Myeloid-Derived Suppressor Cells Mediate Inflammation Resolution in Humans and Mice with Autoimmune Uveoretinitis.

Resolution of inflammation is an active process that leads to tissue homeostasis and involves multiple cellular and molecular mechanisms. Myeloid-derived suppressor cells (MDSCs) have recently emerged as important cellular components in the resolution of inflammation because of their activities to suppress T cell activation. In this article, we show that HLA-DR-CD11b+CD33+CD14+ human MDSCs and CD11b+Ly6G-Ly6C+ mouse MDSCs markedly increased in patients and mice during and before the resolution phase of autoimmune uveoretinitis. CD11b+Ly6C+ monocytes isolated from autoimmune uveoretinitis mice were able to suppress T cell proliferation in culture, and adoptive transfer of the cells accelerated the remission of autoimmune uveoretinitis in mice. Alternatively, depletion of CD11b+Ly6C+ monocytes at the resolution phase, but not CD11b+Ly6G+ granulocytes, exacerbated the disease. These findings collectively indicate that monocytic MDSCs serve as regulatory cells mediating the resolution of autoimmune uveoretinitis.

Anatomical configurations of vitreomacular traction syndrome: influence on clinical course and surgical outcomes.

PURPOSE: To develop a new classification system for vitreomacular traction (VMT) syndrome according to spectral-domain optical coherence tomography (SD-OCT) imaging and to investigate the clinical course of VMT patients. METHODS: This study included 68 eyes of 68 consecutive patients who were followed with observation or treated with vitrectomy for idiopathic VMT. Eyes were classified into one of three groups according to SD-OCT findings: group A (foveal pseudocyst, which was defined as the formation of cystoid cavity located in the inner part of the central fovea along with foveal thickening), group B (parafoveal retinoschisis, which was defined as intraretinal cysts or clefts along with no apparent foveal thickening), and group C (outer retinal dehiscence at the fovea, which is sometimes accompanied by foveal thinning). The minimum required follow-up period was 1 year. Clinical course and anatomical and functional outcomes were compared among the groups. RESULTS: Twenty-seven eyes (39.7%) were included in group A, 22 eyes (32.4%) were included in group B, and 19 eyes (27.9%) were included in group C. Among the 24 eyes that were managed by observation, a significantly larger percentage of patients in group A (6/10 [60%]) exhibited more spontaneous resolution of VMT compared with those in groups B (9.1%) or C (0%) (P = 0.010). In the 44 eyes that were managed with vitrectomy, a significantly larger percentage of patients in group C (4/16 [25%]) experienced subsequent full-thickness macular hole development following vitrectomy compared with those in groups B (0%) or C (0%) (P = 0.014). The percentage of patients with photoreceptor inner segment/outer segment disruption was significantly reduced in group A after vitrectomy, with group C exhibiting the lowest recovery rate. Postoperatively, group A experienced a significantly better visual outcome than group C (P = 0.021). CONCLUSIONS: A novel configuration system offering insight into the clinical course of VMT is proposed. According to this system, anatomical and functional outcomes were favorable in group A and worse in group C.

RECOVERY OF FOVEAL PHOTORECEPTOR INTEGRITY AFTER VITRECTOMY IN EYES WITH AN IMPENDING MACULAR HOLE WITH VITREOMACULAR TRACTION SYNDROME.

PURPOSE: To identify factors associated with the recovery of foveal photoreceptor disruption in eyes with an impending macular hole (MH) with vitreomacular traction syndrome after surgery. METHODS: This study comprised 33 consecutive patients who underwent vitrectomy for Stage 1 impending macular hole with disrupted photoreceptor inner segment/outer segment (IS/OS) layer and were followed up for a minimum of 1 year after surgery. Preoperative optical coherence tomography (OCT) parameters were compared between eyes that achieved complete restoration of the IS/OS layer (Group A) and those that did not (Group B). Postoperative serial changes in best-corrected visual acuity (BCVA) and IS/OS disrupted length were also investigated. RESULTS: Smooth and symmetric foveolar contour was restored in 29 eyes (87.9%). Complete recovery of IS/OS disruption was observed in 11 of 33 cases (33.3%, Group A). Group A exhibited a larger percentage of foveal pseudocysts (54.5% vs. 13.6%, P = 0.033) and a smaller mean aperture size (102.1 ± 182.1 µm vs. 241.5 ± 163.8 µm, P = 0.031) than Group B. Postoperatively, Group A revealed a significantly better visual outcome than Group Be, which was the same as Group B, but with the four eyes that developed a full-thickness macular hole excluded. CONCLUSION: Restoration of the foveal photoreceptor layer was more likely to occur in eyes with a foveal pseudocyst and smaller aperture size.

