Purpose:It is our purpose to address concerns regarding visual field loss as a barrier to optimal performance of encircling laser retinopexy as a prophylaxis for retinal detachment, especially when extended posteriorly, as in prophylaxis for retinal detachment in Stickler syndrome (SS). Methods:We retrospectively analyzed visual field and visual acuity changes after encircling laser prophylaxis extending to the posterior edge of the vortex vein ampullae (ora secunda cerclage/Stickler syndrome, OSC/SS) in our first four SS patients who underwent such prophylaxis. We then used disability tables and validated patient questionnaires to characterize the extent of visual disability and/or symptoms resulting from such encircling prophylaxis. Results:The reduction in peripheral visual field from OSC/SS posterior prophylaxis (to an average diameter of approximately 100 degrees in five treated eyes) was a far smaller percentage impairment (0-21% by various estimations) than the 85% impairment from loss of both visual acuity and visual field after RD in the primary eye of a typical SS patient prior to fellow eye prophylaxis. Turano and NEI VFQ-25 Questionnaires both indicated that everyday mobility and travel visual tasks were not significantly affected by the laser prophylaxis. Conclusion:Encircling laser retinopexy, extending posteriorly to and between the vortex vein ampullae, did not cause significant visual disability or any symptomatic visual field loss in an initial cohort of four patients with SS. Nor did we encounter any symptomatic visual field loss in 22 patients so treated subsequently. OSC/SS encircling laser prophylaxis safety and effectiveness is now being prospectively studied in a larger clinical trial (NCT07146516).

Rhegmatogenous retinal detachment (RD) is typically caused by retinal tears anterior to the equator, usually occurring in normal appearing retina. We here review the chronological history of encircling (360-degree) laser retinopexy to the peripheral retina as a stand-alone prophylaxis for retinal tears in asymptomatic eyes determined to be at high risk. We describe recent strong proof that such encircling prophylaxis prevents RD in Stickler syndrome, the highest risk predisposing condition known. Finally, we note that peripheral vitreous traction tears are the common pathogenesis of RD in both syndromic and non-syndromic eyes, so that such prevention may ultimately prove effectual in eyes determined to be at high risk in both.

PURPOSE:Using retrospective data, we demonstrate a technique of grid laser retinopexy together with vitrectomy and gas tamponade (pneumatic maculopexy) to permanently resolve branch retinal vein occlusion (BRVO)-related cystoid macular edema (CME). METHODS:After laser ablation to ischemic peripheral retina, and six months of unsuccessful medical therapy with intravitreal bevacizumab injections, we performed vitrectomy with grid laser treatment to superotemporal macular edema, and C3F8 15% gas tamponade (pneumatic maculopexy). RESULTS:Immediately after resolution of gas tamponade all CME had resolved, and visual acuity had improved from 20/40 to 20/30. Twenty-four months after vitrectomy and without further therapy, visual acuity had improved to 20/25 and the macula remained dry. CONCLUSION:When medical therapy is insufficiently effective, maculopexy by grid laser combined with intravitreal drying agents and/or gas tamponade can achieve long-term resolution of cystoid macular edema in selected cases. Parafoveal laser treatment must be precisely performed.

Significant literature evidence of retinal detachment prophylaxis safety and effectiveness for asymptomatic but high-risk eyes has appeared during the last five years. But it is still deemed "insufficient evidence to guide management" of asymptomatic fellow eyes in the American Academy of Ophthalmology's Preferred Practice Pattern for 2025. However, both focal and encircling prophylaxis for asymptomatic fellow eyes with lattice degeneration, and encircling laser prophylaxis for asymptomatic fellow eyes with attached posterior vitreous, now justify treatment consideration versus continued observation, based on the evidence we do have, even though it is not "level one".

