How private equity achieves return on investment in ophthalmology.

PURPOSE OF REVIEW: To review how private equity entities generate profit for investors and ophthalmologists. RECENT FINDINGS: There is a preponderance of private equity acquisitions and consolidation in ophthalmology. These private equity entities generate revenue by growth, profit improvement, and efficient use of capital structure. Physician partners sell their revenue and assets to a private equity entity while retaining a percentage of future profit. In general, a greater percentage going forward, will result in a smaller initial buyout. Partners typically receive payment in the form of cash and stock in the private equity entity, aligning incentives of both parties to grow and succeed. Junior associates and future partners typically do not benefit from the cash buyout but might have opportunity to buy shares in the private equity entity. SUMMARY: The ophthalmology job market has changed significantly with the rise in private equity. Private equity investors profit from organic growth, economies of scale, and future revenue of ophthalmology practices. Ophthalmology partners benefit from often sizeable buyouts and potentially profitable shares in the private equity entity. Junior and future ophthalmologist may be less likely to succeed financially compared with their contemporaries. Some private equity entities will thrive and other may fail, particularly if they are unable to attract talented new ophthalmologists.

Proliferative Diabetic Retinopathy Events in Patients With Diabetic Macular Edema: Post Hoc Analysis of VISTA and VIVID Trials.

Purpose: This work aimed to assess the incidence of proliferative diabetic retinopathy (PDR) events and improvement to mild non-PDR (NPDR) or better after intravitreal aflibercept injection (IAI) or laser treatment (control) in diabetic macular edema (DME). Methods: PDR events in the VISTA (NCT01363440) and VIVID (NCT01331681) phase 3 clinical trials were evaluated in a combined IAI-treated group (IAI 2 mg every 4 weeks or 2 mg every 8 weeks after 5 initial monthly doses; n = 475) and a macular laser control group (n = 235) through week 100 in eyes without PDR at baseline (Diabetic Retinopathy Severity Scale [DRSS] score ≤ 53). Improvement in the DRSS score to 35 or better was evaluated in those with a baseline DRSS score of 43 or greater. Results: A lower proportion of eyes in the IAI group than in the laser group developed a PDR event through week 100 (4.4% vs 11.1%; adjusted difference, -6.7%; 97.5% CI, -11.7 to -1.6; nominal P = .0008). All PDR events occurred in eyes with a baseline DRSS score of 43, 47, or 53 and not in those with a score of 35 or less. A greater proportion of eyes in the IAI group than in the control group achieved a DRSS score of 35 or less (20.0% vs 3.8%; nominal P < .0001). Conclusions: Fewer eyes with NPDR and DME treated with IAI than eyes treated with a laser had a PDR event. More eyes treated with IAI improved to mild NPDR or better (DRSS score ≤ 35) through 100 weeks.

The Influence of Universal Face Mask Use on Endophthalmitis Risk after Intravitreal Anti-Vascular Endothelial Growth Factor Injections.

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 (~20/2200) for "no face mask" group compared with 1.65 (~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.

MULTILAYERED OPTIC DISK HEMORRHAGE IN ADULTS WITHOUT A POSTERIOR VITREOUS DETACHMENT.

PURPOSE: To describe 2 cases of multilevel optic disk hemorrhages in adults without a posterior vitreous detachment. METHODS: The findings on clinical examination, color fundus photography, fluorescein angiography, spectral domain optical coherence tomography at presentation and follow-up are presented. RESULTS: Two patients ages 61 and 49 years presented with unilateral floaters secondary to microscopic vitreous hemorrhage. Their best-corrected visual acuities were 20/30 and 20/20, respectively. Fundus examination showed similar nasal crescent of peripapillary subretinal hemorrhage and superior flame hemorrhage. Fluorescein angiography for both patients showed blockage from hemorrhages without leakage. Spectral domain optical coherence tomography showed that the posterior hyaloid was attached at the macula and optic nerve for both patients. Both patients experienced spontaneous resolution of symptoms and signs. CONCLUSION: Previous reports of multilevel optic disk hemorrhages in adults variably suggested the necessity of a posterior vitreous detachment. This report illustrates that a posterior vitreous detachment confirmed on spectral domain optical coherence tomography is not a necessary prerequisite for this entity.