FLUOCINOLONE ACETONIDE IMPLANT FOR VOGT-KOYANAGI-HARADA DISEASE: Three-Year Outcomes of Efficacy and Safety.

PURPOSE: To investigate the efficacy and safety of fluocinolone acetonide intravitreal implant in patients with Vogt-Koyanagi-Harada disease. METHODS: A post hoc, subgroup analysis on patients with Vogt-Koyanagi-Harada was performed using data sets from two multicenter randomized trials on fluocinolone acetonide implant. Each subject received fluocinolone acetonide implantation in one eye and standard-of-care treatment in the fellow eye and was followed for 3 years. RESULTS: Thirty patients were included with the mean age of 38.5 years. The cumulative rate of uveitis recurrence for 3 years was significantly reduced in implanted eyes compared with fellow eyes (33 vs. 87%; P < 0.001). The reduction of daily corticosteroid dose was well maintained (12.8 mg before implantation vs. 3.7 mg after implantation; P = 0.001), but final vision was similar to preoperative vision in the implanted eyes (P = 0.082) and in the fellow eyes (P = 0.187). Postoperative elevation of intraocular pressure was more frequent in the implanted eyes than in the fellow eyes (70 vs. 20%; P < 0.001). Cataract progression occurred in all phakic implanted eyes. CONCLUSION: Fluocinolone acetonide intravitreal implant reduced uveitis recurrence rate and the dosage of systemic corticosteroid and immunosuppressant requirement in patients with Vogt-Koyanagi-Harada. However, cataract and intraocular pressure elevation developed frequently.

Comparison of 1-year therapeutic effect of ranibizumab and bevacizumab for myopic choroidal neovascularization: a retrospective, multicenter, comparative study.

BACKGROUND: To compare the long-term efficacy of ranibizumab versus bevacizumab for myopic choroidal neovascularization (CNV). METHODS: This was a retrospective, multicenter, comparative, non-randomized study of 64 consecutive patients with myopic CNV treated with ranibizumab (22 patients) or bevacizumab (42 patients). Best-corrected visual acuity (BCVA) and central foveal thickness (CFT) on optical coherence tomography were evaluated before and after treatment. All the patients were followed for at least 12 months. RESULTS: BCVA (logarithm of the minimal angle of resolution) improved from 0.63 ± 0.30 to 0.43 ± 0.27, 0.41 ± 0.37, 0.40 ± 0.39, 0.39 ± 0.43, and 0.39 ± 0.42 at 1, 2, 3, 6, and 12 months after treatment in the ranibizumab group, and from 0.67 ± 0.28 to 0.52 ± 0.31, 0.49 ± 0.31, 0.47 ± 0.31, 0.42 ± 0.32, and 0.46 ± 0.43 in the bevacizumab group (all P < 0.05 compared with baseline BCVA in each group). CFT decreased by 20.21%, 19.58%, and 22.43% from the baseline 304 ± 76 µm at 3, 6, and 12 months after treatment in the former group, and by 15.20%, 15.67%, and 15.56% from the baseline 297 ± 62 µm in the latter group (all P < 0.05 compared with baseline CFT in each group). BCVA improvement and CFT reduction did not statistically differ when compared at the same periods from treatment between 2 groups. Neither ocular nor systemic safety problems appeared during follow up. CONCLUSIONS: This study showed a similar functional and anatomical improvement after treatment of ranibizumab and bevacizumab for myopic CNV over a 12-month follow-up period.

Intraperitoneal infusion of mesenchymal stem/stromal cells prevents experimental autoimmune uveitis in mice.

