Publications by authors named "George A Williams"

95 Publications

Long-Term Visual Outcomes and the Timing of Surgical Repair of Fovea-Splitting Rhegmatogenous Retinal Detachments.

Retina 2021 Aug 27. Epub 2021 Aug 27.

Associated Retinal Consultants, P.C., Royal Oak, Michigan; William Beaumont Hospital, Royal Oak, Michigan Oakland University William Beaumont School of Medicine, Rochester, Michigan Michigan State University College of Osteopathic Medicine, East Lansing, Michigan.

Purpose: To evaluate the visual outcomes and the impact of timing of surgical repair of fovea-splitting rhegmatogenous retinal detachments (RRD).

Method: A retrospective, consecutive cohort from multiple surgeons at a single center. Fovea status (fovea-on, fovea-splitting, or fovea-off) was classified by preoperative optical coherence tomography. The primary outcome measure was visual acuity (VA) at last follow-up which was further correlated with the timing of surgical repair.

Results: 195 eyes were included with 62 fovea-on, 65 fovea-splitting, and 68 fovea-off detachments. Mean preoperative logMAR VA for fovea-on, fovea-splitting, and fovea-off groups were 0.16±0.21, 0.70±0.56, and 1.67±0.87, respectively (p=<0.001). Mean postoperative logMAR VA for fovea-on, fovea-splitting, and fovea-off groups were 0.07±0.13, 0.10±0.15, and 0.20±0.22, respectively (p=<0.001). A statistically significant difference in mean postoperative logMAR VA was found between fovea-off and fovea-on groups (p=0.003) and between fovea-off and fovea-splitting groups (p=0.013), however not between fovea-on and fovea-splitting groups (p=0.827). VA improved when repair was performed earlier after presentation for fovea-on (R=0.378, p=0.002) and fovea-off groups (R=0.277, p=0.022), but not for the fovea-splitting group (R=0.089, p=0.481).

Conclusion: We described the favorable visual outcomes of surgery for fovea-splitting RRD and correlated these with the timing of surgical repair, which may help guide the management of this urgent, vision-threatening condition.
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http://dx.doi.org/10.1097/IAE.0000000000003293DOI Listing
August 2021

Use of Bevacizumab Injections in Medicare Fee For Service in the IRIS® Registry.

Ophthalmol Retina 2021 Sep 6;5(9):935-936. Epub 2021 Mar 6.

American Academy of Ophthalmology, San Francisco, California; Oakland University William Beaumont School of Medicine, Rochester, Michigan.

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http://dx.doi.org/10.1016/j.oret.2021.03.003DOI Listing
September 2021

Temporary Keratoprosthesis with Penetrating Keratoplasty in Conjunction with Pars Plana Vitrectomy for Repair of Retinal Detachments in Patients with Anterior and Posterior Segment Pathology.

Retin Cases Brief Rep 2021 Feb 1. Epub 2021 Feb 1.

Beaumont Eye Institute, Beaumont Health. 3535 West 13 Mile Road suite #555, Royal Oak, Michigan, USA, 48073 Georgetown University School of Medicine. 3900 Reservoir Road Northwest, Washington, DC, 20007. Oakland University William Beaumont School of Medicine. 586 Pioneer Drive, Rochester, Michigan, 48309.

Purpose: The purpose of this study is to review the visual and anatomic outcomes of combined anterior and posterior segment surgery for retinal detachment (RD) repair.

Methods: and Patients: Eight patients with combined retinal and corneal disease underwent combined temporary keratoprosthesis with penetrating keratoplasty (PKP) combined with pars plana vitrectomy for RD repair with silicone oil tamponade. Visual and anatomic outcomes were reviewed retrospectively. Follow up ranged from 12 months to 37 months.

Results: Preoperative visual acuity ranged from light perception to hand motion. All but one case had proliferative vitreoretinopathy present at the time of surgery. Postoperative visual acuity ranged from hand motion to light perception. At the most recent follow up visit, all of the patients had attached retinas, no patients had phthisis bulbi, and all but one patient had a clear cornea. However, three of these cases (38%) required repeat RD repair and one of them also required repeat PKP, which was performed at the time of retinal repair.

Conclusion: Combined full-thickness PKP and RD repair has good anatomic outcomes and is an efficient way to treat complex anterior and posterior segment pathology. Although post-operative visual function is limited, almost all patients were agreeable to repeat surgery if they were presented with the choice again.
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http://dx.doi.org/10.1097/ICB.0000000000001136DOI Listing
February 2021

CLINICAL OUTCOMES AND TREATMENT COURSE OF EYES WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION FOLLOWING THE DEVELOPMENT OF ENDOPHTHALMITIS.

Retina 2021 Jun;41(6):1242-1250

Associated Retinal Consultants, PC., Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Royal Oak, MI.

Purpose: To evaluate the clinical course of patients with neovascular age-related macular degeneration (nAMD) after developing endophthalmitis during their treatment with intravitreal injections.

Methods: Multicenter, retrospective series.

