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.

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.

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.

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.

Expanded criteria for pneumatic retinopexy and potential cost savings.

PURPOSE: To provide insight into the preoperative factors that affect outcome after pneumatic retinopexy (PR) for treatment of primary rhegmatogenous retinal detachment repair. Additionally, we sought to analyze the cost of rhegmatogenous retinal detachment repair in the United States to determine potential cost savings with pneumatic retinopexy. DESIGN: Single-center, retrospective, observational consecutive case series and third party payer-perspective comparative cost analysis. PARTICIPANTS: We included 141 eyes undergoing pneumatic retinopexy for the treatment of primary rhegmatogenous retinal detachment. METHODS: Preoperative characteristics, anatomic outcomes, and best-available visual acuity were collected. Anatomic and visual outcomes were analyzed based on the presence of selected preoperative factors. The primary cohort was divided into 2 groups based on preoperative characteristics: (1) traditional pneumatic retinopexy and (2) nontraditional pneumatic retinopexy. Comparative cost analyses were performed between pneumatic retinopexy, scleral buckling, and vitrectomy. MAIN OUTCOME MEASURES: Anatomic and visual outcomes at 6 months. RESULTS: Overall anatomic success was 78.7% and visual acuity improved significantly (logarithm of the minimum angle of resolution [logMAR] 0.48-0.25; P <0.005). A 97.6% final anatomic success rate was achieved. Anatomic outcomes were similar between traditional versus nontraditional (84.1% vs 74.4%; P = 0.16), phakic versus pseudophakic (79.1% vs 78.0%; P = 0.88), and macula-on versus macula-off (77.9% vs 81.1%; P = 0.68) groups. Anatomic failure was predicted by the presence of an inferior retinal break (P <0.005) or visible vitreous traction on a retinal break (P = 0.04). Visual outcomes were similar between each of the traditional versus nontraditional (logMAR 0.21 vs 0.27; P >0.05) and phakic versus pseudophakic groups (logMAR 0.23 vs 0.28; P >0.05). Visual outcomes were better in macula-on detachments compared with those in which the macula was detached (logMAR 0.18 vs 0.42; P <0.005). Annual health care cost savings in the United States ranging from $6 to $30 million are theoretically possible by increasing pneumatic retinopexy utilization from the current rate of 15% to 20%-35%. CONCLUSIONS: Pneumatic retinopexy is an effective treatment modality for primary rhegmatogenous retinal detachment. Anatomic and visual outcomes are similar for traditional and nontraditional preoperative inclusion criteria, as well as phakic and pseudophakic eyes. Inferior breaks and visible vitreous traction on a tear predicted failure. Increased utilization of pneumatic retinopexy would achieve significant cost savings while maintaining outcomes.

Rapid grading of fundus photographs for diabetic retinopathy using crowdsourcing.

BACKGROUND: Screening for diabetic retinopathy is both effective and cost-effective, but rates of screening compliance remain suboptimal. As screening improves, new methods to deal with screening data may help reduce the human resource needs. Crowdsourcing has been used in many contexts to harness distributed human intelligence for the completion of small tasks including image categorization. OBJECTIVE: Our goal was to develop and validate a novel method for fundus photograph grading. METHODS: An interface for fundus photo classification was developed for the Amazon Mechanical Turk crowdsourcing platform. We posted 19 expert-graded images for grading by Turkers, with 10 repetitions per photo for an initial proof-of-concept (Phase I). Turkers were paid US $0.10 per image. In Phase II, one prototypical image from each of the four grading categories received 500 unique Turker interpretations. Fifty draws of 1-50 Turkers were then used to estimate the variance in accuracy derived from randomly drawn samples of increasing crowd size to determine the minimum number of Turkers needed to produce valid results. In Phase III, the interface was modified to attempt to improve Turker grading. RESULTS: Across 230 grading instances in the normal versus abnormal arm of Phase I, 187 images (81.3%) were correctly classified by Turkers. Average time to grade each image was 25 seconds, including time to review training images. With the addition of grading categories, time to grade each image increased and percentage of images graded correctly decreased. In Phase II, area under the curve (AUC) of the receiver-operator characteristic (ROC) indicated that sensitivity and specificity were maximized after 7 graders for ratings of normal versus abnormal (AUC=0.98) but was significantly reduced (AUC=0.63) when Turkers were asked to specify the level of severity. With improvements to the interface in Phase III, correctly classified images by the mean Turker grade in four-category grading increased to a maximum of 52.6% (10/19 images) from 26.3% (5/19 images). Throughout all trials, 100% sensitivity for normal versus abnormal was maintained. CONCLUSIONS: With minimal training, the Amazon Mechanical Turk workforce can rapidly and correctly categorize fundus photos of diabetic patients as normal or abnormal, though further refinement of the methodology is needed to improve Turker ratings of the degree of retinopathy. Images were interpreted for a total cost of US $1.10 per eye. Crowdsourcing may offer a novel and inexpensive means to reduce the skilled grader burden and increase screening for diabetic retinopathy.