Autoimmune uveitis is one of the leading causes of blindness. We here investigated whether intraperitoneal administration of human mesenchymal stem/stromal cells (hMSCs) might prevent development of experimental autoimmune uveitis (EAU) in mice. Time course study showed that the number of IFN-γ- or IL-17-expressing CD4(+) T cells was increased in draining lymph nodes (DLNs) on the postimmunization day 7 and decreased thereafter. The retinal structure was severely disrupted on day 21. An intraperitoneal injection of hMSCs at the time of immunization protected the retina from damage and suppressed the levels of proinflammatory cytokines in the eye. Analysis of DLNs on day 7 showed that hMSCs decreased the number of Th1 and Th17 cells. The hMSCs did not reduce the levels of IL-1ß, IL-6, IL-12, and IL-23 which are the cytokines that drive Th1/Th17 differentiation. Also, hMSCs did not induce CD4(+)CD25(+)Foxp3(+) cells. However, hMSCs increased the level of an immunoregulatory cytokine IL-10 and the population of IL-10-expressing B220(+)CD19(+) cells. Together, data demonstrate that hMSCs attenuate EAU by suppressing Th1/Th17 cells and induce IL-10-expressing B220(+)CD19(+) cells. Our results support suggestions that hMSCs may offer a therapy for autoimmune diseases mediated by Th1/Th17 responses.

Bilateral same-day intravitreal injections using a single vial and molecular bacterial screening for safety surveillance.

PURPOSE: To evaluate the safety of bilateral same-day intravitreal injections using a single vial and to introduce a molecular surveillance system to screen bacterial drug contamination using eubacterial polymerase chain reaction (PCR). METHODS: Retrospective review of the medical records of 135 patients who received 574 bilateral same-day intravitreal injections for various retinal diseases in 2 tertiary referral hospitals between January 2008 and March 2010 was performed. Data were obtained regarding the diagnosis, kinds of drugs injected, postinjection complications, and the result of molecular bacterial screening of the injected drugs. Drugs for bilateral intravitreal injections were drawn from a single vial and injected using separate syringes or needles. Molecular bacterial screening was performed using the remaining drug in the syringe by 16S ribosomal DNA real-time PCR. RESULTS: A total of 574 injections (384 bevacizumab, 154 ranibizumab, and 36 triamcinolone) were administered on bilateral eyes of 135 patients. There were no complications, including endophthalmitis, uveitis, retinal tear, or retinal detachment. Of the 278 injections screened for bacterial contamination using eubacterial PCR, no cases (0%) showed drug contamination by bacteria. The sensitivity of eubacterial PCR for molecular bacterial screening was 10 colony-forming units (CFUs)/mL or lower. CONCLUSION: Bilateral same-day intravitreal injections drawn from a single vial using separate syringes or needles are well tolerated by patients, and its safety profile may be equivalent to unilateral injections. The bacterial molecular surveillance system using eubacterial PCR demonstrated the safety of bilateral same-day intravitreal injections and may be used for safety surveillance and for timely intervention of possible drug-related endophthalmitis.

Intraocular Foreign Body: Diagnostic Protocols and Treatment Strategies in Ocular Trauma Patients.

Intraocular foreign bodies (IOFBs) are critical ophthalmic emergencies that require urgent diagnosis and treatment to prevent blindness or globe loss. This study aimed to examine the various clinical presentations of IOFBs, determine the prognostic factors for final visual outcomes, establish diagnostic protocols, and update treatment strategies for patients with IOFBs. We retrospectively reviewed patients with IOFBs between 2005 and 2019. The mean age of the patients was 46.7 years, and the most common mechanism of injury was hammering (32.7%). The most common location of IOFBs was the retina and choroid (57.7%), and the IOFBs were mainly metal (76.9%). Multivariate regression analysis showed that poor final visual outcomes (<20/200) were associated with posterior segment IOFBs (odds ratio (OR) = 11.556, p = 0.033) and retinal detachment (OR = 4.781, p = 0.034). Diagnosing a retained IOFB is essential for establishing the management of patients with ocular trauma. To identify IOFBs, ocular imaging modalities, including computed tomography or ultrasonography, should be considered. Different strategies should be employed during the surgical removal of IOFBs depending on the material, location, and size of the IOFB.

Secondary macular hole formation after vitrectomy.