Results: From April 2013 to October 2018, 196,598 intravitreal anti-vascular endothelial growth factor (VEGF) injections were performed, with 75 cases of endophthalmitis (incidence 0.0381%). There was no association between intravitreal anti-VEGF drug (P = 0.29), anesthetic method (P = 0.26), povidone concentration (P = 0.22), or any intraprocedure variable and endophthalmitis incidence. Seventy-two patients (96%) were treated with intravitreal tap and inject , while 3 underwent immediate pars plana vitrectomy. After endophthalmitis resolution, 17 patients (22.7%) were not re-treated for nAMD (in 10 cases due to inactive disease; follow-up, 115 ± 8.4 weeks). Patients required less frequent anti-VEGF injections after infection (7.4 ± 0.61 weeks vs. 11.5 ± 1.8 weeks; P = 0.004). Preinfection logarithm of the minimum angle of resolution visual acuity was 0.585 ± 0.053 (∼20/77). It worsened with endophthalmitis (1.67 ± 0.08, ∼20/935; P < 0.001) and again on postendophthalmitis treatment day 1 (1.94 ± 0.064; count fingers; P < 0.001), but improved after reinitiating nAMD therapy (1.02 ± 0.11; ∼20/209; P < 0.001). Better visual acuity on postendophthalmitis week 1 (P = 0.002) and reinitiation of nAMD treatment (P = 0.008) were associated with better final visual acuity, and streptococcal culture with worse visual acuity (P = 0.028). The postendophthalmitis treatment interval was associated with the anti-VEGF drug used (aflibercept = ranibizumab > bevacizumab; P < 0.001).

Conclusion: Patients with nAMD required fewer injections after endophthalmitis, suggesting a biological change in disease activity. Neovascular age-related macular degeneration became quiescent in 13.3% of eyes. Most achieved better outcomes with anti-VEGF reinitiation.
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http://dx.doi.org/10.1097/IAE.0000000000002998DOI Listing
June 2021

PERIPHERAL RETINAL ANGIOGRAPHIC FINDINGS IN MACULAR TELANGIECTASIS TYPE 2.

Retina 2021 Mar;41(3):480-486

Associated Retinal Consultants, PC, Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan.

Purpose: To evaluate the retinal periphery in patients with idiopathic juxtafoveal telangiectasis or macular telangiectasis Type 2 (MacTel2), using widefield fluorescein angiography.

Methods: Single-center, retrospective, observational case series of 50 eyes of 50 patients with MacTel2 and 50 eyes of 50 age-matched controls.

Results: Thirty-seven eyes in the MacTel2 group (74%) showed peripheral capillary nonperfusion or dropout, compared with 37 eyes in the control group (74%, P = 1.0). Morphologically, the MacTel2 group trended toward having a higher proportion of pruning-type capillary dropout (44%) compared with controls (28%), but this was not statistically significant (P = 0.12). Patients with MacTel2 had a higher incidence of microaneurysms compared with controls (MacTel2 56%; controls 42%; P = 0.048), independent of age or systemic risk factors. There was no difference in the incidence of venous-venous shunts (MacTel2 10%; controls 10%; P = 1.0), arteriovenous shunts (MacTel2 14%; controls 18%; P = 0.60), venous tortuosity (MacTel2 60%; controls 66%; P = 0.58), or arterial tortuosity (MacTel2 54%; controls 68%; P = 0.20), which was mild in most cases.

Conclusion: We note a high incidence of peripheral vascular and retinal findings in both patients with MacTel2 and age-matched controls, using widefield fluorescein angiography. Patients with MacTel2 had significantly more microaneurysms, independent of age or other systemic risk factors.
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http://dx.doi.org/10.1097/IAE.0000000000002981DOI Listing
March 2021

Reoperation Rates of Patients Undergoing Primary Noncomplex Retinal Detachment Surgery in a Cohort of the IRIS Registry.

Am J Ophthalmol 2021 02 6;222:69-75. Epub 2020 Sep 6.

American Academy of Ophthalmology, San Francisco, California, USA; Associated Retinal Consultants, Royal Oak, Michigan, USA.

Purpose: To present the reoperation rates of patients who underwent a primary noncomplex RD repair in a cohort of the American Academy of Ophthalmology IRIS Registry.

Design: Retrospective, nonrandomized comparative clinical study.

Methods: This was a retrospective, nonrandomized cohort study of patients who underwent a primary noncomplex RD repair with either a scleral buckle (SB) or vitrectomy with or without scleral buckle (PPV±SB) between 2013 and 2016. The primary outcome was the odds of reoperation within 12 months.

Results: Of 24,068 patients, 2,937 patients (12.2%) underwent an SB and 21,131 patients (87.8%) a PPV ± SB. The overall reoperation rate was 12.2% for SB and 11.6% for PPV ± SB. After multivariate adjustment for age and initial RD diagnosis, the PPV ± SB group exhibited a lower odds of reoperation within 12 months compared with SB only (OR 0.84, 95% CI 0.75-0.96, P = .007). However, there was an age interaction. Patients ≤50 years old with PPV ± SB exhibited a higher odds of reoperation (OR 1.46, 95% CI 1.14-1.88, P = .003) compared to SB only. Patients >50 years with PPV ± SB had a lower odds of reoperation (OR 0.73, 95% CI 0.63-0.84, P < .0001).

Conclusion: The odds of reoperation of PPV ± SB compared with SB only varies depending on the patient's age. Further subset analyses are required to determine if there are clinically relevant differences with respect to RD configuration or other RD repair types (PPV only vs PPV with SB).
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http://dx.doi.org/10.1016/j.ajo.2020.08.027DOI Listing
February 2021

REFRACTIVE OUTCOMES AFTER SUTURELESS INTRASCLERAL FIXATION OF INTRAOCULAR LENS WITH PARS PLANA VITRECTOMY.

Retina 2021 Apr;41(4):822-826

Associated Retinal Consultants, P.C., Royal Oak, Michigan.

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.
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http://dx.doi.org/10.1097/IAE.0000000000002916DOI Listing
April 2021

Ophthalmology and "Rubber Bullets".

Ophthalmology 2020 10 4;127(10):1287-1288. Epub 2020 Aug 4.

