Effects of hydroxychloroquine therapy on choroidal volume and choroidal vascularity index.

PURPOSE: To determine changes in choroidal volume (CV) and choroidal vascularity index (CVI) in patients on hydroxychloroquine (HCQ) therapy. METHODS: Retrospective analysis of patients on HCQ therapy. CV and CVI were assessed below the central foveal region on spectral-domain optical coherence tomography using an automatic denoising and localization algorithm. CV and CVI were compared with age-matched controls. Regression analyses were performed to generate associations between CV and CVI with demographics and HCQ treatment parameters. Associations were assessed using a generalized estimating equation model adjusted for intra-subject inter-eye correlations. RESULTS: A total of 137 adult patients (23 males and 114 females) were included. Mean age was 45.6 ± 13.7 years and most patients identified as Caucasian (79%). Total duration of HCQ therapy ranged from 3 months to 20 years. Daily HCQ intake varied from 150-600 mg (mean = 304 mg), while cumulative doses ranged from 18-2,800 g. At presentation, the median CV was 0.51 (IQR:0.356-0.747) mm, and median CVI was 0.559 (IQR:0.528-0.578). Increased cumulative HCQ dose was associated with decreased CV (p = 0.006). Compared to age-matched controls, CV, CVI, and luminal area were significantly lower in the study group (p = 0.0003, 0.0001, and 0.0002). CONCLUSION: In this study, we present a novel analysis of key biomarkers which predate the occurrence of HCQ retinopathy. Choroidal volume and vascularity index are significantly reduced in patients on HCQ therapy, especially at higher cumulative doses. These findings suggest new tools to guide medical decision-making for patients receiving HCQ therapy for rheumatologic diseases.

Screen Failures in Clinical Trials in Retina.

PURPOSE: Disparities in clinical trials are a major problem because of significant underrepresentation of certain gender, racial, and ethnic groups. Several factors including stringent eligibility criteria and recruitment strategies hinder our understanding of retinal disease. Thus, we aimed to study the various reasons of screen failures and specific patient and study characteristics among screen failures. DESIGN: This is a cross-sectional retrospective study. METHODS: Screening data of 87 trials from 6 centers were analyzed. Study characteristics (disease studied, phase of trial, and route of drug administration) and patient demographics (age, gender, race, ethnicity, and employment status) were compared among different causes of screen failures. Screen failures were broadly classified into 6 categories: exclusion because of vision-based criteria, exclusion because of imaging findings, exclusion because of other factors, patient-related criteria, physician-related criteria, and miscellaneous. Descriptive statistics, Pearson chi-square test, and analysis of variance were used for statistical analysis. MAIN OUTCOME MEASURES: Prevalence of various reasons for screen failures in multiple trials and its trend among different study and patient characteristics. RESULTS: Among 87 trials and 962 patients, 465 (48.2%) patients were successfully randomized and 497 (51.8%) patients were classified as screen failures. The trials were conducted for various retinal diseases. Mean age was 76.50 ±10.45 years and 59.4% were females. Predominantly White patients (93.4%) and unemployed/retired patients (66.6%) were screened. Of the 497 screen failures, most were because of patients not meeting inclusion criteria of imaging findings (n = 221 [44.5%]) followed by inclusion of vision-based criteria (n = 73 [14.7%]), exclusion because of other factors (n = 75 [15.1%]), patient-related (n = 34 [6.8%]), physician-related (n = 28 [5.6%]), and miscellaneous reasons (n = 39 [7.8%]). Reason for screen failure was not available for 27 (5.4%) patients. A higher proportion of patients screened for surgical trials (15%) declined to participate in the study compared with noninvasive trials involving topical drugs and photobiomodulation (0%) (P = 0.02). CONCLUSIONS: Patients not meeting the imaging and vision-cased criteria were the most common reasons for screen failures. White patients and unemployed patients predominantly participated in clinical trials. Patients are more inclined to continue participation in noninvasive clinical trials compared with surgical trials. Better recruitment strategies and careful consideration of study criteria can aid in decreasing the rate of screen failures.

A Case of Full Thickness Parafoveal Hole Associated with Chorio-Retinal Atrophy.

