PURPOSE:To demonstrate a novel surgical technique (intraocular lens imbrication) for persistent postoperative pupillary capture after sutureless scleral intraocular lens fixation.METHODS:Case report and supplemental digital content demonstrating salient steps of a novel surgical technique.RESULTS:The patient did not suffer any further episodes of pupillary capture after intraocular lens imbrication with aforementioned surgical technique five months after the procedure. Postoperative best-corrected visual acuities were 20/40 in both eyes.CONCLUSION:Intraocular lens imbrication is an effective method to address persistent postoperative pupillary capture after sutureless scleral intraocular lens fixation.

Purpose: Routine use of face masks for patients and physicians during intravitreal anti-vascular endothelial growth factor (VEGF) injections has increased with the emergence of the coronavirus disease 2019 pandemic. This study evaluates the impact of universal face mask use on rates and outcomes of post-injection endophthalmitis (PIE). Design: Retrospective, multicenter, comparative cohort study. Participants: Eyes receiving intravitreal anti-VEGF injections from October 1, 2019, to July 31, 2020, at 12 centers. Methods: Cases were divided into a "no face mask" group if no face masks were worn by the physician or patient during intravitreal injections or a "universal face mask" group if face masks were worn by the physician, ancillary staff, and patient during intravitreal injections. Main Outcome Measures: Rate of endophthalmitis, microbial spectrum, and visual acuity (VA). Results: Of 505 968 intravitreal injections administered in 110 547 eyes, 85 of 294 514 (0.0289%; 1 in 3464 injections) cases of presumed endophthalmitis occurred in the "no face mask" group, and 45 of 211 454 (0.0213%; 1 in 4699) cases occurred in the "universal face mask" group (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.51-1.18; P = 0.097). In the "no face mask" group, there were 27 cases (0.0092%; 1 in 10 908 injections) of culture-positive endophthalmitis compared with 9 cases (0.004%; 1 in 23 494) in the "universal face mask" group (OR, 0.46; 95% CI, 0.22-0.99; P = 0.041). Three cases of oral flora-associated endophthalmitis occurred in the "no face mask" group (0.001%; 1 in 98 171 injections) compared with 1 (0.0005%; 1 in 211 454) in the "universal face mask" group (P = 0.645). Patients presented a mean (range) 4.9 (1-30) days after the causative injection, and mean logarithm of the minimum angle of resolution (logMAR) VA at endophthalmitis presentation was 2.04 (similar to 20/2200) for "no face mask" group compared with 1.65 (similar to 20/900) for the "universal face mask" group (P = 0.022), although no difference was observed 3 months after treatment (P = 0.764). Conclusions: In a large, multicenter, retrospective study, physician and patient face mask use during intravitreal anti-VEGF injections did not alter the risk of presumed acute-onset bacterial endophthalmitis, but there was a reduced rate of culture-positive endophthalmitis. Three months after presentation, there was no difference in VA between the groups. (C) 2021 by the American Academy of Ophthalmology