PURPOSE: The purpose of this study was to report the incidence and the underlying ocular pathology of a macular hole (MH) that develops in vitrectomized eyes and to evaluate its prognosis. METHODS: A retrospective chart review was performed in patients who underwent vitrectomy between March 2004 and June 2009. Cases that developed an MH in vitrectomized eyes were identified, and the data from all ophthalmology examinations were collected. Patients with recurrent MHs after the initial MH surgery were excluded. RESULTS: We identified 10 cases of secondary MH during a period of 64 months (incidence, 8 of 3,279 [0.24%]). Two cases of secondary MHs were not included in the calculations because the initial vitrectomies were performed before March 2004. The initial vitrectomy was performed on four eyes with vitreous hemorrhage caused by proliferative diabetic retinopathy, three eyes with retinal detachment from high myopia, one eye with combined retinal detachment with uveitis, one eye with rhegmatogenous retinal detachment, and one eye with an epiretinal membrane. The macular pathology identified before MH formation included cystoid macular edema in two eyes, epiretinal membrane in four eyes, and no specific lesion in another four eyes. The secondary MHs were managed by additional vitrectomy, peeling of the internal limiting membrane, and intravitreal gas tamponade. Nine of 10 eyes achieved hole closure after the secondary surgery, and 8 eyes recovered their previous visual acuity; the other 2 eyes had visual loss within 2 Snellen chart lines, and none of the 9 patients had a recurrence during a mean follow-up of 20.7 months (range, 4-31 months). CONCLUSION: The development of secondary MHs after vitrectomy is rare. Pathogenic mechanisms other than idiopathic MH may be involved in these cases. The anatomical and functional outcome of the secondary MHs that developed after vitrectomy was good, although the final visual acuity was dependent on the underlying ocular pathology.

Natural killer/T-cell lymphoma of nasal type with intraocular involvement: case report.

PURPOSE: To report an unusual presentation of disseminated, intraocular, extranodal natural killer/T-cell lymphoma, nasal type (NK/T-cell lymphoma), originating from nasal NK/T-cell lymphoma. METHODS: Case report. RESULTS: A 63-year-old woman who had been treated with systemic chemotherapy and radiotherapy for NK/T-cell lymphoma in the nasal cavity presented with vitreous haze of the right eye. Despite anti-inflammatory therapy, the right eye showed poor clinical response and received diagnostic vitrectomy. The vitreous opacity resembled a thin sheet, with no sign of subretinal infiltrate or vascular sheathing. The vitreous specimen contained many large, pleomorphic lymphoma cells. The malignant cells were positive for CD3, CD8, and granzyme B. Systemic workups showed no involvement of other organs. A diagnosis of T-cell lymphoma in the vitreous was made; the tumor likely originated from nasal NK/T-cell lymphoma. The patient was treated with intrathecal chemotherapy and intravitreal methotrexate injection. The eye was clinically clear of malignant cells after the injections. CONCLUSIONS: Vitreous infiltration without uveoretinal involvement can be an unusual manifestation of intraocular NK/T-cell lymphoma. Clinician awareness of possible ocular involvement may assist in the diagnosis of disseminated NK/T-cell lymphoma.

Quiescence and Subsequent Anterior Chamber Inflammation in Adalimumab-treated Pediatric Noninfectious Uveitis.

PURPOSE: To evaluate the effect of adalimumab in pediatric uveitis and subsequent changes in anterior chamber inflammation following the inactivation of uveitis. METHODS: In this retrospective study, patients with noninfectious uveitis younger than 18 years of age who were treated with adalimumab for more than 12 months were included. The rate of complete suppression and the relapse in anterior chamber inflammation following the initiation of adalimumab therapy were evaluated using anterior chamber cell score and laser flare photometry (LFP) values, if available. Changes in visual acuity and the sparing effect of topical steroid agents were also evaluated. RESULTS: Among 22 eyes of 12 pediatric uveitis patients enrolled, 13 eyes were associated with juvenile idiopathic arthritis and nine eyes had idiopathic uveitis. The mean ± standard deviation age was 10.2 ± 3.6 years. Types of uveitis included anterior uveitis (n = 17) and panuveitis (n = 5). Quiescence was observed in 14 eyes (63.6%) at 3 months and in 21 eyes (95.5%) at 12 months after initiation, respectively. After achieving inactive uveitis, uveitis relapsed in two eyes at 6 months, even with adalimumab treatment. In 11 eyes, anterior chamber showed 0.5+ cell scores during the rest of the follow-up period and one of those eyes met the criteria for the relapse based on LFP values. The dosage of topical steroids decreased significantly at 3, 9, and 12 months after the initiation of therapy (p ≤ 0.05). Visual acuity did not show improvement. There were no severe adverse effects of anti-tumor necrosis factor-α treatment reported. CONCLUSIONS: In this study, adalimumab achieved a quiescent state in most eyes with pediatric noninfectious uveitis for 12 months with a relapse rate of 9.5%. LFP values together with the anterior chamber cell score can be utilized to monitor the improvement or relapse in anterior chamber inflammation in pediatric noninfectious uveitis.

