DIRECTIONAL OPTICAL COHERENCE TOMOGRAPHY IMAGING OF MACULAR PATHOLOGY.

PURPOSE: To survey the impact of directional reflectivity on structures within optical coherence tomography images in retinal pathology. METHODS: Sets of commercial optical coherence tomography images taken from multiple pupil positions were analyzed. These directional optical coherence tomography sets revealed directionally reflective structures within the retina. After ensuring sufficient image quality, resulting hybrid and composite images were characterized by assessing the Henle fiber layer, outer nuclear layer, ellipsoid zone, and interdigitation zone. Additionally, hybrid images were reviewed for novel directionally reflective pathological features. RESULTS: Cross-sectional directional optical coherence tomography image sets were obtained in 75 eyes of 58 patients having a broad range of retinal pathologies. All cases showed improved visualization of the outer nuclear layer/Henle fiber layer interface, and outer nuclear layer thinning was, therefore, more apparent in several cases. The ellipsoid zone and interdigitation zone also demonstrated attenuation where a geometric impact of underlying pathology affected their orientation. Misdirected photoreceptors were also noted as a consistent direction-dependent change in ellipsoid zone reflectivity between regions of normal and absent ellipsoid zone. CONCLUSION: Directional optical coherence tomography enhances the understanding of retinal anatomy and pathology. This optical contrast yields more accurate identification of retinal structures and possible imaging biomarkers for photoreceptor-related pathology.

A 66-year-old woman with two weeks of distorted vision in the left eye.

PURPOSE: To report a case of concurrent melanoma metastasis to the orbit and MEK inhibitor-associated retinopathy. METHODS: Case report of a 66-year-old female patient undergoing mutation targeted MEK-inhibitor treatment for metastatic melanoma with retinal manifestations. RESULTS: After initiating MEK-inhibitor therapy our patient presented with bilateral blurred vision. Clinical examination and OCT imaging revealed multifocal bilateral serous retinal detachments consistent with MEKAR. Extrafoveal subretinal fluid foci resolved after discontinuation of MEK-inhibitor therapy, but her foveal lesions persisted for over 18 months. Years after her initial evaluation for MEKAR, our patient developed metamorphopsia in the left eye resulting from chorioretinal folds secondary to intraconal orbital metastasis. MRI revealed additional intracerebral and lung metastases, and the patient expired in 2 months. CONCLUSION: We report a case of prolonged MEKAR with concomitant orbital metastasis from melanoma. Multimodal imaging in conjunction with history and clinical features allows for disease identification and monitoring.

FULL-THICKNESS MACULAR HOLE FORMATION FOLLOWING PANRETINAL PHOTOCOAGULATION FOR PROLIFERATIVE DIABETIC RETINOPATHY.

PURPOSE: To report two patients who developed full-thickness macular holes following panretinal photocoagulation for proliferative diabetic retinopathy. METHODS: Case series. RESULTS: Case 1 was a 58-year-old woman with Type 1 diabetes mellitus and proliferative diabetic retinopathy and Case 2, a 72-year-old man with Type 2 diabetes mellitus and proliferative diabetic retinopathy. Before panretinal photocoagulation, each patient had an epiretinal membrane and an irregular foveal contour noted on optical coherence tomography. At 2 months follow-up, each patient showed foveal floor thinning and Case 2 also had a lamellar macular hole. At 6 months follow-up, each patient had a full-thickness macular hole. Each were successfully repaired with vitrectomy, membrane peeling, and gas tamponade. CONCLUSION: The relationship between hole formation and previous panretinal photocoagulation in the patients reported here is unclear and possibly coincidental.

Late Pleistocene osseous projectile point from the Manis site, Washington-Mastodon hunting in the Pacific Northwest 13,900 years ago.

Bone fragments embedded in a rib of a mastodon (Mammut americanum) from the Manis site, Washington, were digitally excavated and refit to reconstruct an object that is thin and broad, has smooth, shaped faces that converge to sharp lateral edges, and has a plano-convex cross section. These characteristics are consistent with the object being a human-made projectile point. The 13,900-year-old Manis projectile point is morphologically different from later cylindrical osseous points of the 13,000-year-old Clovis complex. The Manis point, which is made of mastodon bone, shows that people predating Clovis made and used osseous weapons to hunt megafauna in the Pacific Northwest during the Bølling-Allerød.

PURTSCHER-LIKE RETINOPATHY IN A PATIENT WITH MILK-ALKALI SYNDROME AND PANCREATITIS.