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http://dx.doi.org/10.1016/j.ophtha.2020.07.001DOI Listing
October 2020

Intravitreal Anti-Vascular Endothelial Growth Factor Cost Savings Achievable with Increased Bevacizumab Reimbursement and Use.

Ophthalmology 2020 12 13;127(12):1688-1692. Epub 2020 Jun 13.

Associated Retinal Consultants, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan.

Purpose: To model Medicare Part B and patient savings associated with increased bevacizumab payment and use for intravitreal anti-vascular endothelial growth factor (VEGF) therapy.

Design: Cost analysis.

Participants: Intelligent Research in Sight (IRIS®) Registry data.

Methods: Medicare claims and IRIS® Registry data were used to calculate Medicare Part B expenditures and patient copayments for anti-VEGF agents with increasing reimbursement and use of bevacizumab relative to ranibizumab and aflibercept.

Main Outcome Measures: Medicare Part B costs and patient copayments for anti-VEGF agents in the Medicare fee-for-service population.

Results: Increasing bevacizumab reimbursement to $125.78, equalizing the dollar margin with aflibercept, would result in Medicare Part B savings of $468 million and patient savings of $119 million with a 10% increase in bevacizumab market share.

Conclusions: Increased use of bevacizumab achievable with increased reimbursement to eliminate the financial disincentive to its use would result in substantial savings for the Medicare Part B program and for patients receiving anti-VEGF intravitreal injections.
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http://dx.doi.org/10.1016/j.ophtha.2020.06.012DOI Listing
December 2020

Primary Retinal Detachment Outcomes Study: Methodology and Overall Outcomes-Primary Retinal Detachment Outcomes Study Report Number 1.

Ophthalmol Retina 2020 08 4;4(8):814-822. Epub 2020 Mar 4.

Mid-Atlantic Retina, Philadelphia, Pennsylvania.

Purpose: To detail the methodology for a large multicenter retrospective cohort study (RCS) of primary rhegmatogenous retinal detachment (RRD) with detailed data collection and to present overall anatomic outcomes.

Design: This study used an RCS method.

Participants: All patients undergoing pars plana vitrectomy (PPV), scleral buckling (SB), and combined PPV/SB for primary RRD in 2015 from 5 large retina groups were included in the database.

Methods: To ensure validity of the cohort method, a large and detailed database was generated. Double data entry validation was conducted, and data audits were conducted. Anatomic and visual outcomes for all the cases in the dataset will be described but not compared, because the cases were not matched. In future studies, comparable cases of moderate-complexity RRD will be chosen naive to surgeon, surgery, and outcome for subgroup analysis.

Main Outcome Measures: Precision of data entry was confirmed by inter-rater reliability (IRR). Main surgical outcome for each procedure type was single-surgery anatomic success (SSAS).

Results: Inter-rater reliability showed significant agreement among raters (P < 0.001). Of 2620 patients, 2335 had >90 days of follow-up. Of these, 320 eyes (13.7%) underwent SB, 1200 eyes (51.4%) underwent PPV, and 815 eyes (34.9%) underwent PPV/SB. The SSAS was 84.2% for PPV, 91.2% for SB, and 90.2% for PPV/SB.

Conclusions: We compiled a large, accurately documented database of primary RRD cases repaired by PPV, SB, and PPV/SB from which cohort studies of moderately complex RRDs can be carried out. All 3 approaches had a high SSAS rate. Procedures chosen and their outcomes are described, but the broad case mix makes comparisons not possible until future cohort studies are completed.
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http://dx.doi.org/10.1016/j.oret.2020.02.014DOI Listing
August 2020

Primary Retinal Detachment Outcomes Study: Pseudophakic Retinal Detachment Outcomes: Primary Retinal Detachment Outcomes Study Report Number 3.

Ophthalmology 2020 11 8;127(11):1507-1514. Epub 2020 May 8.

The Retina Service of Wills Eye Hospital, Mid-Atlantic Retina, Philadelphia, Pennsylvania.

Purpose: This study evaluates outcomes of comparable pseudophakic rhegmatogenous retinal detachment (RRD) treated with pars plana vitrectomy (PPV) or PPV with scleral buckle (PPV-SB).

Design: Multicenter, retrospective, interventional cohort study.

Participants: Data were gathered from patients from multiple retina practices in the United States with RRD in 2015.

Methods: A large detailed database was generated. Pseudophakic patients with RRD managed with PPV or PPV-SB were analyzed for anatomic and visual outcomes. Eyes with proliferative vitreoretinopathy, giant retinal tears, previous invasive glaucoma surgery, and ≤90 days of follow-up were excluded from outcomes analysis. Single surgery anatomic success (SSAS) was defined as retinal attachment without ongoing tamponade and with no other RRD surgery within 90 days.

Main Outcome Measures: Single surgery anatomic success and final Snellen visual acuity (VA).

Results: A total of 1158 of 2620 eyes (44%) with primary RRD were pseudophakic. A total of 1018 eyes had greater than 90 days of follow-up. Eyes with proliferative vitreoretinopathy, previous glaucoma surgery, and giant retinal tears were excluded, leaving 893 pseudophakic eyes eligible for outcome analysis. A total of 461 (52%) were right eyes. A total of 606 patients (67%) were male, with a mean age of 65±11 years. Pars plana vitrectomy and PPV-SB as the first procedure were performed on 684 eyes (77%) and 209 eyes (23%), respectively. The mean follow-up was 388±161 days, and overall SSAS was achieved in 770 eyes (86%). Single surgery anatomic success was 84% (577/684) for PPV and 92% (193/209) for PPV-SB. The difference in SSAS between types of treatment was significant (P = 0.009). In eyes with macula-on RRD, SSAS was 88% in eyes treated with PPV and 100% in eyes treated with PPV-SB (P = 0.0088). In eyes with macula-off RRD, SSAS was 81% in eyes treated with PPV and 89% in eyes treated with PPV-SB (P = 0.029). Single surgery anatomic success was greater for PPV-SB than PPV for inferior (96% vs. 82%) and superior (90% vs. 82%) detachments. Mean final VA was similar for PPV (20/47) and PPV-SB (20/46; P = 0.805).