Estimating heritability of refractive error in Koreans: the Korea National Health and Nutrition Examination Survey.

PURPOSE: To estimate the familial correlation and heritability of refractive error in general Korean population. METHODS: From the Korea National Health and Nutrition Examination Survey, 13 258 subjects of 7920 families, who were aged ≥19 years, were included in the study. Using variance components analysis, the additive genetic effect, or heritability, and the common and unique environmental effects on refractive error were examined, adopting common environments shared by cohabiting family or by siblings. RESULTS: The proportions of hyperopia, myopia and high myopia in Koreans were 0.8%, 45.2% and 5.7% respectively. The correlation coefficients of spherical equivalent (SE) were 0.257 for parent-offspring pairs, 0.410 for sibling pairs and 0.112 for spouse pairs (p < 0.001 for all). Common environment shared by siblings affected the variation of SE significantly (p < 0.001), but that shared by cohabitants did not (p = 0.395). Adopting common environment shared by siblings, the heritability, common environmental effect and unique environmental effect of refractive error were 42.1 ± 3.3%, 11.8 ± 3.5% and 46.1 ± 3.9% respectively. Heritabilities of hyperopia, myopia and high myopia were 45.7%, 44.3% and 68.9% respectively. Adjusted odds ratios of myopia among offspring were 3.78 given one parent has myopia and 4.43 when both parents have myopia. CONCLUSION: Refractive error is influenced by common environment shared by siblings. The heritability of refractive error is higher for high myopia than for myopia or hyperopia.

Correlation of visual acuity with foveal hypoplasia grading by optical coherence tomography in albinism.

PURPOSE: To develop a new foveal hypoplasia grading system using optical coherence tomography (OCT) and to determine the correlations of visual acuity to the iris transillumination, macular transparency, and foveal hypoplasia grades, respectively, in young albinism patients. DESIGN: Observational case series. PARTICIPANTS: Thirteen patients who were clinically diagnosed with oculocutaneous albinism. METHODS: The authors obtained refraction and correction for participants, who then underwent anterior segment photography and fundus photography. Foveal hypoplasia was evaluated using a fast macular cross-hair scan with StratusOCT (Carl Zeiss Meditec, Dublin, CA). The authors developed a new grading system based on foveal hyporeflectivity, the degree of choroidal transillumination, the presence of the tram-tract sign, and foveal depression as determined from OCT images. Correlations of Snellen visual acuity to the iris transillumination, macular transparency, and foveal hypoplasia grades were calculated, and areas under receiver operating characteristic curves (AROCs) were measured to evaluate the predictive value of foveal hypoplasia grading using OCT. MAIN OUTCOME MEASURES: The AROCs of foveal hypoplasia grading by OCT. RESULTS: Thirteen patients were enrolled. Correlations of visual acuity to the iris transillumination (P<0.001), macular transparency (P = 0.014), and foveal hypoplasia (P = 0.004) grades were significant. The AROC values for foveal hypoplasia measurement by OCT, iris transillumination, and macular transparency measurements were 0.98, 0.91, and 0.87, respectively. CONCLUSIONS: The prognostic value of foveal hypoplasia as assessed by OCT in young patients with albinism is superior to grades based on iris transillumination or macular transparency.

Early versus late intravitreal triamcinolone acetonide for macular edema associated with branch retinal vein occlusion.

PURPOSE: To compare the effect of early versus late intravitreal injection of triamcinolone in patients with macular edema due to branch retinal vein occlusion (BRVO). METHODS: Twenty eyes of 20 patients with macular edema from BRVO, including 10 with duration after onset of or 3 months, improvements in visual acuity and foveal thickness, though apparent at 1 month, were not maintained at 3 and 6 months post-triamcinolone. CONCLUSIONS: Intravitreal triamcinolone is more effective in patients with BRVO who are treated earlier.

Risk factors for and management of pupillary intraocular lens capture after intraocular lens transscleral fixation.