OBJECTIVE: Routine use of face masks for patients and physicians during intravitreal anti-vascular endothelial growth factor (VEGF) injections has increased with the emergence of the COVID-19 pandemic. This study evaluates the impact of physician, ancillary staff, and patient face use on rates and outcomes of post-injection endophthalmitis. DESIGN: Retrospective, multicenter, comparative cohort study PARTICIPANTS: Eyes receiving intravitreal anti-VEGF injections from 10/1/2019 to 7/31/2020 at twelve centers from the United States of America. INTERVENTION: Cases were divided into a face mask group if no face masks were worn by the physician or patient during intravitreal injections or a universal face mask group if face masks were worn by the physician, ancillary staff, and patient during intravitreal injections. MAIN OUTCOME MEASURES: Rate of endophthalmitis, microbial spectrum, and visual acuity. RESULTS: Of 505,968 intravitreal injections from 110,547 eyes administered, 85 of 294,514 (0.0289%; 1 in 3,464 injections) cases of presumed endophthalmitis occurred in the face mask group, and 45 of 211,454 (0.0213%; 1 in 4,699) cases occurred in the universal face mask group (odds ratio [OR], 0.74; 95%CI, 0.51-1.18; p=0.097). In the face mask group, there were 27 cases (0.0092%; 1 in 10,908 injections) of culture-positive endophthalmitis compared to 9 cases (0.004%; 1 in 23,494) in the universal face mask group (OR, 0.46; 95%CI, 0.22-0.99; p=0.041). Three cases of oral flora-associated endophthalmitis occurred in the face mask group (0.001%; 1 in 98,171 injections) compared to one (0.0005%; 1 in 211,454) in the universal face mask group (p=0.645). Patients presented a mean (range) 4.9 (1-30) days after the causative injection, and mean logMAR visual acuity at endophthalmitis presentation was 2.04 [∼20/2200] for face mask group compared to 1.65 [∼20/900] for the universal face mask group (p=0.022), although no difference was observed three months after treatment (p=0.764). CONCLUSION: In a large, multicenter, retrospective study, physician and patient face use during intravitreal anti-VEGF injections did not alter the risk of presumed acute-onset bacterial endophthalmitis, but there was a reduced rate of culture-positive endophthalmitis. Three months following presentation, there was no difference in visual acuity between the groups.

This case report describes a woman with Leri-Weill dyschondrosteosis who was found to have Coats-like retinopathy in her left eye.

PURPOSE:To evaluate the refractive outcomes of sutureless intrascleral fixation of intraocular lens with pars plana vitrectomy. METHOD:A retrospective, consecutive cohort from multiple surgeons of a single center. Primary outcomes included spherical equivalent (SEQ) and change in SEQ (ΔSEQ) from preoperative intraocular lens power calculations. Secondary outcomes included refractive outcomes of fixation at 1.5 mm, 2 mm, and 2.5 mm posterior to the limbus. RESULTS:In total, 84 eyes of 80 patients were included. Preoperative logarithm of the minimum angle of resolution visual acuity was 1.21 ± 0.68 (20/320). The mean follow-up time was 2.33 ± 1.36 years. At 3 months, SEQ was -0.50 ± 1.59 D and ΔSEQ was 0.58 ± 1.49 D. At 1 year, SEQ was -0.55 ± 1.32 D and ΔSEQ was 0.39 ± 1.42 D. At the last follow-up, logarithm of the minimum angle of resolution visual acuity was 0.34 ± 0.34 (20/40), SEQ was -0.51 ± 1.44 D, and ΔSEQ was 0.57 ± 1.27 D. There was no difference between SEQ or ΔSEQ throughout follow-up (P = 0.97 and P = 0.96, respectively). At fixation distances more posterior to the limbus, mean ΔSEQ was more hyperopic at 3 months, 1-year, and the last follow-up (P = 0.02, P = 0.01, and P = 0.006, respectively). CONCLUSION:Refractive outcomes for sutureless intrascleral fixation of intraocular lens with pars plana vitrectomy were favorable and showed stability postoperatively. These results may aid surgeons achieve better desired refractive outcomes for this technique.

Purpose: The relationship between poor hemoglobin A1c (HbA1c) control and risk of proliferative diabetic retinopathy (PDR) is well known. Nevertheless, some patients have discordant disease (controlled HbA1c and severe PDR or vice versa). One potential explanation for this discrepancy is the presence of underlying genetic mutations in the Wingless-related integration site (Wnt) signaling pathway. However, minimal clinical data exist on the presence of Wnt signaling mutations in patients with diabetes mellitus (DM) and the correlation with diabetic retinopathy. Methods: Retrospective, nonconsecutive case review of patients with type 1 or 2 DM who underwent genetic testing for at least 1 recognized Wnt signaling pathway mutation from 2011 to 2016. The clinical course and retinal images were reviewed for patients with identifiable mutations. Results: Thirty-six patients, ages 13 to 79 years, consented for genetic analysis. Three patients (8.3%) exhibited at least 1 recognized genetic mutation in the Wnt signaling pathway. Case 1 was a 65-year-old female with type 1 diabetes for > 20 years, HbA1c <7.0%, and no findings of diabetic retinopathy (Tetraspanin 12). Case 2 was a 13-year-old male with type 1 diabetes for 8 years, moderate HbA1c control (7.6-8.3%), and absence of diabetic retinopathy (Norrin). Case 3 was a 48-year-old male with severe PDR requiring multiple laser and antivascular endothelial growth factor (anti-VEGF) treatments despite well-controlled HbA1c (6.0%) (Frizzled-4). Conclusion: Wnt signaling pathway mutations exist in patients with DM. Further studies investigating the prevalence and clinical significance of these mutations in a larger diabetic population are warranted. Identification of these patients with genetic testing may enable earlier medical intervention.