Topical aqueous suppression does not significantly affect duration of intraocular gas tamponade after vitrectomy.

PURPOSE: To determine if topical aqueous suppression affects the duration of intraocular sulfur hexafluoride (SF6) gas tamponade after pars plana vitrectomy. METHODS: A prospective randomized controlled trial was conducted on patients undergoing 23-gauge sutured pars plana vitrectomy with air-fluid exchange and 20% SF6 gas tamponade. Eyes were randomly assigned to receive either postoperative topical dorzolamide 2%-timolol 0.5% twice a day or no additional drops (control group). Standard postoperative topical antibiotics and corticosteroids were used by all patients. RESULTS: A total of 21 patients were recruited for the study. Four were excluded because of noncompliance with use of dorzolamide-timolol. In the remaining 17 patients, 8 were randomly assigned to the dorzolamide-timolol group and 9 to the control group. Topical dorzolamide-timolol drops twice a day did not affect the duration of SF6 gas tamponade after pars plana vitrectomy (17.1 vs. 18.1 days with no drops, P = 0.35). The difference in mean gas duration was -1.0 days with a 95% confidence interval of -3.2 days to 1.2 days. Secondary analyses did not reveal a difference in SF6 duration based on lens status, presence of diabetes or hypertension, vitrectomy versus combined buckle with vitrectomy, or patient age. CONCLUSION: Topical aqueous suppression with dorzolamide-timolol does not have a large effect on duration of SF6 gas tamponade after pars plana vitrectomy.

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.

Outcomes and risk factors associated with endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents.

OBJECTIVE: To describe outcomes of and risk factors for endophthalmitis after intravitreal anti-vascular endothelial growth factor (VEGF) injection. DESIGN: Single-center, consecutive, case series and retrospective case-control study. PARTICIPANTS: Between January 1, 2009, and May 31, 2010, 16 vitreoretinal surgeons administered a total of 27 736 injections. During this period, 23 cases of presumed infectious endophthalmitis occurred. Each surgeon used his own preferred injection technique. INTERVENTION: Vitreous or aqueous tap, or both, with intravitreal antibiotic injection and subsequent topical antibiotic and steroid drops. MAIN OUTCOME MEASURES: Visual acuity, bladed lid speculum use, conjunctival displacement, hemisphere of injection, bevacizumab versus ranibizumab, and infectious organism. RESULTS: Seven of 23 cases had positive culture results; 3 grew coagulase-negative Staphylococcus. All cases had pain and vitritis on average 3.4 days (range, 1-6 days) after injection, with no difference between culture-positive and culture-negative groups. Eighteen (78%) of 23 cases had a hypopyon. Fifteen of 23 cases returned to baseline vision (±2 lines) within 3 months. Neither lid speculum use (0.10% vs. 0.066% in the no-use group; P = 0.27), conjunctival displacement (0.11% vs. 0.076% in the no-displacement group; P = 0.43), hemisphere of injection (0.11% superior vs. 0.079% inferior; P = 0.56), or bevacizumab versus ranibizumab (0.11% vs. 0.066%; P = 0.21) affected risk. Analysis of only culture-positive results yielded similar results. There was no statistically significant difference between the proportion of culture-negative cases after bevacizumab injection (83%) versus ranibizumab injection (55%; P = 0.13). CONCLUSIONS: Most patients in whom presumed infectious endophthalmitis develop after anti-VEGF injection regained baseline vision after treatment. Bladed lid speculum use, conjunctival displacement, hemisphere of injection, and type of anti-VEGF agent did not affect risk. No difference in culture-negative endophthalmitis rates was detected after bevacizumab versus ranibizumab injection. Neither the presence of pain, vitritis, decreased vision, hypopyon, nor the interval between injection and development of symptoms differentiate culture-positive from culture-negative cases. Because a subgroup of patients had poor outcomes, a low threshold for vitreous tap with intravitreal antibiotic injection may be warranted. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Bilateral uveal melanoma in an arc welder.

PURPOSE: To report sequential bilateral uveal melanoma in an arc welder. METHODS: Case report. RESULTS: A 57-year-old Caucasian male, with a 15-year profession of arc welding, was found to have an iridociliary mass in his left eye (OS), measuring 14 × 10 × 4 mm, and proven on fine needle aspiration biopsy to be spindle B-cell melanoma. A coincidental small choroidal nevus was observed in the right eye (OD). There was no ocular melanocytosis. Plaque radiotherapy was applied OS, with regression of the iridociliary melanoma. Four years later, the choroidal nevus OD enlarged into melanoma measuring 8 × 7 × 2.7 mm and was treated successfully with plaque radiotherapy. There was no evidence of systemic metastasis at 56-month follow-up. CONCLUSION: Arc welding is a known environmental risk for unilateral uveal melanoma, and possibly predisposed our patient to bilateral uveal melanoma.