Purpose: This retrospective case report describes the diagnosis, treatment, and clinical outcome of subacute Terson syndrome in a patient with monocular vision following craniofacial ballistic injury. Methods: A single case and its findings were analyzed. Results: A 26-year-old man presented to the retina clinic 5 weeks after a gunshot injury to the right craniofacial region. At presentation, the patient, who was rendered monocular from the gunshot injury, reported experiencing vision loss in the uninjured left eye during the postacute period. Dilated examination of the left eye revealed hand motion visual acuity with dense vitreous hemorrhage. A 25-gauge pars plana vitrectomy of the left eye was performed, during which multiple sub-internal limiting membrane hemorrhages characteristic of Terson syndrome were discovered and evacuated. Visual acuity was restored to 20/25 by postoperative week 2. Conclusions: The excellent visual outcome achieved by vitrectomy within 1 week of presentation demonstrates the importance of (1) retaining Terson syndrome in the differential diagnosis for patients with vision loss after nonaneurysmal central nervous system injury, and (2) expediting surgical intervention, particularly in patients with monocular vision.

Rhegmatogenous retinal detachment (retinal detachment, RD) is the most common cause of spontaneous vision loss in aging eyes that were seeing normally until the moment of its occurrence. Causative retinal breaks usually occur in the form of peripheral tears at the vitreous base, resulting from traction exerted by the aging vitreous as it detaches posteriorly. Peripheral encircling laser retinopexy increases retinal resistance to vitreous traction in high-risk eyes. To achieve maximal lifetime prophylaxis, we show that in selected high-risk cases the vitreous can thereafter be removed by advanced vitrectomy techniques, reducing vitreous traction itself.

Introduction Intraocular foreign bodies (IOFBs) are known to cause endophthalmitis at a high rate. Media opacity (corneal edema, cataract, vitreous hemorrhage) and the need for diagnostic testing often prevent timely recognition of an infection; the resulting treatment delay worsens the prognosis. We present a case in which direct visualization of a posterior-segment IOFB and the incipient endophthalmitis allowed foregoing further testing (computed tomography), shortening the time to sight-saving vitrectomy.Case Description A 16-year-old male presented 19 h after a hammering-related injury. The media remained clear, permitting recognition of a large area of purulent retinal infiltrate adjacent to the intravitreal IOFB. Within one hour the patient underwent comprehensive surgery (wound closure, vitrectomy, IOFB removal, and intravitreal antibiotic injection). The development of full-blown endophthalmitis was prevented, even though the vitreous culture yielded Staphylococcus epidermidis. Final visual acuity at one year was 20/30, with the retinal injury approaching to within 1 mm of the fovea.Conclusions In opaque-media eyes with a suspected IOFB treatment delay is common, due to waiting for computed tomography (CT) - instead of ultrasonography, which can safely identify the IOFB in over 90% of cases. Expediting surgery is the best prophylaxis against post-presentation endophthalmitis. Our case highlights the benefits of early vitrectomy based on direct inspection of the IOFB alone; instant ultrasonography instead of a CT-caused delay may save eyes with infection developing behind media opacity.

Symptomatic vitreous opacities (SVO, "floaters") in the mobile, aging vitreous that substantially interfere with daily visual activities (DVA) constitute degenerative vitreous syndrome (DVS). DVS is best distinguished from common "nuisance" floaters by use of "floater stories" written by presenting patients describing their symptoms. Here I discuss why vitreous opacity vitrectomy, though curative, has been adopted only belatedly and is still controversial, and I describe my long-term experience with its use for this disease.