Conclusions: In pseudophakic RRDs, SSAS was better in patients treated with PPV-SB compared with PPV alone, whereas visual outcomes were similar for both groups.
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http://dx.doi.org/10.1016/j.ophtha.2020.05.005DOI Listing
November 2020

Primary Retinal Detachment Outcomes Study Report Number 2: Phakic Retinal Detachment Outcomes.

Ophthalmology 2020 08 9;127(8):1077-1085. Epub 2020 Mar 9.

Mid-Atlantic Retina, Philadelphia, Pennsylvania.

Purpose: Anatomically similar rhegmatogenous retinal detachments (RRDs) can be treated with scleral buckle (SB), pars plana vitrectomy (PPV), or SB combined with PPV (PPV/SB). This study compares moderately complex phakic primary RRD treated with SB, PPV, or PPV/SB to review anatomic and visual outcomes.

Design: Multicenter, retrospective, interventional cohort study.

Participants: Data were gathered on all patients from multiple retina practices in the United States with RRD in 2015 and >90 days of follow-up. The cohort of phakic patients with moderately complex RRD was analyzed.

Methods: A large and detailed database was generated. Eyes with findings that would bias toward PPV (vitreous hemorrhage, dense cataract, proliferative vitreoretinopathy, giant retinal tear, among others) were excluded. Age <40 years (bias toward SB) was excluded. Comparable cases of moderately complex RRD were then chosen naive to surgeon, surgery, and outcome for subgroup analysis.

Main Outcome Measures: Single surgery anatomic success (SSAS), defined as retinal attachment with no other RRD surgery within 90 days, is the main outcome measure. Final visual acuity is the secondary outcome measure. Pearson's chi-square and analysis of variance were used to test treatment effect of surgery type on SSAS and vision.

Results: Single surgery anatomic success was noted in 155 of 169 SB cases (91.7%), 207 of 249 PPV cases (83.1%), and 271 of 297 PPV/SB cases (91.2%). Scleral buckle and PPV/SB were superior to PPV for SSAS (P = 0.0041). For macula-on or split cases, SB had significantly better visual outcomes than PPV or PPV/SB even after controlling for cataract (cases with minimal cataract at final follow-up or after cataract surgery) (P < 0.001).

Conclusions: For phakic moderately complex primary RRDs in this study of PPV versus SB versus PPV/SB, SB had the best visual outcomes, and PPV had the worst SSAS outcomes.
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http://dx.doi.org/10.1016/j.ophtha.2020.03.007DOI Listing
August 2020

The retina revolution: signaling pathway therapies, genetic therapies, mitochondrial therapies, artificial intelligence.

Curr Opin Ophthalmol 2020 May;31(3):207-214

William Beaumont Hospital, Royal Oak.

Purpose Of Review: The aim of this article is to review and discuss the history, current state, and future implications of promising biomedical offerings in the field of retina.

Recent Findings: The technologies discussed are some of the more recent promising biomedical developments within the field of retina. There is a US Food and Drug Administration-approved gene therapy product and artificial intelligence device for retina, with many other offerings in the pipeline.

Summary: Signaling pathway therapies, genetic therapies, mitochondrial therapies, and artificial intelligence have shaped retina care as we know it and are poised to further impact the future of retina care. Retina specialists have the privilege and responsibility of shaping this future for the visual health of current and future generations.
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http://dx.doi.org/10.1097/ICU.0000000000000656DOI Listing
May 2020

Safety and Efficacy of Subretinally Administered Palucorcel for Geographic Atrophy of Age-Related Macular Degeneration: Phase 2b Study.

Ophthalmol Retina 2020 04 19;4(4):384-393. Epub 2019 Nov 19.

Janssen Research & Development, Spring House, Pennsylvania.

Purpose: To evaluate safety and successful use of a novel subretinal delivery system and suprachoroidal surgical approach and safety and activity of human umbilical tissue-derived cells (palucorcel) via a novel delivery system in patients with geographic atrophy (GA).

Design: Multicenter, open-label phase 2b study.

Participants: Participants were 55 to 90 years with GA secondary to age-related macular degeneration (AMD) and best-corrected visual acuity (BCVA) of 20/80 to 20/800. Exclusion criteria included neovascular AMD in the intervention eye, glaucoma with intraocular pressure of 25 mmHg or more, or other significant ophthalmologic conditions.

Methods: Participants received a subretinal injection of palucorcel, 3.0 × 10 cells in 50 μl, using the custom-designed delivery system and surgical procedure.

Main Outcome Measures: Safety assessments included treatment-emergent adverse events (AEs), immunologic assessments, and ophthalmologic evaluations. Efficacy was evaluated as change in mean number of BCVA letters from baseline, proportion of participants gaining 15 BCVA letters or more, and growth rate of GA lesions at 12 months.

