PURPOSE:The purpose of this study was to describe the clinical course and multimodal chorioretinal imaging of an eye that had a concurrent racemose hemangioma, retinal vasoproliferative tumor, and Coats-like vasculopathy. METHOD:Comprehensive ophthalmic examinations and multimodal imaging studies were performed initially, during sessions of laser photocoagulation and aflibercept therapy for the patient's macular exudation and vasoproliferative tumor, and at subsequent follow-up clinical visits for a period of 2 years after therapy. RESULTS:A 14-year-old boy presented with 20/400 visual acuity in his right eye. Examination revealed macular exudation associated with a group 3 racemose hemangioma, a vasoproliferative tumor nasal to the optic disc, and a sclerosed retinal vein with collateral vessels in the temporal periphery from a prior branch retinal vein occlusion. Additional findings in the right eye included peripheral retinal telangiectasis, aneurysms, and extensive capillary nonperfusion consistent with a Coats-like vasculopathy. The left eye was normal. Systemic testing revealed no abnormalities. Macular exudation resolved and the vasoproliferative tumor regressed after laser photocoagulation and three monthly intravitreal aflibercept injections. The best-corrected visual acuity in the right eye was 20/40 2 years after treatment. CONCLUSION:The unusual combination of uncommon retinal vascular abnormalities in the patient's right eye showed marked improvement after laser photocoagulation and anti-VEGF therapy. Racemose hemangioma exudation and abnormal retinal hemodynamics may have contributed to development of the vasoproliferative tumor and Coats-like vasculopathy. This case demonstrates that targeted treatment of exudation and vasoproliferation can provide significant visual improvement despite a patient's complex combination of retinal vascular abnormalities.

PURPOSE:To characterize the surgical outcomes of endoscopy-assisted pars plana vitrectomy (E-PPV) in dropped lens fragments retrieval in patients with corneal opacity. BACKGROUND:Corneal opacity may delay dropped lens fragment retrieval because of limited fundus view. E-PPV permits posterior segment visualization through corneal opacity. There are limited data on E-PPV use for dropped lens fragments retrieval in the literature. DESIGN:Retrospective cohort study. METHODS:A retrospective chart review was performed of dropped lens fragments retrieval procedures done between 2013 and 2023 at a tertiary referral center. Data were collected on the surgical approach, visual acuity (VA), and intraocular pressure (IOP), as well as complication rates including retinal detachment (RD), cystoid macular edema (CME), and epiretinal membrane formation (ERM). Statistical analysis was performed using t tests and chi-square tests. Statistical significance was defined as a P value of .05. RESULTS:There were 74 patients who met the inclusion criteria (31 patients had E-PPV, and 43 patients had standard pars plana vitrectomy [S-PPV]). Groups were balanced in age and gender. Postoperative CME rate was 25.8% after E-PPV and 25.58% after S-PPV (P = .95). Postoperative RD rate was 0% after E-PPV and 7% S-PPV (P = .13). After 1 year, there was no difference in postoperative VA, IOP, and rates of RD, CME, or ERM between groups. Interval time to dropped lens retrieval did not change the final outcome in either group. CONCLUSIONS:This study showed that performing E-PPV to extract dropped lens fragments through corneal opacity had similar final outcomes compared with S-PPV, regardless of the interval time to surgery after the dropped lens fragments. Removing dropped lens fragments using E-PPV before cornea opacity clearance provided outcomes similar to those of delayed cases. Further studies are needed on the psychological benefit in patients undergoing dropped lens removal sooner than others.

PURPOSE:To describe unilateral vasculitic central retinal vein occlusion in a young adult whose vision problems preceded systemic symptoms of COVID-19 infection. METHODS:Observational clinical case report. RESULTS:A 39-year-old immunocompetent man without prior ocular disease presented for vitreoretinal care complaining of decreasing vision in his right eye for 2 weeks. Headaches, pharyngitis, and coughing began 4 days after his visual symptoms. COVID-19 testing was negative before initial vitreoretinal evaluation and positive afterward. Dilated and tortuous major retinal veins in his right eye had prominent perivascular sheathing. A large subhyaloid hemorrhage spanned the macula. Subretinal hemorrhages were present in areas of sheathing, and diffuse nerve fiber layer hemorrhages were arrayed in the distribution of the radial peripapillary capillary plexus. Laboratory tests for inflammatory diseases were negative. The patient was hospitalized for COVID-19 pneumonia a few days after his initial vitreoretinal evaluation. Pars plana vitrectomy was performed for persistent subhyaloid hemorrhage 8 weeks after his hospitalization. The VA in the patient's right eye improved from counting-fingers to 20/30 postoperatively. CONCLUSION:The patient's findings are consistent with an atypical central retinal vein occlusion which we hypothesize to be of vasculitic origin because of prominent associated retinal phlebitis and venous sheathing. Concomitant subhyaloid, nerve fiber layer, and subretinal hemorrhages involved the superficial and deep retinal vascular complexes. The patient's COVID-19-related hospitalization and systemic management delayed surgical management of his subhyaloid hemorrhages, but a good visual result was achieved despite persistence of macular preretinal blood for 3 months.

