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Purpose: A ranibizumab prefilled syringe (PFS) has been approved by the US Food and Drug Administration. Here we evaluate the use of the ranibizumab PFS for intravitreal injection by assessing whether the PFS enables healthcare providers to successfully prepare and administer an injection without prior training. Design: Simulated-use and actual-use human factors usability studies. Participants: Retina specialists and ophthalmic medical personnel. Methods: In a simulated-use summative usability study, retina specialists (n=15) and ophthalmic medical personnel (n=15) prepared the ranibizumab PFS and performed injections into a model eye. In an actual-use formative usability study (ClinicalTrials.gov identifier: NCT02698566), three assistants and three retina specialists prepared the PFS and performed intravitreal injections, respectively, in study eyes of patients with retinal diseases (n=35). Main Outcome Measures: Twelve tasks specific to the unpacking, preparing, and properly administering the PFS for intravitreal injection were evaluated by a study assessor. Task performances were evaluated for use errors, close calls, and operational difficulties. Post-injection subjective user evaluations were performed to assess ease of use. Results: All participants successfully performed all essential and safety-critical tasks without use error in both the simulated-use and actual-use human factors usability studies. The majority of participants rated the tasks required to use the ranibizumab PFS as "Easy" or "Very Easy." Conclusions: Both the simulated-use and actual-use usability studies yielded consistent data, showing that healthcare professionals are able to use the ranibizumab PFS by successfully performing all critical tasks involved in preparing and delivering an intravitreal injection. The simulated-use usability testing was sufficiently realistic and representative of real world use, and was appropriate and preferred over actual-use usability testing for proper evaluation of the product user interface.

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 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."

This PVR summary was performed after analysing 30 PVR questionnaires from expert vitreoretinal surgeons. There are many tips and tricks shared by many of them despite they are referred to only one. I want to appreciate their kind collaboration with this chapter.

In a fresh RD surgery, what technique would you use to identify a retinal hole or microtear if you could not find it after looking for it?

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.

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.

The purpose of this study was to evaluate the clinical outcomes of patients with anterior segment neovascularization treated with or without intravitreal bevacizumab.This was a retrospective, comparative case series of 60 patients with anterior segment neovascularization: 30 consecutive patients treated with intravitreal bevacizumab and 30 age-, gender-, and race-matched controls treated without bevacizumab.The mean follow-up time was 9.1+/-6.3 months in the bevacizumab group and 8.6+/-6.2 months in the control group (P=0.769). At baseline, no significant difference was observed in initial visual acuity, intraocular pressure, gonioscopy, and iris or angle neovascularization (P=0.179, 0.432, 0.065, and 0.966, respectively). At the final examination, no significant difference was observed in mean intraocular pressure (P=0.464), mean number of glaucoma medications (P=1.00), or presence of anterior segment neovascularization (P=0.699). Final visual acuity better than 20/60 was achieved in six patients in the bevacizumab group and none in the control group (P=0.013). Comparison of linear regressions of baseline and final visual acuity (LogMAR) showed a significant difference between the two groups (P=0.040). In the bevacizumab group, 18 patients required glaucoma surgery, whereas 30 patients in the control group required surgery (P0.001), usually with a glaucoma drainage implant. Both bevacizumab and control patients who presented with closed angles required glaucoma surgery (P=1.000).Treatment of anterior segment neovascularization with intravitreal bevacizumab significantly improves visual outcomes and significantly decreases the need for glaucoma surgery. In patients with closed anterior chamber angle, addition of bevacizumab treatment does not reduce the need for glaucoma surgery.

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.

The purpose of our studies was to evaluate different strategies for possible neuroprotection in glutamate-induced neurotoxicity in the retina. In a first set of experiments we attempted to determine if dextrorphan antagonism of glutamate action on NMDA receptors would protect against excitotoxic injury associated with secondary damage seen after surgical laser treatment in retina. In a second set of experiments, the effects of different calcium channel blockers in an in-vitro model of N-methyl-D-aspartate (NMDA)-induced retinal ganglion cell excitotoxicity that utilized rabbit retinal explants were evaluated. Dextrorphan infusion prior to laser treatment of rabbit retina produced a significant decrease in the area of neural retinal damage. We attribute the apparent dextrorphan protection to attenuation of glutamate mediated excitotoxicity secondary to laser induced cell death. Preincubation of rabbit retinal explants with verapamil, nimodipine or ω-conotoxin MVIIA did not cause a significant change in NMDA induced cell death in the ganglion cell layer.

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.