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.

Treatment of acute retinal necrosis.

OBJECTIVES: To compare outcomes from patients with acute retinal necrosis (ARN) treated in the acyclovir-only era with those treated in the era of newer antiviral therapies, identify variables affecting outcomes in ARN, and evaluate strategies for fellow eye prophylaxis. DESIGN: Multicenter, nonrandomized, retrospective, interventional series. PARTICIPANTS: A cohort of 58 patients diagnosed with ARN by a retina specialist at 1 of 4 referral centers between 1981 and 2008. The cohort was divided into 2 subgroups: patients treated during the acyclovir-only era (n = 36) and patients treated during the current era of newer antiviral medications (n = 22). INTERVENTION: Intravenous, oral, or intravitreal antiviral medications, including acyclovir, valacyclovir, famciclovir, valganciclovir, ganciclovir, and foscarnet; prophylactic laser retinopexy; aspirin; oral steroids. MAIN OUTCOME MEASURES: Visual acuity, retinal detachment, and fellow eye involvement. RESULTS: A wide range and combination of antiviral agents are currently used for initial and long-term treatment of ARN. Outcomes from the newer antivirals era were similar to those achieved during the acyclovir-only era. In both groups, the incidence of 20/200 or worse visual acuity was 24% per person-year (P = 0.91). The prevalence of retinal detachment was approximately 50% in each group (P = 0.59). No variables, including prophylactic laser retinopexy, were associated with risk of retinal detachment. Two patients (3.4%) developed ARN in the initially unaffected eye. CONCLUSIONS: Current treatment trends vary widely, including single agents or combinations of oral, intravenous, and intravitreal agents. Differing strategies did not affect outcomes. The final visual acuity in ARN was generally poor. Retinal detachment was common and could neither be predicted nor prevented. Development of ARN in the unaffected fellow eye occurred rarely. Long-term oral antiviral treatment strategies varied with unclear relative efficacy. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Ranibizumab for exudative age-related macular degeneration in eyes previously treated with alternative vascular endothelial growth factor inhibitors.

BACKGROUND AND OBJECTIVE: To evaluate ranibizumab for exudative age-related macular degeneration previously treated with pegaptanib, bevacizumab, or both. PATIENTS AND METHODS: This was a retrospective, interventional case series of patients with exudative age-related macular degeneration who were treated with ranibizumab after being initially treated with pegaptanib, bevacizumab, or both. The primary outcome was change in visual acuity following the switch to ranibizumab. RESULTS: One hundred two eyes of 92 patients were identified. Following the switch to ranibizumab, there was an average gain of 0.7 lines in visual acuity. Ninety-four eyes (92%) lost 3 or fewer lines, 29 eyes (28%) gained more than 3 lines, and 3 eyes (3%) lost more than 6 lines after switching to ranibizumab. Lesion type and time between previous vascular endothelial growth factor inhibitor and ranibizumab did not affect the response. CONCLUSION: Ranibizumab maintained visual acuity in the majority of patients and appears to be an effective treatment regardless of previous anti-vascular endothelial growth factor therapy.

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.].

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.

The association of cutaneous and iris nevi with uveal melanoma: a meta-analysis.

PURPOSE: To study the relationship between cutaneous and iris nevi with uveal melanoma. DESIGN: Meta-analysis. METHODS: Three researchers independently searched the literature using Medline from 1966 to August 2007 (with both Ovid and PubMed), EMBASE, MD Consult, and the Web of Science. All bibliographies were searched, and an attempt to contact all primary authors was made to find further unpublished studies. MAIN OUTCOME MEASURES: Risk factor data were extracted into 4 a priori groups: (1) atypical cutaneous nevi, (2) common cutaneous nevi, (3) cutaneous freckles, and (4) iris nevi. RESULTS: Meta-analysis of 4 studies (850 cases) examining atypical cutaneous nevi yielded a summary odds ratio (OR) of 2.82 (95% confidence interval [CI], 1.10-7.26; P=0.032). Common cutaneous nevi were reported in 4 studies (825 cases), yielding a summary OR of 1.74 (CI, 1.27-2.39; P=0.001). Cutaneous freckles using 7 studies (2122 cases) found an OR of 1.22 (CI, 1.03-1.45; P=0.022). Iris nevi using 4 studies (825 cases) found an OR of 1.53 (CI, 1.03-2.27; P=0.036). There was no evidence of publication bias for the aforementioned risk factors, with the exception of atypical cutaneous nevi (P=0.03). CONCLUSIONS: This meta-analysis supports an association between uveal melanoma and atypical cutaneous nevi, common cutaneous nevi, cutaneous freckles, and iris nevi.

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.].