Purpose: To determine whether haptic flanging during 27-gauge sutureless intrascleral fixation of intraocular lenses (IOLs) increases IOL stability and to report the short-term clinical outcomes of sutureless intrascleral surgery using 27-gauge trocar cannulas with haptic flanging. Methods: Retrospective surgical case series using live and cadaveric human eyes. Results: In the cadaveric experiment using five eyes, flanged haptics required more force to dislocate the IOL compared with unflanged haptics (14 ± 4 vs. 3 ± 1 g, P = 0.03). The clinical series included 52 eyes from 52 patients. The average age at the time of surgery was 73 ± 14 years, with a mean follow-up of 27 ± 19 weeks. The most common indication for surgery was IOL dislocation/subluxation (n = 43, 83%). Mean visual acuity improved from 20/140 preoperatively to 20/50 at postoperative Month 1 (P < 0.001). The most common postoperative issue was intraocular pressure elevation (n = 12, 23%). Two patients (4%) needed a reoperation for IOL dislocation. Conclusion: Haptic flanging during 27-gauge sutureless intrascleral surgery creates a more stable scleral-fixated IOL compared with the traditional unflanged technique based on a cadaveric human eye study. In addition, this variation of sutureless intrascleral surgery seems safe and effective for patients who require secondary IOLs.

To determine the incidence of endophthalmitis after anti-vascular endothelial growth factor (VEGF) therapy at our institution and to identify potential risk factors for endophthalmitis occurring after injection.Retrospective, single-center cohort study.All patients who received an intravitreal injection of an anti-VEGF medication between January 1, 2014, and March 31, 2017.Current Procedural Terminology and International Classification of Diseases billing codes were used to identify instances of anti-VEGF administration and cases of endophthalmitis. Medical records and injection technique were reviewed carefully in each case. Multivariable logistic regression analysis was performed in a stepwise fashion to determine independent predictors of endophthalmitis based on injection protocol.Incidence of endophthalmitis after injection and odds of endophthalmitis by injection technique with 95% confidence intervals (CIs).A total of 154 198 anti-VEGF injections were performed during the period of interest, resulting in 58 cases of endophthalmitis (0.038% [1:2659]). After adjustment for confounders, both 2% lidocaine jelly (odds ratio [OR], 11.28; 95% CI, 3.39-37.46; P < 0.001) and 0.5% Tetravisc (Ocusoft, Richmond, TX; OR, 3.95; 95% CI, 1.15-13.50; P = 0.03) use were independent risk factors for endophthalmitis after injection. Lid speculum use, povidone iodine strength (5% vs. 10%), injection location (superior or inferior), conjunctival displacement, use of provider gloves, use of a strict no-talking policy, use of subconjunctival lidocaine, and topical antibiotic use were not statistically significant predictors of endophthalmitis after injection. There was no difference in endophthalmitis rate among the anti-VEGF agents (bevacizumab, ranibizumab 0.3 mg, ranibizumab 0.5 mg, and aflibercept).The incidence of endophthalmitis after anti-VEGF injections is low. Use of lidocaine jelly or Tetravisc may increase the risk of endophthalmitis after injection.