BACKGROUND: An idiopathic full-thickness parafoveal hole (PFH) in the absence of trauma or intraocular surgery is a rare finding. CASE: A 60-year-female who did not gain good vision following an uneventful phacoemulsification with intraocular lens (IOL) implantation in the right eye (RE) consulted a retina specialist, one year after her cataract surgery. There was no history of trauma, radiation exposure, reduced scotopic vision, or any other intraocular surgery. Her personal and family history were unremarkable for any systemic or ocular diseases. Routine blood investigations, an electrocardiogram, and a detailed ocular examination were done. OBSERVATION: She had the best corrected visual acuity (BCVA) of LogMAR 1.0 (20/200; 6/60) in the right eye. The right eye had an axial length (AL) of 23.50 mm and an intraocular lens power of 21.0 dioptres. The ultrawide field fundus examination saw parafoveal chorio-retinal atrophy without significant peripheral myopic degeneration. On optical coherence tomography (OCT), a central foveal thickness of 138 microns with foveal scarring was noticed. There was a full-thickness parafoveal hole between the fovea and optic disc having a height of 198 microns; base diameter of 240 microns; arm lengths of 203 microns and 206 microns; and a minimum linear dimension of 42 microns. The optical coherence tomography angiography scan showed a reduced vessel density in the superficial and deep retina; and increased visibility of choroidal vessels in outer retina chorio-capillaries, chorio-capillaries, and choroid slab at the parafoveal hole The ultrasound B scan was anechoic and there was no posterior vitreous detachment (PVD). CONCLUSION: The axial length, intraocular lens power and fundus examination did not indicate pathological myopia. As there was no preceding posterior vitreous detachment or retinal surgery, the underlying retinochoroidal atrophy most probably caused the full-thickness parafoveal hole.

Functional and Morphological Characteristics of the Retina of Patients with Drusen-like Deposits and Systemic Lupus Erythematosus Treated with Hydroxychloroquine: A Retrospective Study.

PURPOSE: To evaluate the impact of drusen-like deposits (DLD) on retinal layer integrity and retinal function by optical coherence tomography (OCT) and multifocal electroretinography (mfERG) in patients with systemic lupus erythematosus (SLE). METHODS: We identified 66 eyes of 33 SLE patients treated with hydroxychloroquine (HCQ) that were categorized into two groups according to whether DLDs were present (34 eyes, Group One) or absent (32 eyes, Group Two). The groups were matched for age, sex, HCQ treatment duration, daily, and cumulative dosage. OCT (retinal layer thicknesses, central retinal thickness, CRT) and mfERG concentric ring analysis were analyzed and compared. RESULTS: CRT was significantly thicker in Group One compared to Group Two (273.21 ± 3.96 vs. 254.5 ± 7.62) (p = 0.023). Group One also demonstrated an overall thicker retinal pigment epithelium compared to Group Two; however, the other outer retinal layers, outer nuclear layer, and photoreceptor layer were found to be significantly thinner in Group One compared to Group Two. We found no differences in mfERG parameters between the two groups. CONCLUSIONS: DLDs in SLE patients lead to abnormal central retinal layer thickness, which has no measurable impact on cone-mediated retinal function assessed by mfERG.

Unusual presentation of cornea verticillata with intravitreal methotrexate in a case of primary intraocular lymphoma.

A 56-year-old woman presented with floaters and diminution of vision in the right eye for 1 week. On examination, visual acuity was 20/400 in the right eye and 20/60 in the left eye. Indirect ophthalmoscopy revealed vitritis in the right eye and subretinal deposits in both eyes. Vitreous biopsy of the right eye revealed large B-cell-type primary intraocular lymphoma and the patient underwent multiple intravitreal methotrexate injections (400 µg/0.1 mL) in the right eye and systemic chemotherapy for bilateral disease. Following biweekly injections of methotrexate, her visual acuity improved considerably from 20/400 to 20/60 with resolution of vitritis. However, following eighth dose of intravitreal methotrexate, she experienced visual decline to 20/120 along with photophobia, redness and watering. Whorl-shaped opacities, limbitis and corneal haze were noted on slit-lamp examination. Intravitreal methotrexate was stopped, and the patient was started on frequent topical lubricants, loteprednol, topical folinic acid and oral folic acid. Complete resolution of corneal toxicity was observed at 3 weeks and the injections were suspended as there was no recurrence at 6 months follow-up.

A comprehensive review of intravitreal immunosuppressants and biologicals used in ophthalmology.

