrillar white IOL plaques. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Retinal astrocytic hamartomas are rare, benign tumors of glial origin. These lesions are often associated with systemic syndromes, including tuberous sclerosis complex and neurofibromatosis type 1, but also may be encountered in otherwise healthy individuals as an acquired lesion. We present the following case to illustrate clinical and imaging characteristics typically seen in astrocytic hamartoma found as “optic nerve incidentaloma” in an otherwise healthy teenager.

Purpose: To describe the spectral-domain optical coherence tomography features of chorioretinal folds of various etiology. Materials and methods: Cross-sectional observational case series of consecutive patients with chorioretinal folds. All patients underwent enhanced depth imaging optical coherence tomography over a two-month study period. Clinical variables and imaging features including subfoveal choroidal thickness and chorioretinal fold morphology were analysed. Results: 11 of 628 patients evaluated presented with chorioretinal folds. Diagnoses included hyperopia, uveal effusion, and secondary to surgery or medications. 22 patients presented with lesions simulating chorioretinal folds on ophthalmoscopy but were found not to be true chorioretinal folds with optical coherence tomography. Subfoveal choroidal thickness was diffusely thick in hyperopia, uveal effusion, hypotony, and topiramate, and normal in cases following scleral buckle and trauma. Lesions simulating chorioretinal folds occurred in age-related choroidal atrophy, and demonstrated chorioretinal contour changes involving specific choroidal vessels in an overall thin choroid. Conclusion: Chorioretinal folds occurred in the context of a diffusely thick choroid in high hyperopia and hypotony, and with a normal choroidal thickness following scleral buckle or trauma. Enhanced depth imaging OCT is helpful in differentiating chorioretinal folds from various etiologies and from simulating lesions.

The advent of spectral domain optical coherence tomography (SD-OCT) has brought about new insight into aspects of ocular anatomy that cannot be seen during slit lamp examination and provides a powerful tool for the evaluation of ocular disease. Optic nerve OCT has been previously described and is a validated method for evaluating the diagnosis and progression of glaucomatous optic neuropathy (GON).1–7 Current SD-OCTs use automated methods to determine the optic disc border, measure the peripapillary retinal nerve fiber layer (RNFL) thickness, and generate topographic graphs and maps to evaluate the optic nerve head (ONH).2,6,8,9 The SD-OCT allows for the fast, noninvasive, in vivo visualization of intraocular anatomy at the micrometer level.6–9 Although high-definition two-dimensional b-scan images of the optic nerve are feasible, these scans are not part of most clinical ONH protocols and are thus often overlooked or not performed in the evaluation of glaucoma. Recent studies examined additional anatomical parameters10–12 that may be important in glaucoma risk, such as disc size,13–17 prelaminar tissue volume and distensibility,18–21 and peripapillary choroidal thickness.19,22–26 These variables have now been quantified in experimental monkey,18,19,27 rodent,25 and porcine28 models of glaucoma and highlight the importance of early changes in peripapillary structures25 and the laminar insertion.29 We hypothesized that (1) chronic intraocular pressure elevation, combined with specific ONH phenotypes, may lead to distention and thinning of the peripapillary choroid and disk border tissue, as evaluated by SD-OCT; and (2) ganglion cell axon layer may be quantified by the thickness of tissue central to the termination of Bruch membrane on SD-OCT and may correlate to the presence of glaucomatous optic neuropathy. This descriptive pilot study set out to quantify several anatomical variables evident on SD-OCT raster scanning of the ONH to attempt to identify anatomical characteristics common in patients with GON. To our knowledge, this is the first morphology-based human SD-OCT raster scanning correlate to the above animal models. We compared anatomical variables including canal nerve fiber layer (CNFL), disc size (neural canal opening [NCO]), axial distance of disc border to lamina cribrosa (or prelaminar canal depth [PLCD]), and peripapillary choroidal thickness (PPCT) between eyes with disease and normals. We further emphasize the potential importance of manual, high-resolution, cross-sectional viewing of the ONH with SD-OCT as an adjunct to automated topography and in specific clinical situations.