Purpose: Epiretinal proliferation is a distinct clinical entity from epiretinal membrane that classically is associated with lamellar macular holes, but its prevalence and association with full-thickness macular holes (FTMH) have not been well described. We characterized macular hole-associated epiretinal proliferation (MHEP) and its effects on long-term surgical outcomes. Design: Multicenter, interventional, retrospective case-control study. Participants: Consecutive eyes that underwent surgery for FTMH with a minimum of 12 months follow-up. Methods: All eyes underwent pars plana vitrectomy, removal of any epiretinal membranes, and gas tamponade, with or without internal limiting membrane (ILM) peeling. Spectral-domain OCT imaging was obtained before and after surgery. Main outcome measures: Improvement in visual acuity and single-surgery hole closure rates in eyes with, versus without, MHEP at 12 months. Results: Seven hundred twenty-five charts were analyzed, and 113 patients met inclusion criteria. Of 113 eyes with FTMH, 30 (26.5%) showed MHEP. Patients with FTMH and MHEP were older (P < 0.002) and more often men (P = 0.001), and showed more advanced macular hole stages than those without MHEP (P = 0.010). A full posterior vitreous detachment was more common in eyes with MHEP (P < 0.004). Twelve months after surgery, FTMH with MHEP patients showed significantly less improvement in visual acuity (P = 0.019) with higher rates of ellipsoid and external limiting membrane defects (P < 0.05) and with a higher rate of failure to close with 1 surgery compared to FTMH without MHEP (26.7% vs. 4.8%; P = 0.002]). Peeling the ILM was associated with improved rates of hole closure in FTMH with MHEP (P < 0.001). Multivariate testing confirmed that the presence of MHEP was an independent risk factor for less visual improvement (P = 0.031) and for single-surgery non-closure (P = 0.009) and that ILM peeling improved single-surgery closure rates (P = 0.026). Conclusions: We found that FTMH with MHEP showed poorer anatomic and visual outcomes after vitrectomy compared with FTMH without MHEP. Internal limiting membrane peeling was associated with improved closure rates and should be considered when MHEP is detected before surgery. (C) 2019 Published by Elsevier Inc.

BACKGROUND AND OBJECTIVE:To quantify vessel tortuosity among infants with retinopathy of prematurity (ROP).PATIENTS AND METHODS:This was a retrospective study including 61 RetCam images from 33 infants. The laser treatment (LT) group included 17 infants who underwent laser for ROP. The no-treatment (NT) group included 16 infants. The modified ROPtool was used to calculate mean vessel tortuosity (MVT) and highest vessel tortuosity (HVT) for the participants and for the standard plus disease photograph from the Early Treatment for Retinopathy of Prematurity (ETROP) study.RESULTS:The median MVT was 1.226 versus 1.056 for the LT and NT groups, respectively (P < .001). The median HVT was 1.346 versus 1.088 (P < .001). An MVT of 1.124 was 96.7% sensitive and 100% specific for identifying infants with treatment-requiring ROP. Both MVT and HVT cutoff values correctly captured plus disease in the standard ETROP trial photograph.CONCLUSION:The modified ROPtool can be used to identify infants who have treatment-requiring ROP with a high level of sensitivity and specificity. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:215-220.].