Systemic immunosuppressants and biologicals have been a valuable tool in the treatment of inflammatory diseases and malignancies. The safety profile of these drugs has been debatable, especially in localized systems, such as the eye. This has led to the search for fairly local approaches, such as intravitreal, subconjunctival, and topical route of administration. Immunosuppressants have been used as a second-line drug in patients intolerable to corticosteroids or those who develop multiple recurrences on weaning corticosteroids. Similarly, biologicals have also been used as the next line of therapy, when adequate control of inflammation could not be attained or immunosuppressants were contraindicated to patients. Intravitreal immunosuppressants, such as methotrexate and sirolimus, have been extensively studied in noninfectious posterior uveitis, whereas limited studies have established the efficacy of intravitreal biologicals, such as infliximab and adalimumab. Most of these drugs have shown good safety profile and tolerability in animal studies alone and have not been studied further in human subjects. However, most of the studies in literature are single-case reports or case series which limits the level of evidence. In this comprehensive review, we discuss the mechanism of action, pharmacodynamics, pharmacokinetics, indications, efficacy, and side effects of different intravitreal immunosuppressants and biologicals that have been studied in literature.

Real-life comparison of three intravitreal antibiotic drug regimens in endophthalmitis.

Purpose: Real-life comparison of three intravitreal drug regimens used in cases of endophthalmitis at a tertiary care center in India. Methods: In this prospective, comparative study, patients of bacterial endophthalmitis were grouped according to intravitreal antibiotic drug regimens into Group 1 (ceftazidime and vancomycin), Group 2 (piperacillin + tazobactam and vancomycin), and Group 3 (imipenem and vancomycin). Forty-eight hours after injection nonresponding/worsening patients underwent vitrectomy. Vitreous samples were subjected to microbiological and pharmacokinetic tests. Results: A total of 64 patients were included and divided into Group 1: 29, Group 2: 20, and Group 3: 15 cases. Also, 75% of patients were post-surgical endophthalmitis, whereas 25% were post-traumatic. Improvement in vision (V90-0) and vision at 3 months (V90) were comparable between the three groups. Visual recovery was poorer in post-traumatic cases. In post-surgical cases, visual recovery was poorer in those presenting beyond 72 h of onset of symptoms (P = 0.0002). Polymerase chain reaction (PCR) positivity (66%) was higher than BACTECTM (33%) and culture (14%). Antibiotic resistance was comparable amongst the three groups. Most patients (62/64) further underwent vitrectomy. Ceftazidime and vancomycin achieved vitreous concentrations more than the minimum inhibitory concentration (MIC) at 48 h after the first injection. Conclusion: The choice of antibiotics did not affect the rate of vitrectomy and final vision in a real-life scenario. Ceftazidime and vancomycin can still be used as first-line intravitreal antibiotics owing to their comparable microbial sensitivity profile and adequate ocular bioavailability.

Optical Coherence Tomography Angiography following Scleral Buckling Surgery.

INTRODUCTION: The retinal changes following scleral buckling surgery (SBS) for rhegmatogenous retinal detachment (RRD) have been rarely evaluated with optical coherence tomography angiography (OCTA). METHODS: A 40 years old male presented with subtotal RD involving the macula and had best corrected visual acuity of logmar 2.3 in the affected right eye. Five months after applying 120 degree scleral buckle, swept source optical coherence tomography (SSOCT) and swept source optical coherence tomography angiography (SS-OCTA) were done. RESULT: At five months post-surgery, despite a settled retina in the operated eye, the patient had vision of logmar 1 and thin retinal nerve fibre layer (115 micrometer). The SSOCT showed inner segment-outer segment (IS-OS) junction disruption, thinned retinal pigment epithelium, central macular thickness of 275 micrometer and subfoveal choroidal thickness of 222 micrometer. A 3x3 mm macular OCTA scan showed a normal foveal avascular zone along with higher values for vascular density in superficial capillary plexus in all quadrants except temporal quadrant in operated eye as compared to fellow eye. CONCLUSION: The SBS with 120 degree buckle did not lead to a reduced vascular density in superficial capillary plexus in the operated eye with respect to fellow eye.

Heads-up 3D viewing system in rhegmatogenous retinal detachment with proliferative vitreoretinopathy - A prospective randomized trial.