Wallsh et al1 reported that 116 of 353 fellow eyes with an OCT-demonstrated vitreous attachment at presentation, developed a posterior vitreous detachment (PVD) during a 5.2-year follow-up period. Of these 116 fellow eyes, 41.5% sustained a "rhegmatogenous event" (23.7% retinal detachment, 17.8% retinal tear) resulting from PVD-induced vitreous traction.1

Encircling (360 degree) retinal detachment prophylaxis using indirect ophthalmoscope laser delivery recently achieved strong proof of safety and effectiveness by preventing the development of peripheral retinal tears and detachments in the eyes of patients with Stickler syndrome (syndromic eyes). Untreated, Stickler syndrome patients have a 65% lifetime risk of retinal detachment (half by age 20, 80% bilateral). This report describes an optimal technique of encircling laser retinopexy to also prevent the more common retinal detachments seen in aging (non-syndromic) eyes that share with Stickler syndrome the common pathogenesis of peripheral retinal tears caused by vitreous traction.

Purpose: To present a rarely reported systemic infection with streptococcus equi subspecies zooepidemicus (streptococcus equi), transmitted from a horse, and to describe successful treatment when complicated by endogenous endophthalmitis. Observations: We diagnosed suspected streptococcus equi septicemia presenting as loss of vision in the right eye of an otherwise healthy polo player/horse trainer. He received immediate intravenous antibiotics and three vitrectomies with two intravitreal antibiotic injections during the first week, to cure infection and subsequent retinal detachment. Blood and initial vitreous cultures rapidly grew streptococcus equi. The septicemia was quickly controlled by systemic antibiotics without developing commonly seen and often fatal meningitis. The right eye recovered 20/30 visual acuity three months post infection. Conclusions: Presentation of this rare septicemia as endogenous endophthalmitis illustrates the potentially lifesaving role of early diagnosis by the ophthalmologist. Immediate and recurrent vitrectomy in conjunction with intravitreal and systemic antibiotic therapy resulted in recovery of near normal vision, whereas less timely and interventional treatments have failed heretofore.

Purpose Primary opacities that develop in the aging vitreous, commonly termed “floaters,” were once considered merely a nuisance, not justifying any risk of surgical removal. However, vitreoretinal specialists are increasingly recognizing that extensive symptomatic vitreous opacities (SVO) that substantially interfere with activities that critically depend on vision (daily visual activities, DVA), constituting degenerative vitreous syndrome (DVS, see http://floaterstories.com), warrant removal albeit with minimal risk - but no description of how to reduce vitrectomy risks to least possible has been forthcoming. We here describe such a method. Patients and Methods The safest possible removal of extensive SVO as described herein was attained by an operation specifically designed for DVS treatment (vitreous opacity vitrectomy, VOV), rather than as only a means of achieving subsequent retinal surgery in the same procedure, as is usually the case. We retrospectively reviewed the outcomes of 100 consecutive VOV operations (in 81 patients, average age 66) performed with ultra-high speed, 27-gauge vitrectomy probes. Results All eyes rapidly achieved continuously clear vision, and no eye developed a clinically significant complication during a year of follow-up. Three small, existent retinal breaks were discovered prior to peripheral vitrectomy and one apparently iatrogenic retinal tear was found at VOV completion, when each was treated. In the eyes that were not pseudophakic, postoperative nuclear sclerosis progression was successfully managed by subsequent cataract extraction. Conclusion The goals of VOV for DVS are to safely restore continuously clear vision by performing tractionless vitreous removal with respect to the retina and to reduce the lifetime risk of retinal detachment, both by such vitreous removal and by microscopic examination of the peripheral retina under anesthesia (MEPRUA), guiding appropriate prophylactic retinopexy. The otherwise healthy DVS eyes so treated warrant this specific form of vitrectomy, continually focused on achieving least possible risk, to maintain an acceptable risk/benefit ratio.

Stickler syndrome, a rare inherited disease, carries a lifetime risk of rhegmatogenous retinal detachment (RRD) of up to 65%, higher than any other predisposing condition known. Both syndromic and non-syndromic eyes suffer RRD predominately from the same pathogenesis, vitreous tractional tears in the peripheral retina. Consequently, extraordinary publications in 2021-2022, each reporting successful prevention of RRD in Stickler syndrome, using 360-degree (encircling) laser retinopexy, provide the first strong evidence upon which similar prophylaxis in non-syndromic eyes at high risk of RRD from peripheral retinal tears can confidently go forward.