Purpose: To determine the incidence of endophthalmitis after anti-vascular endothelial growth factor (VEGF) therapy at our institution and to identify potential risk factors for endophthalmitis occurring after injection. Design: Retrospective, single-center cohort study. Participants: All patients who received an intravitreal injection of an anti-VEGF medication between January 1, 2014, and March 31, 2017. Methods: Current Procedural Terminology and International Classification of Diseases billing codes were used to identify instances of anti-VEGF administration and cases of endophthalmitis. Medical records and injection technique were reviewed carefully in each case. Multivariable logistic regression analysis was performed in a stepwise fashion to determine independent predictors of endophthalmitis based on injection protocol. Main Outcome Measures: Incidence of endophthalmitis after injection and odds of endophthalmitis by injection technique with 95% confidence intervals (CIs). Results: A total of 154198 anti-VEGF injections were performed during the period of interest, resulting in 58 cases of endophthalmitis (0.038% [1:2659]). After adjustment for confounders, both 2% lidocaine jelly (odds ratio [OR], 11.28; 95% CI, 3.39-37.46; P < 0.001) and 0.5% Tetravisc (Ocusoft, Richmond, TX; OR, 3.95; 95% CI, 1.15-13.50; P = 0.03) use were independent risk factors for endophthalmitis after injection. Lid speculum use, povidone iodine strength (5% vs. 10%), injection location (superior or inferior), conjunctival displacement, use of provider gloves, use of a strict no-talking policy, use of subconjunctival lidocaine, and topical antibiotic use were not statistically significant predictors of endophthalmitis after injection. There was no difference in endophthalmitis rate among the anti-VEGF agents (bevacizumab, ranibizumab 0.3 mg, ranibizumab 0.5 mg, and aflibercept). Conclusions: The incidence of endophthalmitis after anti-VEGF injections is low. Use of lidocaine jelly or Tetravisc may increase the risk of endophthalmitis after injection. (C) 2018 by the American Academy of Ophthalmology

BACKGROUND AND OBJECTIVE:To describe a novel technique of scleral indentation and transillumination for single-surgeon, unassisted vitrectomy and vitreous base shaving enhanced with a digital heads-up display system (NGENUITY 3D Visualization System; Alcon, Fort Worth, TX).PATIENTS AND METHODS:This technique was utilized in six eyes of six patients during vitrectomy surgery for common vitreoretinal surgical diagnoses. In each case, the transillumination was performed with the traditional intraocular light pipe set at 100% power, placed obliquely just posterior to the vitreous base insertion, with or without a transillumination adapter. The visualization of the vitreous cavity was digitally enhanced using a heads-up display system (NGENUITY 3D) with light amplification settings increased to near-maximal gain. In each case, the adequacy of the surgical view was judged intraoperatively by two independent surgeons who shared the same surgical view as the primary surgeon.RESULTS:In this series, the surgical view provided by the scleral transillumination was deemed adequate to safely perform surgery in five of six cases. In the one patient in whom this was not the case, vitrectomy was completed using traditional endo-illumination and scleral depression performed by a skilled assistant. Lighter fundus pigmentation, myopia, thin sclera, and absence of dense peripheral media opacities were associated with improved view with scleral transillumination. There were no intraoperative complications.CONCLUSION:Digitally enhanced scleral transillumination affords surgeons another option for safe and effective simultaneous scleral depression and illumination for unassisted peripheral vitrectomy. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:436-439.].

Purpose: The purpose of this article is to report the characteristics of patients with retinoschisis-related retinal detachments and to summarize their clinical outcomes after surgical repair. Methods: A single-center interventional case series of 37 eyes from 35 patients who underwent surgery to repair a retinoschisis-related retinal detachment between January 1, 2009 and January 1, 2017 was conducted. Results: The mean ± SD age at the time of the first retinal detachment repair was 63 ± 13 years. As the initial surgery, scleral buckle was performed in 14 eyes, scleral buckle + vitrectomy in 14 eyes, and vitrectomy in 9 eyes. The single-operation success rate for the entire cohort was 65% (24/37), and the final anatomic success rate was 97% (36/37). Among eyes requiring more than 1 surgery, 46% (6/13) developed proliferative vitreoretinopathy. Best-corrected visual acuity improved or remained stable after 1 year of follow-up in the majority (n = 27, 73%) of eyes. The mean (SD) number of surgeries required to achieve the final anatomic and visual result was 1.8 (1.2) for all eyes (range, 1-5 surgeries). Conclusion: The single-surgery success rate for retinoschisis-related retinal detachments was lower than that reported for typical rhegmatogenous retinal detachments, and the incidence of proliferative vitreoretinopathy was higher. When counseling patients with retinoschisis-related retinal detachments, it is important to caution them that they may require more than 1 surgery to achieve anatomic success.