Effect of Adjuvant Topical Dorzolamide-Timolol vs Placebo in Neovascular Age-Related Macular Degeneration: A Randomized Clinical Trial.

Importance: Some eyes with neovascular age-related macular degeneration (AMD) have persistent exudation despite frequent intravitreal anti-vascular endothelial growth factor (VEGF) injections. Adjuvant therapies that further reduce edema may improve vision outcomes. Objective: To compare the short-term effect of topical dorzolamide-timolol vs placebo in eyes with neovascular AMD that have persistent exudation following intravitreal anti-VEGF injections. Design, Setting, and Participants: Randomized placebo-controlled clinical trial with enrollment from March 1, 2017, through October 30, 2018. Multicenter trial at 4 clinical sites in the United States. Sixty-three patients with neovascular AMD who had persistent exudation despite intravitreal anti-VEGF injections at 4-week, 5-week, or 6-week intervals. Interventions: Patients were randomized to use dorzolamide-timolol or artificial tears for the study duration. They continued to receive the same anti-VEGF drug at the same interval as the 2 visits before enrollment for 3 additional study visits. Main Outcomes and Measures: The primary outcome measure was change in mean central subfield thickness on optical coherence tomography from baseline to visit 3 (approximately 3 months). Secondary measures included change in mean maximum subretinal fluid height, mean maximum pigment epithelial detachment height, and mean visual acuity (VA). Results: This trial included 52 patients. All 27 patients (100%) assigned to dorzolamide-timolol and 23 of 25 (92%) assigned to placebo were analyzed for the primary outcome. Mean (SD) age was 78.4 (7) years, and 34 of 50 patients (68%) were women. Mean (SD) injections were 20.5 (14) (range, 4-58) before enrollment. Mean (SD) baseline logMAR VA was 0.361 (0.26) (approximate Snellen equivalent, 20/50). Comparing the dorzolamide-timolol with placebo group from baseline to visit 3, mean (SD) change in central subfield thickness (primary outcome) was -36.6 (54) µm vs 1.7 (52.3) µm (difference, 30.8; 95% CI, 0.3-61.3; P = .04); secondary outcomes: maximum PED height was -39.1 (65) µm vs 1.1 (16) µm (difference, 39.6; 95% CI, 9.6-69.6; P = .01) and change in VA from baseline to visit 3 was -2.3 (5) vs 0.3 (1) letters (difference, 2.6 letters; 95% CI, -1.9 to 7.1 letters; P = .78). Conclusions and Relevance: These findings suggest use of dorzolamide-timolol in patients with neovascular AMD with persistent exudation resulted in anatomic but not visual acuity improvements compared with placebo at approximately 3 months. Additional clinical trials with longer follow-up and larger sample sizes presumably would be needed to determine the role, if any, of dorzolamide-timolol in neovascular AMD. Trial Registration: ClinicalTrials.gov Identifier: NCT03034772.

Laser vitreolysis for symptomatic floaters is not yet ready for widespread adoption.

Vitreous floaters are common, related to age, myopia, genetic predisposition, and infiltration of the vitreous body. A subset of patients report symptoms impacting their quality of vision. Treatment with laser vitreolysis, the use of an Nd:YAG laser to vaporize the collagenous vitreous opacities appears to be used more frequently; however, data regarding long-term safety and effectiveness are lacking. We present currently available data regarding efficacy and safety, as well as additional considerations. Laser vitreolysis of symptomatic floaters should not be routinely performed without additional studies documenting its safety and long-term efficacy. Ideally, the procedure would be effective in most patients and be approved by the Food and Drug Administration based on the results of a Food and Drug Administration registration trial before widespread adoption.

Long-Term Follow-Up of Efficacy and Safety of YAG Vitreolysis for Symptomatic Weiss Ring Floaters.