Retinal vasoproliferative tumors (VPTs) are benign, vascularized, yellowish-pink retinal masses occurring in the third or fourth decade of life. They are classified as secondary when associated with other disorders or primary otherwise. The term primary rather than idiopathic is potentially misleading etiologically because VPTs are generally considered reactive lesions. The primary-idiopathic versus secondary categories are useful clinically, however, because secondary lesions usually occur at a younger age and are more widely distributed, aggressive, and visually debilitating than primary VPTs. It is difficult to prove that secondary associations are causal but thorough evaluations are indicated to rule out associated disorders when VPTs are identified, especially in younger patients. Clinical evidence supports a neovascular origin for VPTs with secondary glial proliferation whereas histopathological evidence is consistent with a glial (astrocytic) genesis and secondary vascularization. VPTs cause serious vitreoretinal problems including vitreous hemorrhage, intraretinal and subretinal exudation, exudative retinal detachment, and remote epiretinal membranes (ERMs) and cystoid macular edema (CME). These tumors can be difficult to identify because of their peripheral location, indistinct borders, and color similarity to adjacent peripheral retina. We speculate that unrecognized or subclinical tumors may be involved in the pathogenesis of some cases of otherwise idiopathic ERMs, CME, and vitreoretinal traction or related interface disorders. VPT differential diagnosis includes retinal capillary hemangioblastoma, Coats disease, peripheral exudative hemorrhagic chorioretinopathy, and choroidal melanoma. Ultra-widefield photographic and OCT imaging systems are useful for identifying, analyzing, and monitoring VPTs. Ultrasonography and tissue biopsy are valuable for identifying very peripheral and/or diagnostically ambiguous lesions. Reliable biomarkers are not currently available for predicting lesion expansion, necessitating sequential ophthalmoscopy and imaging for VPT management. Small, asymptomatic VPTs can be followed by observation. Symptomatic tumors are usually treated with cryopexy or laser photocoagulation. Large lesions are often treated with episcleral plaque therapy. Pars plana vitrectomy is used to remove ERMs and vitreous hemorrhage. Anti-VEGF, anti-TNF, or steroid medications have been combined with the preceding treatments or used as monotherapy. The low incidence of VPTs has precluded randomized controlled trials needed to optimize their management, but decades of relevant research provide a firm foundation for future studies on this issue.

BACKGROUND:An idiopathic macular hole (IMH) is a foveal opening in the neurosensory retina caused by perifoveal vitreomacular traction and detachment. IMH prevalence varies considerably across populations, highlighting a need for further investigation, especially in underrepresented groups such as Hispanics. METHODS:This retrospective, descriptive, cross-sectional study analyzed IMH prevalence in a Hispanic population over four years. Electronic records of patients were reviewed at a single referral center. All patients aged 18 years and above who presented for a first-time comprehensive ophthalmology evaluation were included. IMH diagnosis was clinically made and confirmed with optical coherence tomography (OCT). Data analysis involved descriptive and inferential statistics, adhering to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. RESULTS:Of 116,655 electronic records analyzed from March 2018 to July 2022, 397 subjects were identified in our analysis. The estimated prevalence of IMH was 0.34% (95% confidence interval (CI): 0.307-0.375), with a female-to-male ratio of 4:1. The mean age of the participants was 67.75 ± 9.38 years. Initial visual acuity, laterality, comorbidities, and clinical findings were assessed. No significant gender differences were documented. Subgroup analyses revealed significant age discrepancies based on comorbidities and clinical symptoms. CONCLUSIONS:Our study provides insight into the prevalence of IMHs in a Hispanic population. Its findings are similar to those published for other populations. The observed prevalence emphasizes the importance of proactive screening for IMHs in older patients, especially if they are women. Clinical markers such as the Watzke-Allen sign are helpful in the early detection of IMHs.