PURPOSE: To report a case of Purtscher-like retinopathy in a patient with milk-alkali syndrome and pancreatitis. METHODS: Case report and review of the literature. RESULTS: A 46-year-old woman presented with decreased vision following discharge from the intensive care unit, where she had been admitted for milk-alkali syndrome secondary to long-term calcium supplementation and over-the-counter antacid use, and pancreatitis. Dilated examination showed ischemic retinal whitening and retinal hemorrhages in the posterior pole bilaterally consistent with Purtscher-like retinopathy. Over three months, the retinopathy resolved and her vision improved. CONCLUSION: Milk-alkali syndrome is the clinical triad of hypercalcemia, renal failure, and metabolic alkalosis and occurs secondary to the consumption of large amounts of calcium and alkali. The hypercalcemia associated with milk-alkali syndrome may cause pancreatitis, which can lead to Purtscher-like retinopathy.

CATASTROPHIC, BILATERAL RETINAL VASCULAR OCCLUSION AFTER INTRAVITREAL BEVACIZUMAB INJECTION.

PURPOSE: To describe two cases of catastrophic, bilateral retinal vascular occlusion after intravitreal (IVT) bevacizumab injection. METHODS: Case series. Main outcome measures included clinical and fluorescein angiography findings. RESULTS: Case 1-A 65-year-old woman with calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasis syndrome developed acute, severe, bilateral visual loss 2 weeks after bilateral IVT bevacizumab injection for proliferative diabetic retinopathy. Examination and fluorescein angiography revealed moderate anterior chamber inflammation, bilateral perivascular retinal hemorrhages, and near total retinal vascular occlusion. Extensive testing revealed moderately elevated anti-B2 glycoprotein (antiphospholipid) antibodies. Case 2-An 85-year-old man with polymyalgia rheumatica and left eye exudative age-related macular degeneration experienced severe, bilateral, sequential visual loss in the left eye and then right eye approximately 3 weeks after IVT bevacizumab left eye injection. Examination revealed bilateral panuveitis, diffuse perivascular exudates, and intraretinal hemorrhages. Fluorescein angiography showed diffuse venous leakage. Extensive testing revealed an elevated antinuclear antibody and mildly elevated anticardiolipin antibody. CONCLUSION: Patients with underlying retinal vascular vulnerabilities may be at increased risk of catastrophic, bilateral retinal vascular occlusion after treatment with IVT bevacizumab. The moderate-to-severe intraocular inflammation in both cases and the contralateral involvement after unilateral IVT injection in Case 2 suggest a possible delayed immune-mediated mechanism.

NIVOLUMAB-INDUCED HARADA-LIKE UVEITIS WITH BACILLARY DETACHMENT MIMICKING CHOROIDAL METASTASIS.

PURPOSE: To describe a patient with metastatic clear cell renal cell carcinoma in remission on maintenance nivolumab therapy who developed late-onset ocular toxicity manifesting as creamy chorioretinal lesions with exudative retinal detachment concerning for choroidal metastasis. METHOD: Case report. Main outcome measures include ophthalmoscopic examination, fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, spectral domain optical coherence tomography, and B-scan ultrasonography. RESULTS: A 49-year-old woman with a medical history of metastatic clear cell renal cell carcinoma in remission for two years after immunotherapy with four cycles of ipilimumab and nivolumab followed by maintenance nivolumab infusions developed lesions concerning for choroidal metastases in her right eye. Optical coherence tomography of the lesions revealed a bacillary layer detachment containing possible fibrinous exudate organized into layers and underlying choroidal thickening with chorioretinal folds. Later, choroidal thickening and chorioretinal folds also occurred in the left eye. Given that pan imaging detected no metastasis and the posterior segment abnormalities resolved after cessation of nivolumab and treatment with systemic corticosteroids, the patient was diagnosed with nivolumab-induced Vogt-Koyanagi-Harada-like uveitis. CONCLUSION: This case expands on the clinical spectrum of nivolumab-induced Vogt-Koyanagi-Harada-like uveitis, a condition that can also present with bacillary layer detachment mimicking an early choroidal metastasis, manifest asymmetrically in each eye, and develop after long-standing treatment.

BARTONELLA HENSELAE -ASSOCIATED OPTIC NEUROPATHY PRESENTING AS A CENTRAL SCOTOMA IN THE ABSENCE OF OVERT PAPILLITIS: A MULTIMODAL IMAGING STUDY.