Purpose: To compare the outcomes of vitreoretinal surgery in patients with primary and recurrent rhegmatogenous retinal detachment (RRD) with proliferative vitreoretinopathy (PVR) on 3 dimensional digitally assisted visualization system (3D-DAVS) and conventional analogue microscope (CAM). Methods: 68 patients with primary (50) and recurrent (18) RRD with PVR > C1 were included. One group underwent surgery on 3D-DAVS while the other on CAM. The parameters studied included detachment rate, best-corrected visual acuity (BCVA), duration of surgery, mean endo-illumination levels of 23 G (Gauge) micro incision vitrectomy system (MIVS) and microscope and satisfaction of surgeon and observers based on a framed questionnaire. The mean duration of follow up was three months. Results: 68 eyes of 68 patients with median age 52.5 (range 18-68) years were included. 50 had primary RRD and 18 had recurrent RRD. Detachment rate at the end of three months was comparable in both groups of primary (P > 0.99) and recurrent (P = 0.21) RRD. Mean duration of surgery in minutes for 3D DAVS and CAM group was 61.8 (±22.07) and 58.04 (±12.33), respectively, in primary RRD and 37.22 (±10.27) and 36.55 (±5.92), respectively, in recurrent RRD group. Mean endo-illumination in 3D DAVS (14.5%) group was half of that in CAM (34.17%) group. Surgeon and observer satisfaction scores were significantly higher for 3D DAVS group. Conclusion: 3D DAVS is a safe and effective modality or performing VR surgery in RRD with PVR. 3D DAVS allows lower endo-illumination levels provides superior surgeon ergonomics and offers better learning opportunities to the trainees.

Demography, clinical profile and surgical outcomes of paediatric giant retinal tear related retinal detachments.

OBJECTIVE: To determine the demographic profile, clinical features and surgical outcomes of giant retinal tear (GRT) related retinal detachments (RD) in children. METHODS: In this retrospective study, medical records of children aged 14 years and below, who underwent surgery for RD at our centre in the last 5 years were reviewed. Among these, we selected medical records of children with RDs with GRT, and examined the coloured retinal drawings, ultrawidefield photographs and/or surgical videos. RESULTS: Out of 1536 medical records, 91 eyes of 87 children (5.6% of all RDs) were included. Mean age was 10.21 ± 3.08 years with male:female ratio of 8.6:1. The most common aetiologies for GRTs were high myopia (28 cases-32.18%) and trauma (25 cases-28.73%). Bilateral RD were possibly present in 29/87 (33.3%) cases. Six months follow up data was available for 82/91 eyes. Overall retinal re-attachment was achieved in 52/82 (63.41%) eyes; in 33/82 (40.24%) eyes retinal attachment could be achieved by a single surgery. Absence of proliferative vitreoretinopathy (PVR) (OR: 2.44, p-value:0.03, 95%CI: 1.21-5.08) or PVR-A (OR: 3.62, p-value: 0.03, 95%CI: 1.52-12.26) and presence of preexisting posterior vitreous detachment (OR: 7.14, p-value: 0.02, 95%CI: 1.31-38.73) were associated with successful retinal re-attachment after single surgery. Median time to presentation of cases succeeding after 1 surgery was 10 days. Ambulatory vision (1/60 and better) at final followup could be achieved in 45/82 (54.88%) eyes. CONCLUSION: GRT relatedRDs constitute a significant proportion of paediatric RDs. Anatomical success can currently be achieved in a large number of cases. Early surgery, absence of PVR and presence of PVD are associated with higher surgical success.

Optical coherence tomography angiography-guided photodynamic therapy for extrafoveal choroidal neovascularization.

Type 1 extrafoveal choroidal neovascularization (CNV) secondary to neovascular age-related macular degeneration was diagnosed in a 68-year-old woman using optical coherence tomography angiography (OCT-A) alone. The entire network of vessels was clearly visible on a 12 × 12 mm OCT-A scan segmented below the retinal pigment epithelium. The patient was initially treated with intravitreal ranibizumab followed by photodynamic therapy (PDT) guided by OCT-A. Complete resolution of subretinal fluid with shrinkage of the neovascular complex was noted 1 month after PDT.

Intraoperative optical coherence tomography-guided subretinal cocktail injection in a case of ruptured retinal artery macro-aneurysm with multilevel bleed.