Importance:Neovascular age-related macular degeneration (nvAMD) is a leading cause of vision loss. The optimal screening protocol to detect choroidal neovascularization (CNV) in fellow eyes of patients undergoing treatment for unilateral CNV has not been determined. Objective:To compare the visual outcomes of eyes with established, active nvAMD in index eyes with outcomes of fellow eyes that subsequently developed CNV during the management protocol. Design, Setting, and Participants:In this retrospective single-center case series conducted at a private vitreoretinal practice, data were collected for all patients treated for bilateral nvAMD between October 1, 2015, and October 1, 2016, for whom we could determine the date of index eye and fellow eye conversion to nvAMD (n = 1600). Per institutional protocol, patients were screened for new CNV in the fellow eye at every office visit. Patients were excluded if they had a condition that could result in marked asymmetric vision loss. Exposures:Development of nvAMD. Main Outcomes and Measures:Visual acuity (VA) at the time of diagnosis of nvAMD and at equivalent time points following conversion to nvAMD for both index eyes and fellow eyes. Results:A total of 264 patients met the inclusion criteria; 197 (74.6%) were women and 253 (95.8%) were white, and the mean (SD) age was 79.1 (8.2) years at time of index eye conversion to nvAMD and 80.6 (8.2) years at time of fellow eye conversion to nvAMD. Fellow eyes presented with better VA (mean VA, 20/50 [0.40 logMAR]) compared with index eyes (mean VA, 20/90 [0.67 logMAR]) at the time of conversion (difference, 14 letters [0.27 logMAR]; 95% CI, 10-17 [0.20-0.34]; P < .001). Index eyes did not achieve the same level of VA as fellow eyes after an equivalent postconversion follow-up of approximately 20 months (mean VA: index eye; 20/70 [0.56 logMAR]; fellow eye, 20/50 [0.40 logMAR]; difference, 8 letters [0.15 logMAR]; 95% CI, 4-11 [0.08-0.22]; P < .001). No difference was detected between the mean number of anti-vascular endothelial growth factor injections received by fellow eyes and index eyes (9.7 vs 10.0 injections, respectively). Conclusions and Relevance:This retrospective study suggests that fellow eyes of previously treated patients with nvAMD may achieve better VA than their index eye counterparts after an equivalent amount of follow-up. This may be because the CNV was detected and treated earlier and at a better level of VA, although it is unknown whether the frequent office visits, VA measurements, or optical coherence tomography testing was responsible for the detection at a better level of VA.

Purpose: To describe a technique to reduce intraocular lens (IOL) tilt after sutureless intrascleral (SIS) fixation. Methods: Case report with review of surgical technique. Results: We report a technique that can be used to correct IOL tilt that may rarely accompany SIS IOL fixation. The procedure involves placing pupil-spanning polypropylene sutures on either side of the IOL optic to keep the optic parallel to the plane of the iris. Conclusion: Sutureless intrascleral IOL tilt correction can be achieved using polypropylene suture, thus obviating the need for more invasive surgical maneuvers, such as IOL exchange.

Objective: To evaluate the use of a novel retinal projection display in vitreoretinal surgery. Methods: The Avegant Glyph virtual retinal display, which uses a light-emitting diode and micromirror array to project directly onto the retinas of the user, was evaluated. This unit was modified for better operating room characteristics. It was evaluated by 6 surgeons performing mock vitreoretinal surgeries. Results: The majority reported high 3-dimensional (3-D) depth rendition, little hindrance to communication, and high confidence to perform procedures. Due to a small ocular size, surgeons conveyed that the Glyph provides a novel enhanced view for performing procedures benefiting from simultaneous intra- and extraocular visualization such as scleral depression. Safety analysis by performing fundus autofluorescence after 2 hours of Glyph operation did not reveal any gross qualitative change. Conclusion: Use of the Avegant Glyph to perform vitreoretinal surgery may provide ergonomic advantages, while its visualization and high 3-D stereoscopic depth rendition instill high surgeon confidence to safely perform procedures. We are performing further studies with objective data to validate the potential of this technology.