PURPOSE: To analyze risk factors and management of pupillary intraocular lens (IOL) capture after IOL transscleral fixation. SETTING: Department of Ophthalmology, Seoul National University Hospital, Seoul, South Korea. DESIGN: Retrospective case series. METHODS: A chart review was performed of patients who had transscleral fixation of IOLs between January 1, 2012, and December 31, 2013. Eyes were divided into 2 groups depending on whether the IOL was pupillary captured. Perioperative corrected distance visual acuity (CDVA), intraocular pressure (IOP), spherical equivalent (SE) with refraction, axial length (AL), and total follow-up time were compared between the 2 groups. Ultrasound biomicroscopy images were used to analyze iris morphology and IOL position. RESULTS: The chart review identified 138 patients, 112 patients of whom were included in this analysis. The preoperative and final mean CDVA, IOP, SE, AL, and most iris morphologic parameters were not significantly different between the 2 groups. In the pupillary capture IOL group, the mean age of patients with was younger, the anterior chamber depth (ACD) was narrower, and the rate of reverse pupillary block was higher (P = .003, P = .03, and P = .016, respectively). Intraocular lens decentration in the captured group was significantly larger (P = .002). Multiple logistic regression analysis showed that ACD, reverse pupillary block, and main decentration were associated with pupillary capture of the IOL. CONCLUSIONS: Pupillary capture of an IOL occurred more in eyes with reverse pupillary block and poor IOL positioning. Accordingly, laser iridotomy must be considered for treatment.

Rate of Macular Ganglion Cell-inner Plexiform Layer Thinning in Glaucomatous Eyes With Vascular Endothelial Growth Factor Inhibition.

PURPOSE: To evaluate the rate of progressive macular ganglion cell-inner plexiform layer (GCIPL) thinning in patients with open-angle glaucoma (OAG) who had been treated with intravitreal antivascular endothelial growth factor (VEGF) injection for wet age-related macular degeneration (AMD). METHODS: This study was a retrospective modified case control study with fellow eye comparison. We enrolled bilateral OAG patients who had been treated with repeated anti-VEGF injections for unilateral wet AMD and followed-up on for a minimum of 24 months by Cirrus high-definition optical coherence tomography. The rate of macular GCIPL thinning was determined by linear regression of serial optical coherence tomography GCIPL thickness measurements over time. We compared the rate of macular GCIPL thinning between anti-VEGF-treated eyes and fellow untreated dry AMD eyes. RESULTS: This study involved 32 OAG eyes of 16 subjects. The total follow-up period was 58.4±25.5 (24 to 98) months, and the mean number of anti-VEGF injections was 10.6±10.4 (3 to 40). The eyes with repeated anti-VEGF treatment differed significantly from their fellow eyes in the rate of GCIPL thinning (-2.95±3.58 vs. -0.77±0.95 µm/y, P=0.015). Also, multivariable regression analyses showed that anti-VEGF injection was significantly associated with the rate of GCIPL thinning (P=0.025). CONCLUSIONS: In subjects with bilateral OAG, the rate of GCIPL thinning is significantly faster in eyes treated with anti-VEGF injection for wet AMD than in untreated dry AMD fellow eyes. This finding suggests that in glaucomatous eyes, VEGF inhibition could play a role, at least in part, in progressive change of inner retinal layers.

The effects of external subretinal fluid drainage on secondary glaucoma in Coats' disease.

PURPOSE: We sought to investigate the effect of external subretinal fluid drainage (SRFD) on secondary or impending secondary glaucoma caused by bullous exudative retinal detachment for saving eyes with Coats' disease. METHODS: By retrospective chart review, we collected the treatment results of 56 patients younger than 15 years of age with Coats' disease. External SRFD was performed when exudative retinal detachment became bullous enough to cause anterior displacement of the lens-iris diaphragm or when secondary angle-closure glaucoma occurred. Treatment results were regarded as successful when secondary angle-closure glaucoma was prevented or responded to treatment. RESULTS: The mean age of those who underwent external SRFD was 3.1+/-1.8 years. Exudative retinal detachment was found in 48 eyes (86%), and external SRFD was needed initially in 19 (28%). External SRFD initially was performed in 19 eyes (28%) and in 2 (3%) after initial cryotherapy. Of these 21 eyes, no definite neovascular glaucoma was detected, and it took on average 1.2 SRFDs to treat or prevent secondary angle-closure glaucoma. All treatments were successful, and no eye was enucleated. CONCLUSIONS: External SRFD should be considered early as a treatment for secondary angle-closure glaucoma associated with bullous exudative retinal detachment in Coats' disease.