Purpose: To describe a series of patients with recurrent inferior retinal detachment complicated by proliferative vitreoretinopathy (PVR) treated with pars plana vitrectomy and postoperative perfluoro-n-octane (PFO). Methods: Consecutive patients with recurrent inferior retinal detachment and Grade C PVR were prospectively treated with 25-gauge pars plana vitrectomy and postoperative “medium-term” PFO for 2- to 3-week duration. All patients had subsequent PFO removal in a planned staged procedure. Results: Forty-four eyes of 44 patients were included. Mean follow-up time was 30.71 ± 12.92 months. Successful reattachment was achieved in 86% of eyes (38/44). Reattachment rates were statistically equivalent between eyes with and without previous scleral buckle. Reasons for redetachment were recurrent inferior PVR (four of six) and new superior break without PVR (two of six). Additional complications observed were cataract progression requiring surgery (42%), persistent intraocular pressure elevation (36%), and transient inflammation (32%). Macula-off status (P = 0.02) and persistent intraocular pressure elevation (P = 0.02) were factors associated with worse visual outcome. Conclusion: Medium-term PFO was found to be an efficacious technique for operative management of recurrent inferior retinal detachments complicated by Grade C PVR. The method of primary repair (scleral buckle vs. pars plana vitrectomy) did not affect reattachment rates. Transient inflammation and intraocular pressure elevation are potential complications associated with this technique. Persistent intraocular pressure elevation was associated with worse visual outcome.

Recent advances in ophthalmic imaging have created the need for accurate, user-friendly, and widely compatible viewing platforms. In addition, post-capture image manipulation including micrometer-level measurements are becoming increasingly important. OsiriX is an open-source viewing platform approved by the U.S. Food and Drug Administration originally designed for viewing Digital Images and Communication in Medicine (DICOM) images generated by radiologic studies. The authors report the use of OsiriX for importing optical coherence tomography images, highlighting details with various contrast windows, and accurate calibration for detailed anatomic measurements. This viewing modality may be useful in performing accurate, detailed manipulations of ophthalmic images for clinical evaluation, research, and publication purposes.

To report the rare occurrence of new inner nuclear layer cystic spaces occurring in eyes treated with pars plana vitrectomy (PPV) and internal limiting membrane (ILM) removal for idiopathic epimacular membrane (EMM). Consecutive patients with EMM without preoperative retinal cystic changes undergoing PPV with ILM peeling were retrospectively evaluated. Patients developing a characteristic inner nuclear layer cystic change were analyzed. Inner nuclear layer cystic changes appeared in eight of 768 (1.04 %) eyes at a mean postoperative time period of 3.2 ± 0.89 months. No leakage or pooling was demonstrated on postoperative fluorescein angiography. Morphologic characteristics included vertically elongated hyporeflectant spaces within the inner nuclear layer on spectral domain optical coherence tomography (SD-OCT). A minority of patients undergoing PPV with ILM peeling develop new, delayed onset, postoperative inner nuclear layer cystic spaces with a characteristic SD-OCT appearance and no evidence of angiographic leakage.