BACKGROUND AND OBJECTIVE: To describe long-term outcomes and complications after YAG vitreolysis. PATIENTS AND METHODS: This is an observational extension study to a previously reported, randomized, controlled study. Thirty-five of 52 patients returned at an average of 2.3 years (range: 1.1 to 3.0) after their last YAG vitreolysis treatment to assess long-term efficacy and safety. RESULTS: At 2.3 years, 50% of patients felt their symptoms were significantly or completely better, similar to results at 6 months (53%). There was a 59.4% improvement in symptoms, similar to 6 months (54%). The 25-item National Eye Institute Visual Function Questionnaire revealed improvements in: near activities, distance vision, mental health, and role difficulties. Adverse events included three eyes with delayed retinal tears, noted 1.4 to 2.8 years after YAG vitreolysis. CONCLUSIONS: The efficacy of YAG vitreolysis observed at 6 months was sustained at 2.3 years, with half reporting significant or complete resolution of their floater symptoms. Three patients developed delayed retinal tears not evident at 6 months. A large, long-term randomized controlled trial is needed to determine the true risks of YAG vitreolysis. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:85-88.].

The Impact of Prefilled Syringes on Endophthalmitis Following Intravitreal Injection of Ranibizumab.

PURPOSE: To compare the rates of infectious endophthalmitis following intravitreal injection of ranibizumab using prefilled syringes vs conventional preparation. DESIGN: Multicenter retrospective cohort study. METHODS: All eyes receiving intravitreal injection of 0.5 mg ranibizumab for retinal vascular diseases at 10 retina practices across the United States (2016 to 2017) and Japan (2009 to 2017) were included. The total numbers of eyes and injections were determined from billing codes. Endophthalmitis cases were determined from billing records and evaluated with chart review. Primary outcome was the rate of postinjection acute endophthalmitis. Secondary outcomes were visual acuity and microbial spectrum. RESULTS: A total of 243 754 intravitreal 0.5 mg ranibizumab injections (165 347 conventional and 78 407 prefilled) were administered to 43 132 unique patients during the study period. In the conventional ranibizumab group, a total of 43 cases of suspected endophthalmitis occurred (0.026%; 1 in 3845 injections) and 22 cases of culture-positive endophthalmitis occurred (0.013%; 1 in 7516 injections). In the prefilled ranibizumab group, 12 cases of suspected endophthalmitis occurred (0.015%; 1 in 6534 injections) and 2 cases of culture-positive endophthalmitis occurred (0.0026%; 1 in 39 204 injections). Prefilled syringes were associated with a trend toward decreased risk of suspected endophthalmitis (odds ratio 0.59; 95% confidence interval 0.31-1.12; P = .10) and a statistically significant decreased risk of culture-positive endophthalmitis (odds ratio 0.19; 95% confidence interval 0.045-0.82; P = .025). Average logMAR vision loss at final follow-up was significantly worse for eyes that developed endophthalmitis from the conventional ranibizumab preparation compared to the prefilled syringe group (4.45 lines lost from baseline acuity vs 0.38 lines lost; P = .0062). Oral-associated flora was found in 27.3% (6/22) of conventional ranibizumab culture-positive endophthalmitis cases (3 cases of Streptococcus viridans, 3 cases of Enterococcus faecalis) compared to 0 cases in the prefilled ranibizumab group. CONCLUSION: In a large, multicenter, retrospective study the use of prefilled syringes during intravitreal injection of ranibizumab was associated with a reduced rate of culture-positive endophthalmitis, including from oral flora, as well as with improved visual acuity outcomes.

Progression to Surgery for Patients With Idiopathic Epiretinal Membranes and Good Vision.

BACKROUND AND OBJECTIVE: Patients with idiopathic epiretinal membranes (ERMs) and visual acuity of 20/40 or better are often monitored until vision or associated symptoms worsen to affect everyday living. This study looks at the rate of progression to surgery and the characteristics associated with progression. PATIENTS AND METHODS: This study was a retrospective, consecutive case series of patients with newly diagnosed idiopathic ERMs who were referred to the Retina Service at the Ophthalmic Consultants of Boston between January 2009 and May 2015 with 20/40 or better visual acuity. Surgical membrane peel was typically offered when vision worsened to 20/50 or beyond and/or when patients could not tolerate symptoms attributable to the ERM. All eligible eyes were categorized by baseline optical coherence tomography (OCT) morphology into normal, mild or incomplete, or complete loss of foveal contour. Visual acuities were averaged through conversion to logMAR. Kaplan-Meier survival curves for progression to surgical membrane peel were calculated. The main outcome measure was progression to surgical intervention. RESULTS: The study included 201 eyes from 170 patients; 29.8% had normal, 18.9% had mild loss, and 51.2% had complete loss of foveal contour on baseline OCT. Overall, 13% of eyes progressed to surgery at 7 years. However, only 5% of eyes with normal foveal contour progressed to surgery by 5.5 years, whereas 17% with incomplete and 16% with complete loss of foveal contour progressed to surgery at 6 and 7 years, respectively. Eyes with worse foveal contours progressed to surgery more rapidly. CONCLUSION: A minority of patients with newly diagnosed ERMs who did not need surgical intervention progressed to needing surgery at 7 years with the rate and speed of progression dependent on baseline OCT morphology. These statistics can be useful in counseling patients who are deciding between watchful waiting and surgical intervention. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:S18-S22.].