Results: Surgery and palucorcel administration were performed in 21 participants at 8 sites by 8 different surgeons. At baseline, median total area of GA was 13.4 mm and median BCVA was 43 letters in the intervention eye. Eye-related AEs occurred in 76% of participants (16/21), including conjunctival hemorrhage (n = 5), retinal hemorrhage (n = 4), and vitreous floaters (n = 4). Most AEs were mild and resolved within 1 month. No serious AEs, no retinal detachment or perforation, and no significant changes in intraocular pressure occurred. At month 12, mean change in BCVA from baseline was -5.9 letters correct (standard deviation, 13.0 letters correct) in the intervention eye and -3.7 letters correct (standard deviation, 9.0 letters correct) in the fellow eye. No participants showed improvement of 15 letters or more in the intervention eye, and 3 participants lost more than 15 letters by month 1. No apparent effect of treatment was observed.

Conclusions: Palucorcel was delivered successfully to the targeted subretinal site using a novel delivery system and suprachoroidal approach for most participants; however, improvement in GA area, retardation of growth, or visual acuity were not demonstrated.
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http://dx.doi.org/10.1016/j.oret.2019.11.011DOI Listing
April 2020

Safety and Efficacy of Subretinally Administered Palucorcel for Geographic Atrophy of Age-Related Macular Degeneration: Phase 2b Study.

Ophthalmol Retina 2020 04 19;4(4):384-393. Epub 2019 Nov 19.

Janssen Research & Development, Spring House, Pennsylvania.

Purpose: To evaluate safety and successful use of a novel subretinal delivery system and suprachoroidal surgical approach and safety and activity of human umbilical tissue-derived cells (palucorcel) via a novel delivery system in patients with geographic atrophy (GA).

Design: Multicenter, open-label phase 2b study.

Participants: Participants were 55 to 90 years with GA secondary to age-related macular degeneration (AMD) and best-corrected visual acuity (BCVA) of 20/80 to 20/800. Exclusion criteria included neovascular AMD in the intervention eye, glaucoma with intraocular pressure of 25 mmHg or more, or other significant ophthalmologic conditions.

Methods: Participants received a subretinal injection of palucorcel, 3.0 × 10 cells in 50 μl, using the custom-designed delivery system and surgical procedure.

Main Outcome Measures: Safety assessments included treatment-emergent adverse events (AEs), immunologic assessments, and ophthalmologic evaluations. Efficacy was evaluated as change in mean number of BCVA letters from baseline, proportion of participants gaining 15 BCVA letters or more, and growth rate of GA lesions at 12 months.

Results: Surgery and palucorcel administration were performed in 21 participants at 8 sites by 8 different surgeons. At baseline, median total area of GA was 13.4 mm and median BCVA was 43 letters in the intervention eye. Eye-related AEs occurred in 76% of participants (16/21), including conjunctival hemorrhage (n = 5), retinal hemorrhage (n = 4), and vitreous floaters (n = 4). Most AEs were mild and resolved within 1 month. No serious AEs, no retinal detachment or perforation, and no significant changes in intraocular pressure occurred. At month 12, mean change in BCVA from baseline was -5.9 letters correct (standard deviation, 13.0 letters correct) in the intervention eye and -3.7 letters correct (standard deviation, 9.0 letters correct) in the fellow eye. No participants showed improvement of 15 letters or more in the intervention eye, and 3 participants lost more than 15 letters by month 1. No apparent effect of treatment was observed.

Conclusions: Palucorcel was delivered successfully to the targeted subretinal site using a novel delivery system and suprachoroidal approach for most participants; however, improvement in GA area, retardation of growth, or visual acuity were not demonstrated.
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http://dx.doi.org/10.1016/j.oret.2019.11.011DOI Listing
April 2020

Degenerative Peripheral Retinoschisis: Observations From Ultra-Widefield Fundus Imaging.

Ophthalmic Surg Lasers Imaging Retina 2019 09;50(9):557-564

Background And Objective: To describe the ultra-widefield (UWF) imaging characteristics of patients with degenerative peripheral retinoschisis (DPR) using Optomap technology.

Patients And Methods: In this multicenter, retrospective, noncomparative, consecutive case series, eligible patients underwent detailed retinal examination including indirect ophthalmoscopy. UWF fundus imaging, including color fundus photography, autofluorescence, and angiography, was performed using standardized protocols and findings were recorded and reviewed and analyzed.

Results: A total of 35 patients (58 eyes) with DPR were identified who underwent 55 sessions of UWF imaging. Mean age was 65 years, and the inferotemporal quadrant was most commonly affected (74% of eyes). Of these patients, 31 underwent fluorescein angiography and 90% of these studies illustrated abnormalities in the area affected by the schisis. The most common finding was retinal vascular leakage originating from the deep capillary plexus observed in 29 eyes (93.5%).

Conclusions: UWF imaging enables a more detailed identification of the clinical features associated with DPR and provides simple, practical, and noninvasive tools to monitor progression of disease. The breadth of retinal vascular complications identified with fluorescein angiography may suggest an important vascular component associated with the pathogenesis of this entity. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:557-564.].
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http://dx.doi.org/10.3928/23258160-20190905-04DOI Listing
September 2019

Surgical Technique Supplement Editorial.

Retina 2019 10;39 Suppl 1:S1

Section Editor, Surgical Techniques Editor-In-Chief, RETINA, The Journal of Retinal and Vitreous Diseases.

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http://dx.doi.org/10.1097/IAE.0000000000002665DOI Listing
October 2019

Reply.

Ophthalmol Retina 2019 08 3;3(8):e7-e8. Epub 2019 Apr 3.

Associated Retinal Consultants, William Beaumont Hospital, Royal Oak, Michigan.

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http://dx.doi.org/10.1016/j.oret.2019.03.017DOI Listing
August 2019

Correlating Changes in the Macular Microvasculature and Capillary Network to Peripheral Vascular Pathologic Features in Familial Exudative Vitreoretinopathy.