Purpose: To evaluate safety and clinical results of intravitreal antiangiogenic agents for choroidal neovascularization in pediatric patients. Methods: Retrospective, multicenter, interventional case series. A total of 45 eyes of 39 pediatric patients with choroidal neovascularization of various etiologies were treated with intravitreal injection of antiangiogenic agents (1.25 mg per 0.05 mL of bevacizumab or 0.5 mg per 0.05 mL of ranibizumab). Results: There were 24 girls and 15 boys with group median age of 13 years (range, 3–17 years). Mean follow-up period was 12.8 months (range, 3–60 months). Median visual acuity in terms of logarithm of the minimum angle of resolution at presentation and last follow-up was 0.87 and 0.7, respectively (P = 0.0003). Mean and median number of injections received over the follow-up period was 2.2 and 1, respectively. At the last follow-up, 22 eyes (48%) gained more than 3 lines of vision and 27 eyes (60%) had final visual acuity 20/50 or better. Nine eyes (20%) did not improve and had severe vision loss (20/200 or worse). Conclusion: Intravitreal antiangiogenic therapy for choroidal neovascularization in pediatric patients seems temporarily safe and effective in majority of affected eyes. Because of the rarity and character of this condition, it is unlikely that any clinical trials will soon take place to study this or other treatment option.

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.]

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.

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.

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.

BACKGROUND AND OBJECTIVE: To present a case series to elucidate a novel technique that involves the creation of an arcuate retinotomy in the treatment of large macular holes after failed primary repair. PATIENTS AND METHODS: retrospective chart review. Six eyes (six patients) with large macular holes, all of which had failed primary repair, underwent 25 gauge pars plana vitrectomy revision coupled with full thickness arcuate retinotomy temporal to the macular hole and fluid-gas exchange. The main outcome measure was anatomic macular hole closure based on optical coherence tomography (OCT), with visual acuity and visual field evaluation as secondary outcome measures. RESULTS: Five of the six patients (83%) had successful hole closure with three of the six patients (50%) exhibiting improvement in visual acuity. CONCLUSION: Arcuate retinotomy is a new approach that may aide in the repair of large macular holes not otherwise amenable to closure with traditional techniques.

Purpose To report the severity of ocular injury in seven children with traumatic hyphemas resulting from the accidental striking of the child in the face with a belt during the administration of corporal punishment. Design Observational case series. Methods We retrospectively reviewed the records of all patients (n = 7, aged 4 to 14 years) with traumatic hyphemas secondary to belt injuries evaluated by the senior author between 1989 to 2002 at Le Bonheur Children’s Medical Center, a regional pediatric referral hospital in Memphis, Tennessee. Results Anterior segment injuries ranged from small hyphemas with normal intraocular pressure and no vision loss to injuries with severe elevations of intraocular pressure and permanent, significant loss of vision. Conclusions Ocular injury to a child can result from trauma inflicted with a belt by a parent or caretaker during corporal punishment and may result in permanent loss of vision.

The purpose of our studies was to evaluate different strategies for possible neuroprotection in glutamate-induced neurotoxicity in the retina. In a first set of experiments we attempted to determine if dextrorphan antagonism of glutamate action on NMDA receptors would protect against excitotoxic injury associated with secondary damage seen after surgical laser treatment in retina. In a second set of experiments, the effects of different calcium channel blockers in an in-vitro model of N-methyl-D-aspartate (NMDA)-induced retinal ganglion cell excitotoxicity that utilized rabbit retinal explants were evaluated. Dextrorphan infusion prior to laser treatment of rabbit retina produced a significant decrease in the area of neural retinal damage. We attribute the apparent dextrorphan protection to attenuation of glutamate mediated excitotoxicity secondary to laser induced cell death. Preincubation of rabbit retinal explants with verapamil, nimodipine or omega-conotoxin MVIIA did not cause a significant change in NMDA induced cell death in the ganglion cell layer.

Objectives To report a child with early-onset autosomal recessive Best vitelliform macular dystrophy and compound heterozygousBEST1mutations, the management of a choroidal neovascular membrane with intravitreal bevacizumab in the proband, the benefits of amblyopia therapy in the fellow eye, and the findings in the parents, carriers of heterozygousBEST1mutations. Methods A 5-year-old white girl presented with monocular visual acuity loss and bilateral vitelliform macular lesions. Her parents were also examined. Examinations included electro-oculograms (EOGs), electroretinograms, imaging studies, andBEST1gene testing. Interventions included off-label treatment with intravitreal bevacizumab in the left eye and amblyopia therapy in the right eye. Results The proband presented with visual acuity of 20/200 OD with an atypical subfoveal vitelliform scar and 20/16 OS with asymptomatic vitelliform deposits. Subfoveal choroidal neovascularization developed at age 6 years, causing marked vision loss (20/200 OS). Visual acuity recovered to 20/20 OS after serial intravitreal bevacizumab injections. Amblyopia therapy improved visual acuity to 20/50 OD. The proband showed subnormal EOG Arden ratios and mild electroretinogram changes. Molecular testing showed missenseBEST1mutations (R141S and R141H) in the proband. Unlike dominant Best vitelliform macular dystrophy, in the heterozygous parents EOGs were normal and minimal autofluorescence changes were seen. Conclusions Choroidal neovascularization treatment with bevacizumab was associated with vision restoration. Amblyopia treatment also yielded significant benefit. Patients presenting with vitelliform lesions should be screened forBEST1mutations, even when parents have normal EOG and imaging results. Clinical Relevance Prompt recognition and treatment of choroidal neovascularization and amblyopia management effectively restores vision. Awareness and recognition of recessive inheritance permits correct diagnosis and counseling.