YAG Laser Vitreolysis vs Sham YAG Vitreolysis for Symptomatic Vitreous Floaters: A Randomized Clinical Trial.

Importance: Vitreous floaters are common and can worsen visual quality. YAG vitreolysis is an untested treatment for floaters. Objective: To evaluate YAG laser vitreolysis vs sham vitreolysis for symptomatic Weiss ring floaters from posterior vitreous detachment. Design, Setting, and Participants: This single-center, masked, sham-controlled randomized clinical trial was performed from March 25, 2015, to August 3, 2016, in 52 eyes of 52 patients (36 cases and 16 controls) treated at a private ophthalmology practice. Interventions: Patients were randomly assigned to YAG laser vitreolysis or sham YAG (control). Main Outcomes and Measures: Primary 6-month outcomes were subjective change measured from 0% to 100% using a 10-point visual disturbance score, a 5-level qualitative scale, and National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25). Secondary outcomes included objective change assessed by masked grading of color fundus photography and Early Treatment Diabetic Retinopathy Study best-corrected visual acuity. Results: Fifty-two patients (52 eyes; 17 men and 35 women; 51 white and 1 Asian) with symptomatic Weiss rings were enrolled in the study (mean [SD] age, 61.4 [8.0] years for the YAG laser group and 61.1 [6.6] years for the sham group). The YAG laser group reported greater symptomatic improvement (54%) than controls (9%) (difference, 45%; 95% CI, 25%-64%; P < .001). In the YAG laser group, the 10-point visual disturbance score improved by 3.2 vs 0.1 in the sham group (difference, -3.0; 95% CI, -4.3 to -1.7; P < .001). A total of 19 patients (53%) in the YAG laser group reported significantly or completely improved symptoms vs 0 individuals in the sham group (difference, 53%; 95% CI, 36%-69%, P < .001). Compared with sham, NEI VFQ-25 revealed improved general vision (difference, 16.3; 95% CI, 0.9-31.7; P = .04), peripheral vision (difference, 11.6; 95% CI, 0.8-22.4; P = .04), role difficulties (difference, 17.3; 95% CI, 8.0-26.6; P < .001), and dependency (difference, 5.6; 95% CI, 0.5-10.8; P = .03) among the YAG laser group. Best-corrected visual acuity changed by -0.2 letters in the YAG laser group and by -0.6 letters in sham group (difference, 0.4; 95% CI, -6.5 to 5.3; P = .94). No differences in adverse events between groups were identified. Conclusions and Relevance: YAG laser vitreolysis subjectively improved Weiss ring-related symptoms and objectively improved Weiss ring appearance. Greater confidence in these outcomes may result from larger confirmatory studies of longer duration. Trial Registration: clinicaltrials.gov NCT02897583.

MICROBIOLOGIC SPECTRUM AND VISUAL OUTCOMES OF ACUTE-ONSET ENDOPHTHALMITIS UNDERGOING THERAPEUTIC PARS PLANA VITRECTOMY.