Ophthalmol Retina 2019 07 4;3(7):597-606. Epub 2019 Mar 4.

Department of Ophthalmology, Shiley Eye Institute and Jacobs Retina Center, University of California, San Diego, La Jolla, California. Electronic address:

Purpose: To evaluate the macular microvasculature in patients with familial exudative vitreoretinopathy (FEVR) using OCT angiography (OCTA) and to assess for peripheral vascular changes using widefield fluorescein angiography (WFA).

Design: Multicenter, retrospective, comparative, observational case series.

Participants: We identified 411 patients with FEVR, examined between September 2014 and June 2018. Fifty-seven patients with FEVR and 60 healthy controls had OCTA images of sufficient quality for analysis.

Methods: Custom software was used to assess for layer-specific, quantitative changes in vascular density and morphologic features on OCTA by way of vessel density (VD), skeletal density (SD), fractal dimension (FD), vessel diameter index (VDI), and foveal avascular zone (FAZ). Widefield fluorescein angiography images were reviewed for peripheral vascular changes including capillary dropout, late-phase angiographic posterior and peripheral vascular leakage (LAPPEL), vascular dragging, venous-venous shunts, and arteriovenous shunts.

Main Outcome Measures: Macular microvascular parameters on OCTA and peripheral angiographic findings on WFA.

Results: OCT angiography analysis of 117 patients (187 eyes; 92 FEVR patients and 95 control participants) demonstrated significantly reduced VD, SD, and FD and greater VDI in patients with FEVR compared with controls in the nonsegmented retina, superficial retinal layer (SRL), and deep retinal layer (DRL). The FAZ was larger compared with that in control eyes in the DRL (P < 0.0001), but not the SRL (P = 0.52). Subanalysis by FEVR stage showed the same microvascular changes compared with controls for all parameters. Widefield fluorescein angiography analysis of 95 eyes (53 patients) with FEVR demonstrated capillary nonperfusion in all eyes: 47 eyes (49.5%) showed LAPPEL, 32 eyes (33.7%) showed vascular dragging, 30 eyes (31.6%) had venous-venous shunts, and 33 eyes (34.7%) had arteriovenous shunts. Decreasing macular VD on OCTA correlated with increasing peripheral capillary nonperfusion on WFA. Decreasing fractal dimension on OCTA correlated with increasing LAPPEL severity on WFA.

Conclusions: Patients with FEVR demonstrated abnormalities in the macular microvasculature and capillary network, in addition to the peripheral retina. The macular microvascular parameters on OCTA may serve as biomarkers of changes in the retinal periphery on WFA.
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http://dx.doi.org/10.1016/j.oret.2019.02.013DOI Listing
July 2019

Characterization of Epiretinal Proliferation in Full-Thickness Macular Holes and Effects on Surgical Outcomes.

Ophthalmol Retina 2019 08 1;3(8):694-702. Epub 2019 Apr 1.

Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts; Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

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 nonclosure (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.
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http://dx.doi.org/10.1016/j.oret.2019.03.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684822PMC
August 2019

Continuing Professional Certification: Perspective of the American Academy of Ophthalmology.

Ophthalmology 2019 07 5;126(7):926-927. Epub 2019 May 5.

San Francisco, California. Electronic address:

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http://dx.doi.org/10.1016/j.ophtha.2019.03.043DOI Listing
July 2019

Ocular Hypertension in Adults with a History of Prematurity.

Ophthalmol Retina 2018 06 1;2(6):629-635. Epub 2017 Dec 1.

Associated Retinal Consultants P.C., Royal Oak, Michigan; Oakland University William Beaumont School of Medicine, Department of Ophthalmology, Royal Oak, Michigan. Electronic address:

Purpose: To determine the ocular hypertension (OHT) incidence in patients with a history of prematurity and the effect of intervention for acute retinopathy of prematurity (ROP) in infancy on OHT incidence.

Design: Retrospective case series at a single tertiary referral vitreoretinal practice.

Participants: A total of 407 eyes of 213 patients were included, with ROP stage 0 to 5.

Methods: A retrospective chart review was conducted of patients aged ≥15 years, seen from 1973 to 2013, with a history of premature birth (gestational age <32 weeks). Data were collected from patient charts, including gender, date of birth, gestational age at birth, birth weight, stage of ROP at presentation, management (including laser, cryotherapy, lens-sparing vitrectomy [LSV], or lensectomy-vitrectomy). Ocular hypertension (if present) data included age of onset, timing of glaucoma surgery (if performed), lens status, and last follow-up examination.

Main Outcome Measures: Development of OHT, defined as eyes requiring a glaucoma medication for more than 6 consecutive months or surgical intervention for elevated intraocular pressure.

Results: Of included eyes, 155 (38.1%) developed OHT within 69 years of follow-up. Subgroup analyses revealed an OHT incidence of 23.2% (36/155 eyes) in eyes without a history of any treatment for acute ROP (spontaneously regressed), 23.3% (10/43 eyes) in eyes that underwent ablative therapy alone, and 58.5% (76/130 eyes) in eyes requiring acute incisional retinal surgery (P < 0.01). Stage 4 eyes had a lower OHT incidence compared with stage 5 eyes (40.5% [17/42] vs. 66.7% [54/81], P < 0.01); however, among stage 4 and stage 5 eyes, phakic eyes at last follow-up had a decreased OHT incidence compared with aphakic eyes (27.8% [5/18] vs. 69.8% [60/86], P < 0.01).