Submacular hemorrhage (SMH) following ruptured retinal artery macro aneurysm (RRAM) has better prognosis as compared to other etiologies. Timely intervention from as early as 24 h to less than 7 days is known to provide better visual outcomes in such cases. A variety of surgical techniques have been described in the treatment of RRAM. In this case report, we describe the advantages of intraoperative optical coherence tomography-guided sub-retinal injection of a cocktail mixture consisting of recombinant tissue plasminogen activator, bevacizumab, and air. Faster visual recovery with an immediate displacement of sub-macular bleed can be achieved with this technique in cases of RRAM-associated SMH.

Three-years follow-up swept source optical coherence tomography angiography findings in post-fever retinitis.

Post fever retinitis (PFR), characterized by multiple cotton wool spot like lesions in the posterior pole, is commonly reported following viral and bacterial infections. Retinal perfusion defects have been documented with the help of optical coherence tomography angiography (OCTA) in cases of PFR. But long term changes in such cases have not been reported earlier. In the following report, we have described the swept-source OCTA findings of two PFR patients at initial presentation and three years follow-up. Initial OCTA scans may not provide accurate information regarding the perfusion status due to associated retinal edema and inflammation. However, persisting perfusion defects at the superficial and deep retinal capillary plexus were noted on long term follow-up in both the cases.

Age-related changes in macular vessels and their perfusion densities on optical coherence tomography angiography.

Purpose: To evaluate age-related changes in macular vessels and their perfusion densities using optical coherence tomography angiography (OCTA). Methods: A total of 108 eyes of 54 healthy subjects between the age group of 11 to 60 years having unaided visual acuity of 20/20 were studied on spectral domain OCTS using 3 * 3 mm macula protocol. These subjects were divided into 5 groups; Group 1: 11-20 years, Group 2: 21-30 years, Group 3: 31-40 years, Group 4: 41-50 years, and Group 5: 51-60 years. An early treatment diabetic retinopathy study (ETDRS) grid overlay at the macula was used to calculate changes in different quadrants of the superficial retinal plexus. Results: A total of 98 eyes of 49 patients were considered for the final analysis. The vessel density values decreased from the second to the sixth decade in all four quadrants (except the third decade, where a slight increase was noted). The total vessel density decreased from 168 ± 78 mm-1 (group 1) to 131.47 ± 18.32 mm-1 (group 5). A similar reduction pattern in perfusion density was seen in each quadrant from the second to the sixth decade. The total perfusion density reduced from 309 ± 15.63% (group 1) to 283.05 ± 45.23% (group 5). The foveal avascular zone area was 0.18 ± 0.09 mm2 in group 1, 0.33 ± 0.13 mm2 in group 2, 0.30 ± 0.10 mm2 in group 3, 0.38 ± 0.05 mm2 in group 4, and 0.46 ± 0.06 mm2 in group 5. Conclusion: In our population, macular vessel density appears to decrease noticeably from the fourth decade onwards but a statistically significant decrease was observed only from the fifth decade onwards. However, it was not uniform along with all the quadrants. Similarly, the percentage of perfusion density dropped from the fourth decade but these values also varied among the different quadrants.

Clinical features, optical coherence tomography findings and treatment outcomes of post-fever retinitis.

OBJECTIVES: To study the clinical features, optical coherence tomography (OCT) findings, treatment options and follow-up outcomes of post-fever retinitis (PFR). SUBJECTS: A total of 19 eyes of 13 patients, diagnosed with PFR (retinitis following febrile episode) over 2 years were retrospectively studied. METHODS: Documented history, baseline clinical features and systemic investigations performed for PFR were reviewed. Fundus findings, foveal architecture on swept-source OCT, the treatment options and the follow-up outcomes including best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were reviewed and analyzed. RESULTS: Common fundus findings included whitish retinitis lesions (100%), macular star (95%, 18eyes), retinal flame-shaped hemorrhages (63%, 12 eyes), inflammatory retinal vessels (30%, 6 eyes), vitreous hemorrhage (one eye) and OCT findings included neuro-sensory detachment (79%, 15 eyes), intraretinal white dots (89.5%,17 eyes). The baseline median log MAR BCVA and CFT were 1.30 (interquartile range (IQR):0.8-1.8) and 423 microns (IQR:182-555). Overall, nine patients (12 eyes) received a combination of oral doxycycline and oral steroids and four patients (7 eyes) received a combination of oral doxycycline, oral steroid and intravitreal anti-vascular endothelial growth factor (IVA). Significant improvement was evident at 8 weeks in median BCVA (0.50, IQR: 0.3-0.8, p < 0.05) and median CFT (223 micron, IQR: 170-256, p < 0.05) though only 26% (5 eyes) attained BCVA > = 6/12. CONCLUSION: Our study puts forth certain characteristic fundus and OCT features of PFR. A combination of oral doxycycline and oral steroids as a treatment option showed improvement in BCVA and CFT. Additional IVA helps in faster visual recovery in patients presenting with severe macular edema at onset.