BACKGROUND AND OBJECTIVE: To describe a series of patients with inferior retinal detachments managed with primary 25-gauge pars plana vitrectomy (PPV), 2 to 3 weeks of postoperative perfluoro-n-octane (MT-PFO) tamponade, and upright positioning followed by secondary PPV and PFO removal. PATIENTS AND METHODS: Interventional case series of 157 patients with inferior retinal detachments with and without proliferative vitreoretinopathy. Eyes were treated with 25-gauge PPV, endophotocoagulation, and MT-PFO tamponade. Patients underwent postoperative upright positioning followed by repeat PPV and PFO removal in a planned, staged procedure. RESULTS: Mean follow-up was 32 ± 4.6 months. Successful reattachment was achieved in 87.5% of 159 eyes. Main initial postoperative complications were persistent intraocular pressure (IOP) elevation in 34% (n = 54), excessive inflammation in 27% (n = 43), and PFO in the anterior chamber in 21% (n = 34). Additional complications occurring after PFO removal included cataract surgery in 16% (n = 22) of initially phakic eyes, redetachment in 13% (n = 21), and need for filtering surgery in 6% (n = 10). Logistic regression analysis revealed macula status ( P = .003) and progression to filtering surgery ( P = .001) as significant factors predicting visual outcome at 1-year follow-up. CONCLUSION: MT-PFO tamponade and upright head positioning may be efficacious for inferior retinal detachment repair in patients unable to assume face-down postoperative positioning. Anatomic and visual outcomes are similar to previously described reattachment procedures. A characteristic granulomatous inflammatory reaction presents in some patients, but does not appear to leave long-term visual or anatomic sequelae. Persistent IOP elevation and progression to filtering surgery may occur in a small percentage of patients and portends a worse visual outcome.

Objective. To perform a survey of the American Society of Retina Specialists (ASRS) regarding the use of vitreous cavity fluorinated gas as an adjunct to pars plana vitrectomy for retinal detachment or macular hole repair.Methods. A multiple-choice online questionnaire was administered to members of ASRS. Physician experience, gas preference for vitrectomy, and categorical estimate of observation of blinding postoperative ischemic events were recorded.Results. 282 questionnaires were completed. Mean years in vitreoretinal practice were15±10. A decrease in yearly vitrectomy volume was associated with increased number of years in practice (P=0.011). Greater than 95% of respondents preferred fluorinated gas to air alone for both retinal detachment and macular hole repair. 38% of respondents reported at least one observation of a blinding ischemic postoperative event. Overall estimated incidence of blinding postoperative ischemic event was 0.06 events/year in practice.Conclusions. Currently, C3F8 and SF6 are the postoperative gas preference for ASRS respondents, in contrast to previous North American surveys. The occurrence of blinding ischemic events appears unrelated to number of years in practice, was reported by less than half of those surveyed, and has occurred at an infrequent rate of approximately once for every ten years of practice for those observing the phenomena.

Recently, many authors have propagated the notion that a specific form of "microcystic macular edema" occurs in patients with optic neuritis and optic atrophy of various etiology and is due to retrograde synaptic degeneration. The finding is isolated to the inner nuclear layer on spectral-domain optical coherence tomography in most cases, and is present in a parafoveal, circumferential, and central macular distribution. This perspective critically reviews the evidence and suggests that inner nuclear layer cystoid changes are an early and nonspecific indicator of typical cystoid macular edema of any cause, and that the finding is likely not a distinct entity.

Age-related macular degeneration (ARMD) continues to be a significant public health concern, given its high prevalence and potential blinding prognosis in the elderly. Several risk factors have been identified in the development of ARMD, including age, race, and family history. The pathogenesis of ARMD continues to be elucidated, and recent research has focused on genetic factors. ARMD presents in either the atrophic or exudative form. Treatment for atrophic disease consists of antioxidants and zinc and close monitoring. Treatment for exudative disease is aimed at targeting choroidal neovascularization. The development of anti-vascular endothelial growth factor (anti-VEGF) agents has revolutionized the treatment of exudative ARMD, providing a more favorable prognosis for previously blinding disease. Considerable amount of research is being carried out on new treatment modalities for both the atrophic and exudative forms of the disease.

Hereditary retinal degenerations comprise a diverse group of inherited genetic defects in one or more retinal or retinal pigment epithelial cellular proteins. Traditionally, anatomic classification based on clinical and histopathologic phenotype has been used to organize these disorders. In the modern era of advanced molecular biological techniques and genetic screening the current classification system may soon become obsolete, due to the fact that significant overlap between different retinal degenerations has been observed, resulting from variation in gene expression, common genetic pathways, and variable inheritance patterns. In this article, we review the various clinical disease entities, emphasize a genetic classification system, and give special attention to recent advances in molecular biology and gene therapy.