Conclusions: Patients with a history of extreme prematurity are at an increased risk of OHT and glaucoma, even if they did not receive acute ROP treatment. More severe acute ROP is associated with higher incidence of OHT, and this is associated with an increased incidence of incisional surgical intervention. Awareness of the increased lifelong risk of adverse ocular sequelae in patients with a history of prematurity will help guide appropriate monitoring.
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http://dx.doi.org/10.1016/j.oret.2017.10.005DOI Listing
June 2018

Thomas A. Swift's Electric Rifle Injuries to the Eye and Ocular Adnexa: The Management of Complex Trauma.

Ophthalmol Retina 2019 03 10;3(3):258-269. Epub 2018 Oct 10.

Retina Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts. Electronic address:

Purpose: To report the ocular and adnexal injuries sustained by patients with Thomas A. Swift's electric rifles (TASER; TASER International, Scottsdale, AZ), review the literature, and discuss the management of this complex trauma.

Design: Multicenter, retrospective case series and literature review.

Participants: Seventeen eyes of 16 patients (5 eyes of 5 patients treated at 3 institutions, and 12 eyes of 11 previously reported cases).

Methods: The clinical data of 17 eyes were pooled. Spearman's correlation coefficient was used to assess the association between the extent of TASER injury and patient outcomes.

Main Outcome Measures: Extent of TASER injury (zone of injury, penetrating vs. perforating) and association with patient outcomes (visual acuity [VA] and retinal detachment [RD]).

Results: In our cohort, 4 patients were transported by law enforcement and 1 was transferred from a community hospital. Four patients were taken to the operating room for TASER removal and globe repair; 1 patient underwent removal in the emergency room. Of 17 pooled cases, 12 (71%) involved open-globe injury. Of these, there was a high rate of zone 3 injuries (100%; n = 12) and a high incidence of RD (73%; 8 of 11, eviscerated eye excluded). Among patients with closed-globe injury (n = 5), 1 patient demonstrated exudative RD and 1 patient demonstrated retinal dialysis with RD. Of 10 patients with RD, 1 (10%) achieved resolution with monitoring (exudative RD); 1 (10%) underwent cryopexy and pneumatic retinopexy; 3 (30%) underwent vitrectomy, and 5 (50%) with poor prognosis did not undergo vitreoretinal surgery. In the 3 patients who underwent vitrectomy, all 3 (100%) demonstrated redetachment resulting from proliferative vitreoretinopathy and required additional surgery. Visual acuity on presentation was significantly correlated with final VA (ρ = 0.783; P = 0.02). Men (94%) were more likely than women (6%) to sustain TASER trauma. Median age was 26 years. There was a 50% rate of loss to follow-up.

Conclusions: Thomas A. Swift's electric rifle injuries to the eyes or ocular adnexa represent complex trauma. Zone 3 injuries are common. The visual prognosis is guarded, and eyes may require multiple surgeries to preserve vision. Patients are at high risk for loss to follow-up by way of incarceration.
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http://dx.doi.org/10.1016/j.oret.2018.10.005DOI Listing
March 2019

Predictors of Endophthalmitis after Intravitreal Injection: A Multivariable Analysis Based on Injection Protocol and Povidone Iodine Strength.

Ophthalmol Retina 2019 01 25;3(1):3-7. Epub 2018 Sep 25.

Associated Retinal Consultants, PC, William Beaumont Hospital, Royal Oak, Michigan; William Beaumont School of Medicine, Oakland University, Rochester, Michigan. Electronic address:

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 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).

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.
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http://dx.doi.org/10.1016/j.oret.2018.09.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6597000PMC
January 2019

STEM CELL THERAPIES, GENE-BASED THERAPIES, OPTOGENETICS, AND RETINAL PROSTHETICS: Current State and Implications for the Future.

Retina 2019 May;39(5):820-835

Associated Retinal Consultants, Royal Oak, Michigan.

Purpose: To review and discuss current innovations and future implications of promising biotechnology and biomedical offerings in the field of retina. We focus on therapies that have already emerged as clinical offerings or are poised to do so.

Methods: Literature review and commentary focusing on stem cell therapies, gene-based therapies, optogenetic therapies, and retinal prosthetic devices.

Results: The technologies discussed herein are some of the more recent promising biotechnology and biomedical developments within the field of retina. Retinal prosthetic devices and gene-based therapies both have an FDA-approved product for ophthalmology, and many other offerings (including optogenetics) are in the pipeline. Stem cell therapies offer personalized medicine through novel regenerative mechanisms but entail complex ethical and reimbursement challenges.

Conclusion: Stem cell therapies, gene-based therapies, optogenetics, and retinal prosthetic devices represent a new era of biotechnological and biomedical progress. These bring new ethical, regulatory, care delivery, and reimbursement challenges. By addressing these issues proactively, we may accelerate delivery of care to patients in a safe, efficient, and value-based manner.
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http://dx.doi.org/10.1097/IAE.0000000000002449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492547PMC
May 2019

Scleral Transillumination With Digital Heads-Up Display: A Novel Technique for Visualization During Vitrectomy Surgery.

Ophthalmic Surg Lasers Imaging Retina 2018 06;49(6):436-439

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.].
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http://dx.doi.org/10.3928/23258160-20180601-08DOI Listing
June 2018

Outcomes of Anti-Vascular Endothelial Growth Factor Treatment for Choroidal Neovascularization in Fellow Eyes of Previously Treated Patients With Neovascular Age-Related Macular Degeneration.

JAMA Ophthalmol 2018 07;136(7):820-823

Associated Retinal Consultants, William Beaumont Hospital, Royal Oak, Michigan.

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.
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http://dx.doi.org/10.1001/jamaophthalmol.2018.1534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6136044PMC
July 2018

Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: A Clinical-Pathophysiological Analysis.