This study aimed to describe the effects of no-dose full-fluence photodynamic therapy without verteporfin (no-dose PDT) and to compare no-dose PDT with half-dose verteporfin full-fluence photodynamic therapy (HDFF PDT) for managing chronic central serous chorioretinopathy (cCSC).This retrospective study evaluated 11 patients with chronic recurrent CSC treated with no-dose PDT between January 2019 and March 2022. Most of these patients were also treated with HDFF PDT a minimum of 3 months before and were considered as the control group. We described the changes of best corrected visual acuity (BCVA), maximum subretinal fluid (mSRF), foveal subretinal fluid (fSRF), and choroidal thickness (CT) 8 ± 2 weeks after no-dose PDT, and we compared BVCA, mSRF, fSRF, and CT of no-dose PDT with those of the of same patients previously treated with HDFF PDT.Fifteen eyes of 11 patients (10 male, mean age 54 ± 12 years) received no-dose PDT; among these, 10 eyes of 8 patients (7 male, mean age 53 ± 12 years) also received HDFF PDT. Three eyes showed complete resolution of fSRF after no-dose PDT. No significant differences were disclosed between treatment with and without verteporfin comparing BCVA, mSRF, fSRF, and CT at baseline and 8 ± 2 weeks from the treatment (p > 0.05 in all analyses).BVCA and CT significantly improved after no-dose PDT. Short-term functional and anatomical treatment outcomes for cCSC were similar for HDFF PDT and no-dose PDT. We hypothesize that the potential benefits of no-dose PDT may arise from thermal elevation that triggers and enhances photochemical activities by endogenous fluorophores, activating a biochemical cascade response that rescues/replaces sick, dysfunctional retinal pigment epithelial (RPE) cells. Results of this study suggest the potential value of a prospective clinical trial to evaluate no-dose PDT for managing cCSC, especially when verteporfin is contraindicated or unavailable.

Objective: To present clinical findings and multimodal imaging of three patients who developed bacillary layer detachments (BALADs) shortly after half-fluence, half-dose (HFHD) verteporfin photodynamic therapy (PDT). Methods: Retrospective observational case series. Three patients were treated with HFHD-PDT for (1) macular neovascularisation five years after resolved central serous chorioretinopathy (CSC), (2) persistent serous retinal detachment (SRD) from chronic CSC, and (3) neovascular age-related macular degeneration with persistent SRD despite intravitreal anti-VEGF therapy. Results: Each patient developed a BALAD after HFHD-PDT. Acute fulminant exudation caused subretinal fluid expansion into the inner photoreceptor layer, cleaving myoid from ellipsoid zones in the central macula. Subretinal fluid and the BALADs subsequently resolved over 6-8 weeks. Conclusions: The subretinal fluid and BALAD following HFHD-PDT were transient and did not cause photoreceptor damage over a 6-month follow-up period. We speculate that the reduced-impact HFHD protocol decreases direct tissue damage but increases proinflammatory cytokines. The long-term pathophysiological consequences of the resolved BALADs are unknown.

Scanning laser ophthalmoscopes (SLOs) are used widely for reflectance, fluorescence or autofluorescence photography and less commonly for retroillumination imaging. SLOs scan a visible light or near-infrared radiation laser beam across the retina, collecting light from each retinal spot as it’s illuminated. An SLO’s clinical applications, image contrast and axial resolution are largely determined by an aperture overlying its photodetector. High contrast, reflectance images are produced using small diameter, centered apertures (confocal apertures) that collect retroreflections and reject side-scattered veiling light returned from the fundus. Retroillumination images are acquired with annular on-axis or laterally-displaced off-axis apertures that capture scattered light and reject the retroreflected light used for reflectance imaging. SLO axial resolution is roughly 300 μm, comparable to macular thickness, so SLOs cannot provide the depth-resolved chorioretinal information obtainable with optical coherence tomography’s (OCT’s) 3 μm axial resolution. Retroillumination highlights and shades the boundaries of chorioretinal tissues and abnormalities, facilitating detection of small drusen, subretinal drusenoid deposits and subthreshold laser lesions. It also facilitates screening for large-area chorioretinal irregularities not readily identified with other en face retinal imaging modalities. Shaded boundaries create the perception of lesion elevation or depression, a characteristic of retroillumination but not reflectance SLO images. These illusions are not reliable representations of three-dimensional chorioretinal anatomy and they differ from objective OCT en face topography. SLO retroillumination has been a useful but not indispensable retinal imaging modality for over 30 years. Continuing investigation is needed to determine its most appropriate clinical roles in multimodal retinal imaging.