PURPOSE: To report the clinical presentation, microbiologic spectrum, and visual outcomes associated with acute-onset infectious endophthalmitis undergoing therapeutic pars plana vitrectomy. METHODS: Multicenter interventional retrospective noncomparative consecutive case series. Billing records were reviewed to identify all charts for patients undergoing pars plana vitrectomy within 14 days of diagnosis of acute-onset infectious endophthalmitis over a 4-year period at 5 large tertiary referral retina practices. Statistical analysis was performed to assess for factors associated with visual outcomes. RESULTS: Seventy patients were identified. The most common clinical setting was postcataract surgery (n = 20). Only 3 patients (4.3%) presented with 20/400 or better visual acuity (VA). Although most of the patients initially underwent vitreous tap and intravitreal antibiotic injection (n = 47, 67.1%), all patients eventually underwent pars plana vitrectomy within 14 days of presentation with 68.5% (48/70) of patients undergoing pars plana vitrectomy within 48 hours of presentation. Positive intraocular cultures were obtained in 56 patients (80%). The most common identified organism was Streptococcus sp (n = 19). Visual acuity at last follow-up was 20/400 or better in 19 patients (27.1%). Three patients underwent evisceration or enucleation (4.3%). Last recorded postoperative VA (mean LogMAR 1.99 ± 0.94, Snellen VA equivalent finger count) improved from presenting VA (mean LogMAR 2.37 ± 0.38, Snellen VA hand motions) (P ≤ 0.001). There was no statistically significant correlation between the underlying etiology or the timing of surgery with this VA outcome. CONCLUSION: Although less than one-third of patients achieved 20/400 or better VA, this VA often improved significantly from presenting VA.

Expanded spectral domain-OCT findings in the early detection of hydroxychloroquine retinopathy and changes following drug cessation.

PURPOSE: To report expanded SD-OCT findings of HCQ retinopathy that may assist the clinician in earlier diagnosis. To characterize structural changes of HCQ retinopathy with SD-OCT after drug cessation. METHODS: Setting: Private practice and academic institution. Patient Population: Patients at New England Eye Center and Ophthalmic Consultants of Boston in Boston, MA diagnosed with HCQ retinopathy and followed after drug cessation. Retrospective clinical data review by the Boston Image Reading Center. Main Outcome Measures: SD-OCT findings suggestive of HCQ retinopathy before parafoveal ellipsoid disruption. Change in SD-OCT morphological appearance and retinal thickness of each of the nine subfields corresponding to the Early Treatment of Diabetic Retinopathy Study areas. RESULTS: Thirty eyes with HCQ retinopathy were followed with SD-OCT after drug cessation. Findings before disruption of the parafoveal EZ included parafoveal outer nuclear layer (ONL) thinning, disruption of the parafoveal interdigitation zone, and reduced reflectivity of the parafoveal EZ. In early toxicity, 75 % developed progression after drug cessation, including disruption of the parafoveal EZ and retinal pigment epithelium and thinning of the ONL. Eyes with obvious toxicity had greater inferior outer ring thinning 12 months after drug cessation compared to early toxicity (p = 0.002, 95 % CI -2 to -8 µm). In obvious toxicity, the nasal inner subfield showed more thinning than the temporal inner subfield at 12 months after drug cessation (p = 0.018, 95 % CI -1 to -8 µm). CONCLUSIONS: Once HCQ retinopathy is diagnosed and the medication is discontinued, structural retinal changes commonly occur.

Aflibercept for Diabetic Macular Edema in Eyes Previously Treated With Ranibizumab and/or Bevacizumab May Further Improve Macular Thickness.

BACKGROUND AND OBJECTIVE: To evaluate the short-term anatomic and visual outcomes after aflibercept (Eylea; Regeneron, Tarrytown, NY) in eyes with diabetic macular edema (DME) previously treated with ranibizumab (Lucentis; Genentech, South San Francisco, CA) and/or bevacizumab (Avastin; Genentech, South San Francisco, CA). PATIENTS AND METHODS: A single-center, retrospective, noncomparative study of 30 eyes in 23 patients with DME treated with prior ranibizumab and/or bevacizumab before switching to aflibercept. RESULTS: Eyes received an average of 16 prior injections (range: three injections to 31 injections; median: 17 injections). The mean central subfoveal thickness (CST) improved from 453 µm at the time of first anti-vascular endothelial growth factor (VEGF) injection (range: 304 µm to 686 µm; median: 429 µm), to 374 µm at the time of the switch to aflibercept (range: 267 µm to 547 µm; median: 361 µm; P = .02), to 332 µm after the first aflibercept injection (range: 242 µm to 545 µm; median: 318 µm; P < .001). Visual acuity improved after switching to aflibercept at the first follow-up visit (logMAR 0.40 [Snellen equivalent 20/50]) to logMAR 0.35 (Snellen equivalent 20/45) (P = .044). CONCLUSIONS: In eyes with persistent DME treated with ranibizumab and/or bevacizumab, switching to aflibercept may further improve macular thickness. Given the cost difference between the three drugs, a randomized trial evaluating a stepwise approach may be worthwhile. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:836-839.].