Am J Ophthalmol 2018 04 6;188:131-140. Epub 2018 Feb 6.

Associated Retinal Consultants, PC, Royal Oak, Michigan; Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester, Michigan. Electronic address:

Purpose: To derive novel insights into the pathophysiology of vancomycin-related hemorrhagic occlusive retinal vasculopathy (HORV) through a careful clinicopathologic correlation.

Methods: We retrospectively reviewed the clinical and pathologic course of 2 consecutive patients who developed HORV. The clinical history, multimodal imaging, ultrasound biomicroscopy (UBM), and intraoperative and histologic findings are reported.

Results: Both patients presented with decreased vision and eye pain within 1 week following otherwise uncomplicated cataract extraction and were diagnosed with HORV after endophthalmitis was ruled out. Both patients presented with significant ocular discomfort that progressively worsened, and both experienced a dismal visual outcome despite early aggressive medical and surgical therapy. One patient requested enucleation for a blind and painful eye. Upon histologic examination of this eye, the iris and ciliary body appeared to be infarcted with separation of the iris and ciliary epithelia from their adjacent stromal components. These findings were corroborated by UBM of the second patient. Histologic examination of the posterior segment demonstrated severe hemorrhagic necrosis of the neurosensory retina and an occlusive nonarteritic vasculopathy of the retina and choroid. The choroid was thickened by prominent nongranulomatous chronic inflammation accompanied by a glomeruloid proliferation of small vessels. The inflammatory infiltrate was almost exclusively confined to the choroid and consisted of predominantly T cells. There was conspicuous absence of inflammatory cells in the retina and no histologic evidence of leukocytoclastic vasculitis.

Conclusions: HORV is a rare condition that can lead to profound vision loss. Significant ocular pain can be a presenting sign of HORV in cases with severe iris and ciliary body ischemia. Although it has been suggested that HORV is a form of leukocytoclastic retinal vasculitis, the histologic findings herein indicate that the pathophysiology is more complex. It is grounded in a necrotizing retinal vasculopathy in the absence of retinal vasculitis, chronic nongranulomatous choroiditis, and an unusual glomeruloid proliferation of endothelial cells in the choroid and elsewhere in the eye.
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http://dx.doi.org/10.1016/j.ajo.2018.01.030DOI Listing
April 2018

STRUCTURAL ANALYSIS AND COMPREHENSIVE SURGICAL OUTCOMES OF THE SUTURELESS INTRASCLERAL FIXATION OF SECONDARY INTRAOCULAR LENSES IN HUMAN EYES.

Retina 2018 09;38 Suppl 1:S31-S40

Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan.

Purpose: To describe surgical outcomes and structural characteristics of intraocular lenses (IOLs) implanted with transconjunctival sutureless intrascleral (SIS) fixation in human eyes.

Design: Retrospective interventional surgical case series involving live and cadaveric human eyes.

Methods: In this study, we investigated the surgical outcomes and structural anatomy of secondary IOLs implanted with the SIS technique in human eyes. All cases involving SIS IOL fixation performed at a single academic center from January 1, 2012, through July 30, 2016, were reviewed to describe the surgical technique, common indications, clinical outcomes, and the rate of common operative complications. To investigate the structure of SIS-fixated IOLs in vivo, slit-lamp biomicroscopy, ultrasound biomicroscopy, and intraoperative endoscopy were analyzed to describe anatomical outcomes. The primary anatomical outcomes were the optic pupillary centration and location of haptic externalization. Results were correlated with cadaveric human eyes that underwent the SIS-IOL technique. Cadaveric eyes were imaged and analyzed using high-resolution photography for centration, stress measurements at the haptic-optic junction, and qualitative descriptors of IOL optic and haptic position.

Results: A total of 122 consecutive patients who underwent IOL placement using SIS technique were included in the study with mean follow-up of 1.52 years (range, 0.4-4.5 years). The majority (75%) of patients received a new 3-piece IOL for primary aphakia or after IOL exchange. The other patients (25%) had a dislocated 3-piece IOL that was rescued using the SIS technique. Preoperative mean Snellen visual acuity was 20/633 (logarithm of the minimum angle of resolution = 1.501). At the final visit, the mean best-corrected visual acuity was 20/83 (logarithm of the minimum angle of resolution = 0.6243) and final mean spherical equivalent was -0.57 diopters. The most common complications were vitreous hemorrhage (22% of eyes), which resolved spontaneously in most cases, and cystoid macular edema. The rates of IOL dislocation, IOL decentration, haptic erosion, IOL tilting, iris capture, and endophthalmitis were low. Intraoperative endoscopy and ultrasound biomicroscopy demonstrated a securely fixated IOL and well-centered optic without iris or ciliary body touch. Structural study of cadaveric eyes confirmed IOL optic and haptic anatomy observed during live human surgery. The ab interno haptic insertion was the anterior pars plana, away from the iris, ciliary processes and ora serrata. The degree of haptic externalization was correlated with the degree of strain on the haptic-optic junction. The angle of the haptic-optic junction in SIS-fixated IOLs (33.97°) was not significantly different compared with overlaid native nonfixated IOL (32.93°) but increased slightly with degree of haptic tip externalization (36.26 and 39.16 for 2 and 3 mm haptic externalizations, respectively).

Conclusion: In this comprehensive study, we demonstrate the surgical outcomes achieved with SIS fixation of IOLs. Surgical and postoperative complications do occur, albeit at a low rate, and can effectively be managed with excellent anatomical and visual outcomes. The structural and anatomical data in this study may help guide SIS placement and optimize long-term surgical results.
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http://dx.doi.org/10.1097/IAE.0000000000001941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6120757PMC
September 2018
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