circle PURPOSE: The blue light hazard is the experimental finding that blue light is highly toxic to the retina (photic retinopathy), in brief abnormally intense exposures, including sungazing or vitreoretinal endoillumination. This term has been misused commercially to suggest, falsely, that ambient environmental light exposure causes photo-toxicity to the retina, leading to age-related macular de-generation (AMD). We analyze clinical, epidemiologic, and biophysical data regarding blue-filtering optical chro-mophores. circle DESIGN: Perspective. circle METHODS: Analysis and integration of data regarding the blue light hazard and blue-blocking filters in ophthal-mology and related disciplines. circle RESULTS: Large epidemiologic studies show that blue-blocking intraocular lenses (IOLs) do not decrease AMD risk or progression. Blue-filtering lenses cannot reduce disability glare because image and glare illumination are decreased in the same proportion. Blue light essential for optimal rod and retinal ganglion photoreception is decreased by progressive age-related crystalline lens yellowing, pupillary miosis, and rod and retinal ganglion pho-toreceptor degeneration. Healthful daily environmental blue light exposure decreases in older adults, especially women. Blue light is important in dim environments where inadequate illumination increases risk of falls and associated morbidities. circle CONCLUSIONS: The blue light hazard is misused as a marketing stratagem to alarm people into using spectacles and IOLs that restrict blue light. Blue light loss is permanent for pseudophakes with blue-blocking IOLs. Blue light hazard misrepresentation flourishes despite absence of proof that environmental light exposure or cataract surgery causes AMD or that IOL chromophores provide clinical protection. Blue-filtering chromophores suppress blue light critical for good mental and physical health and for optimal scotopic and mesopic vision. (Am J Ophthalmol 2022;240: 51-57. (c) 2022 Elsevier Inc. All rights reserved.)

: Statins are used widely to treat hypercholesterolemia and atherosclerotic cardiovascular disease. They have inflammatory and immunomodulatory effects potentially useful for managing systemic autoimmune diseases such as rheumatoid arthritis, lupus erythematosus and multiple sclerosis. Statins also have anti-oxidative and large-vessel endothelial supportive properties that occur independent of their lipid-lowering effects. Additionally, statins can suppress macrophage and microglial activation responsible for initiating inflammatory cytokine release. More than forty percent of adults aged 65 years or older use statins in the United States and Australia, a prevalence that increases with age. The effects of statin usage on ophthalmic practice are probably underrecognized. Cardiovascular disease and age-related macular degeneration (AMD) share common risk factors, consistent with the “vascular model” of AMD pathogenesis that implicates impaired choroidal circulation in Bruch’s membrane lipoprotein accumulation. AMD has a complex multifactorial pathogenesis involving oxidative stress, choroidal vascular dysfunction, dysregulated complement-cascade-mediated inflammation and pro-inflammatory and pro-angiogenic growth factors. Many of these components are hypothetically amenable to the primary (cholesterol lowering) and secondary (anti-inflammatory, anti-oxidative, anti-vasculopathy) effects of statin use. Experimental studies have been promising, epidemiological trails have produced conflicting results and three prospective clinical trials have been inconclusive at demonstrating the value of statin therapy for delaying or preventing AMD. Cumulative evidence to date has failed to prove conclusively that statins are beneficial for preventing or treating AMD.