Vascular endothelial growth factor and diabetic macular edema.

Diabetes mellitus is a major global health epidemic, and diabetic macular edema is the leading cause of vision loss in this population. Macular focal and/or grid laser photocoagulation applied to microaneurysms and thickened retina had long been primary therapy for diabetic macular edema. Chronically elevated serum glucose is known to cause breakdown in the inner and outer retinal blood barrier resulting in upregulation of vascular endothelial growth factor (VEGF). Intravitreal anti-vascular endothelial growth factor agents, including ranibizumab, bevacizumab, and aflibercept, have been shown in randomized clinical trials to be superior to macular laser for the treatment of clinically relevant diabetic macular edema. The READ-2, RISE/RIDE, and RESTORE trials established ranibizumab's superiority to macular laser, whereas the BOLT trial demonstrated bevacizumab's superiority to laser. The DRCR.net Protocol T results showed that intravitreal aflibercept, bevacizumab, and ranibizumab were all effective in reducing retinal thickness secondary to diabetic edema and in improving vision. When the presenting vision was 20/40 or better, visual improvement was equivalent. With eyes presenting with 20/50 or worse vision, aflibercept was superior with respect to visual improvement. Intravitreal anti-VEGF therapy can be burdensome for the patient and health care system, often requiring monthly treatment visits. To reduce burdens, anti-VEGF strategies are in development to lengthen the treatment interval.

Outcomes after Failed Pneumatic Retinopexy for Retinal Detachment.

PURPOSE: To provide visual and anatomic outcomes for patients with retinal detachment (RD) in whom primary pneumatic retinopexy (PR) failed. DESIGN: Retrospective, single-center, consecutive case series. PARTICIPANTS: Eyes with RD that failed a primary PR. METHODS: Anatomic and functional outcomes were evaluated for patients receiving treatment for failed PR. Three secondary procedures were compared, including repeat PR, pars plana vitrectomy (PPV), and combined scleral buckle (SB) plus PPV (SB+PPV). MAIN OUTCOME MEASURES: Anatomic reattachment and visual acuity (VA) at 1 year. RESULTS: Of a total of 423 primary PRs performed for RD, this study included 73 cases that failed. The overall single surgery anatomic success rate for the secondary procedure was 75%; the final success rate at 1 year was 100%. There was no statistically significant difference in success rates between repeat PR (63%), PPV (76%), and SB+PPV (88%). Improvement in VA was similar at 1 year between all 3 groups. Visual acuity at 1 year was similar between eyes undergoing PPV and SB+PPV (0.47 logMAR VA [Snellen equivalent, 20/59] for PPV and 0.52 logMAR VA [Snellen equivalent, 20/66] for SB+PPV; P = 0.75). Visual acuity at 1 year was better for those without macular involvement at the time of secondary procedure compared with eyes whose maculae detached (0.29 logMAR VA [Snellen equivalent, 20/39] vs. 0.73 logMAR VA [Snellen equivalent, 20/106]; P < 0.005). Fifty percent of PR failures underwent a secondary procedure within 1 week of primary PR; 80% occurred within 1 month. CONCLUSIONS: Anatomic success rates for secondary PR, PPV, and SB+PPV after failed PR were lower than published success rates for their use in primary RD. This suggests that a failed primary PR selects for RDs that are inherently more difficult to reattach. There was a trend suggesting that anatomic success rates are greater with SB+PPV than PPV and, in turn, with PPV than repeat PR. However, these differences were not statistically significant and did not translate into better VA gains at 1 year for either procedure. The suitable procedure after failed PR thus depends on patient presentation, surgeon preference, and patient preference.