PURPOSE:To introduce a novel technique of encircling laser prophylaxis (ora secunda cerclage Stickler syndrome, OSC/SS) to prevent rhegmatogenous retinal detachment (RRD) in Stickler syndrome eyes.PATIENTS AND METHODS:After first eye RRD at age 50 and at age 18, respectively, a 53-year-old father and his 22-year-old son with type 2 SS (STL2) gave informed consent and underwent OSC/SS prophylaxis, performed in each fellow eye. A 26-year-old STL2 daughter then suffered first eye retinal detachment and similarly chose fellow eye OSC/SS prophylaxis. A second son, 28 years of age with STL2, chose OSC/SS prophylaxis in both eyes.RESULTS:The three OSC/SS treated fellow eyes have gone 12 years, 11 years, and 8 years without RRD. STL1 and less common STL2 eyes are known to have a similar rate of RRD, and 80% of STL1 fellow eyes develop RRD at a median of 4 years in the absence of prophylaxis. Moreover, five of six (83%) known STL2 family members suffered RRD, only the STL2 son with bilateral OSC/SS remaining bilaterally attached. All five OSC/SS treated eyes (average 8.7 years post-prophylaxis) retained preoperative visual acuity of 20/20 to 20/30, with an average, asymptomatic reduction of meridional field in each eye to 50 degrees. In contrast, in the three eyes having suffered RRD prior to presentation, visual acuity ranged from 20/125 to 8/200 and average meridional field was 29 degrees.CONCLUSION:Encircling grid laser (OSC) modified in Stickler eyes to encompass the ora serrata and extend posteriorly to and between the vortex vein ampullae (OSC/SS) is a reasonable RRD prophylaxis option to offer STL1 and STL2 patients as an alternative to no treatment or less effective prophylaxis. Because of rarity and severity, the ultimate proof of safety and efficacy will likely come not from randomized trials, but from a non-randomized, prospective, cohort comparison study of such individual efforts.

We recently co-authored a report on the ten-year (2007-2017) results achieved at our center (Retina Specialists of Alabama) in the treatment of Acute Post-Cataract Endophthalmitis (APCE). Of all eyes, 77.4% were initially treated with Complete and Early Vitrectomy for Endophthalmitis (CEVE). Visual acuity of ≥ 20/40 was restored in 79% of all eyes versus 53% of eyes reported in the Endophthalmitis Vitrectomy Study. We believe that CEVE is the initial treatment of choice whenever the fundus is obscured by endophthalmitis vitreous opacity.

PURPOSE:To present a case of retinal and uveal necrosis caused by expanding gas tamponade after pars plana vitrectomy.METHODS:Single case report.RESULTS:An otherwise healthy 66-year-old woman underwent pars plana vitrectomy with intended 20% sulfur hexafluoride (SF6) tamponade for macular hole repair of her pseudophakic left eye. She developed intractable nausea, emesis and increasing left eye pain in association with gas expanded to totally fill the left eye, just hours after surgery. Extremely elevated intraocular pressure was lowered with a successful paracentesis but recurred within a few hours. She then underwent vitrectomy evacuation of all vitreous cavity gas, reformation of the anterior chamber, and silicone oil placement, normalizing intraocular pressure. Three weeks later, the left eye had no light perception, and devitalization of the retina, choroid, and iris was evident.CONCLUSION:We present a case of blindness and intraocular tissue dissolution/disorganization after vitrectomy with intended 20% SF6. To our knowledge, this is the most detailed report of the under-recognized complication of expanding gas tamponade. Institutions hosting vitrectomy surgery should consider enacting a formal "Time Out" that requires all team members to witness accurate fractionation of potentially expansile gas. In the event of acute postoperative glaucoma in such eyes, a single small volume paracentesis cannot be relied upon to protect against continued gas expansion.