Purpose: To report the clinical and optical coherence tomography findings of a patient with chronic central serous chorioretinopathy who developed a short-term bacillary layer detachment after photodynamic therapy (PDT). Methods: A 56-year-old man presented with metamorphopsia and 20/100 visual acuity in his right eye. He was diagnosed with active, chronic central serous chorioretinopathy based on clinical findings and multimodal imaging. His visual problems and retinal findings persisted for 3 months before he was treated with half-fluence, half-dose verteporfin PDT. Results: The patient had a prominent decrease in his vision postoperatively. Two days after treatment, multimodal imaging showed a marked increase in exudation that merged preoperative neurosensory retinal detachments. A prominent subfoveal bacillary layer detachment was also present. The subretinal fluid and bacillary layer detachment resolved over the next 8 weeks, with a return of visual acuity to its baseline level and normalization of retinal structures except for a small zone of subfoveal ellipsoid zone and interdigitation zone disruption. Conclusion: Half-fluence, half-dose verteporfin PDT caused a fulminant increase in subretinal fluid and an associated subfoveal bacillary layer detachment. We hypothesize that chronic central serous chorioretinopathy-related chorioretinal dysfunction contributed to the severe PDT-induced local inflammatory reaction that caused the patient's bacillary layer detachment. Hyperacute choroidal exudation too fulminant for containment in subretinal space extended into and exceeded photoreceptor inner segment tensile strength, cleaving the myoid layer and/or dissecting it from the ellipsoid layer. This finding broadens the causality spectrum of bacillary layer detachments and vision losses that can follow PDT.

Dual-mode capsulotomy and selective laser trabeculoplasty (SLT) clinical laser systems provide nanosecond radiation pulses for capsulotomy or SLT. Previous case reports document severe macular injuries after inadvertent attempts to use an SLT laser beam to perform capsulotomy. 1 Liyanage S.E. Kumaran N. De Alwis D. Macular burns resulting from the accidental use of selective laser trabeculoplasty mode during a laser capsulotomy. Br J Ophthalmol. 2014; 98: 141-142 Crossref PubMed Scopus (5) Google Scholar ,2 Flood T.P. Flood C.T. Macular burn during an attempted YAG laser capsulotomy by inadvertent use of selective laser trabeculoplasty mode of a dual-mode laser. Retin Cases Brief Rep. 2020; 14: 224-227 Crossref PubMed Scopus (1) Google Scholar The first case was published a decade after the injury occurred. 1 Liyanage S.E. Kumaran N. De Alwis D. Macular burns resulting from the accidental use of selective laser trabeculoplasty mode during a laser capsulotomy. Br J Ophthalmol. 2014; 98: 141-142 Crossref PubMed Scopus (5) Google Scholar Legal constraints prevent publication of other cases. 3 Mainster M.A. Stuck B.E. Brown Jr., J. Assessment of alleged retinal laser injuries. Arch Ophthalmol. 2004; 122: 1210-1217 Crossref PubMed Scopus (71) Google Scholar We present (1) a multimodal imaging study of the macular photocoagulation and photomechanical damage 4 Mainster M.A. Ajlan R.S. Photic retinal injuries: mechanisms, hazards and prevention. in: Sadda S. Schachat A.P. Wilkinson C.P. Ryan's Retina, 7th ed. Elsevier, London2020 Google Scholar caused by erroneous use of the SLT beam of a capsulotomy-SLT laser system and (2) an analysis of countermeasures that could prevent these injuries. A human subject was included in this report who provided written informed consent. This study adhered to the tenets of the Declaration of Helsinki. This study did not require institutional review board approval.

PURPOSE:Bowtie-shaped polarization artifacts are often present in nonconfocal ultra-widefield scanning laser ophthalmoscope (SLO) images. We studied these artifacts and evaluated their potential value as clinical biomarkers in screening for center-involving diabetic macular edema (DME).METHODS:We performed a retrospective, observational, cohort study on 78 diabetic adult patients (143 eyes) who had spectral domain optical coherence tomography and nonmydriatic nonconfocal ultra-widefield SLO testing on the same day. Scanning laser ophthalmoscope green-only (532 nm), red-only (635 nm), and composite pseudocolor (532 plus 635 nm) images were examined for the presence of a foveal bowtie polarization artifact.RESULTS:Polarization artifacts were absent in all but one eye with center-involving DME (32 of 33 eyes). Polarization artifacts were also absent in many eyes without center-involving DME (49 of 110 eyes in pseudocolor images). As clinical biomarkers of center-involving DME, artifact absence has high specificity (99, 100, and 98% for green, red, and pseudocolor images, respectively) but poor sensitivity (49, 31, and 40% for green, red, and pseudocolor images, respectively).CONCLUSION:Foveal bowtie-shaped polarization artifacts occur routinely in nonconfocal ultra-widefield SLO images. Their presence indicates preserved foveal Henle fiber layer structure. Contemporary nonconfocal ultra-widefield SLO images lack the sensitivity for their bowtie artifacts to serve as reliable biomarkers in screening for center-involving DME.