Coastline like peripheral chorioretinal degeneration as a suspected cause of nasal retinal dialysis.

Retinal dialysis is mostly associated with blunt trauma or at times spontaneous. A patient presented to us with fresh rhegmatogenous retinal detachment with no telltale history or signs of trauma. The causative break was retinal dialysis noted on the superonasal periphery. A characteristic peripheral chorioretinal degeneration simulating a coastline almost extending six clock hours was seen in both the eyes. We have discussed this rare presentation and the possibilities of the association between this newly identified lesion and spontaneous retinal dialysis in the following case report.

Do oblate eyeballs exist? A rare case of rhegmatogenous retinal detachment in an elliptical globe.

A patient, being a moderate myope with an axial length of 24.71 mm, presented to us with a fresh rhegmatogenous retinal detachment and marked peripheral chorioretinal degeneration. Difficulty in maneuvering with the standard 23 gauge vitrectomy cutter, inability to identify the break due to poor peripheral contrast, inadequate laser uptake, and an unusual large silicon oil fill (7.3 ml) were a few findings raising suspicion. Postoperative ocular ultrasonography showed an oblate eyeball with a relatively longer oblique axis (26.1 mm) as compared to the axial length confirming our suspicion. Oblateness should be suspected when the chorioretinal degenerations are more marked in the periphery as compared to the posterior pole. Intraoperative difficulties should be kept in mind while operating such cases.

Polypoidal choroidal vasculopathy: a comprehensive clinical update.

Polypoidal choroidal vasculopathy as a disease is yet to be comprehended completely. The clinical features consisting of huge serosanguineous retinal pigment epithelial and neurosensory layer detachments, although unique may closely mimick neovascular age-related macular degeneration and other counterparts. The investigative modalities starting from indocyanine angiography to optical coherence tomography angiography provide diagnostic challenges. The management strategies based on the available therapies are plenty and not vivid. A detailed review with clarifying images has been compiled with an aim to help the readers in getting a better understanding of the disease.

Comparison of clinical outcomes between "heads-up" 3D viewing system and conventional microscope in macular hole surgeries: A pilot study.

PURPOSE: To compare clinical outcomes of patients undergoing macular hole surgery with heads-up three-dimensional (3D) viewing system and conventional microscope. METHODS: In all, 50 eyes of 50 patients with stage 3 or 4 macular hole were randomized and macular hole surgery [inverted internal limiting membrane (ILM) flap technique] was performed in 25 eyes using 3D viewing system and 25 eyes using conventional microscope. All surgeries were performed by a single surgeon. Patients were followed up for a period of 3 months. Logarithm of the minimum angle of resolution (logMAR) visual acuity, macular hole index, intraoperative parameters such as total surgical time, total ILM peel time, number of flap initiations, duration of Brilliant Blue G dye exposure, illumination intensity, postoperative logMAR visual acuity, and macular hole closure rates were recorded and compared between the two groups. RESULTS: The mean age was 67.92 ± 7.95 and 67.96 ± 4.78 years in both groups, respectively (P = 0.98). Gender (P = 0.38) and right versus left eye (P = 0.39) were also comparable. Preoperative and postoperative best-corrected visual acuity (P = 0.86, 0.92), macular hole index (P = 0.96), total surgical time (P = 0.56), total ILM peel time (P = 0.49), number of flap initiations (P = 0.11), and macular hole closure rates (P = 0.61) were not statistically significant when compared between the two groups. Illumination intensity of microscope (100% vs 45%) and endoillumination (40% vs 13%) were significantly less in the 3D viewing system. CONCLUSION: The clinical outcomes of macular hole surgery using 3D viewing system are not inferior to that of conventional microscopes, and it has the added advantages of better ergonomics, reduced phototoxicity, peripheral visualization, magnification, and less asthenopia, and it serves as a good educational tool.