BACKGROUND/PURPOSE: The purpose of this report was to describe the use of multimodal imaging to establish the diagnosis of Bartonella henselae -associated optic neuropathy in a patient who presented with a central scotoma without overt evidence of optic nerve involvement. METHODS: This was a case report. Main outcome measures included clinical, optical coherence tomography, and fluorescein angiography findings. OBSERVATIONS: A 72-year-old woman presented with a 3-day history of central scotoma in the left eye. Her examination was remarkable for faint exudation in the nasal macula of the left eye but was otherwise normal for her age. Spectral domain optical coherence tomography of the macula revealed mild thickening of the papillomacular bundle with scattered small cystoid spaces and several intraretinal exudates, none of which were visible clinically. Fluorescein angiography revealed localized leakage of the inferotemporal optic disc. When prompted, the patient recalled being scratched multiple times by her two pet kittens. Serial testing showed rising anti- B. henselae ( B. henselae ) immunoglobulin G antibody titers to 1:1,280, confirming the suspected diagnosis of B. henselae -associated optic neuropathy. CONCLUSION: Bartonella -associated optic nerve involvement can occur without overt evidence of optic disc swelling. Multimodal imaging can be used to suggest the diagnosis and support appropriate serologic testing.

A 48-YEAR-OLD CAUCASIAN MAN WITH UNILATERAL "SMUDGE" IN INFERIOR VISUAL FIELD.

PURPOSE: To report an increasingly prevalent fundoscopic manifestation of syphilitic uveitis. METHODS: Case report of a patient with acute retinal necrosis secondary to syphilis. RESULTS: A 48-year-old man presented with decreased vision, anterior segment inflammation, and a wedge-shaped retinal lesion in the superior periphery, with a diaphanous leading edge extending down toward the superior arcade. The patient was HIV+ and poorly compliant with therapy. The top three differential diagnoses were herpetic necrotizing retinitis, syphilis, and lymphoma. An extensive lab workup was positive for syphilis. The patient was treated with IV penicillin G and demonstrated improvement in visual acuity and examination. CONCLUSION: There have been an increasing number of reports of syphilis patients, especially in the population of men who have sex with men, who present with fundus findings similar to acute retinal necrosis. These findings include a characteristic ground glass, translucent appearance of unifocal or multifocal lesions, primarily affecting the inner retina and sometimes associated with co-localizing occlusive vasculitis. Treatment with IV penicillin G is warranted and has demonstrated good visual recovery.

CLINICAL AND STRUCTURAL IMPACT OF SUBMACULAR FLUID AFTER PNEUMATIC RETINOPEXY REPAIR FOR RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To assess the impact of submacular fluid (SMF) after pneumatic retinopexy for primary rhegmatogenous retinal detachment repair. METHODS: Retrospective review of consecutive patients treated with pneumatic retinopexy for primary rhegmatogenous retinal detachment repair. 387 eyes (374 patients) were included, of which 166 underwent optical coherence tomography imaging after successful pneumatic retinopexy. Foveal-centered optical coherence tomography scans were reviewed. RESULTS: SMF occurred in 59 eyes (35.5%) and was associated with macular detachment ( P ≤ 0.001) and phakic lens status ( P = 0.007). Submacular fluid resolved over an average of 9.39 months and was associated with worse preprocedure best-corrected visual acuity and delayed visual recovery. The mean final best-corrected visual acuity was 0.277 logarithm of the minimum angle of resolution (20/40) in eyes with SMF and 0.162 logarithm of the minimum angle of resolution (20/30) in those without SMF ( P < 0.001). Submacular fluid was associated with discontinuity of the interdigitation zone ( P = 0.003), ellipsoid zone ( P = 0.005), and external limiting membrane ( P ≤ 0.001) after SMF resolution. Ellipsoid zone discontinuity was associated with worse visual prognosis ( P = 0.009). CONCLUSION: Trace SMF detected by optical coherence tomography is common after successful pneumatic retinopexy and resulted in delayed visual recovery and increased rates of outer retinal discontinuity after SMF resorption, although the final difference in best-corrected visual acuity in those with and without SMF was minimal.

Paracentral acute middle maculopathy following internal carotid artery stenting.

Purpose: To report a case of paracentral acute middle maculopathy (PAMM) that presented after internal carotid artery stenting despite the use of a filter embolic protection device. Observations: A 74-year-old man presented one week following transfemoral stenting of the right internal carotid artery for high-grade stenosis. A filter-type embolic protection device was used during the stenting procedure to prevent distal embolization of atherosclerotic debris. Dilated examination of the right eye revealed a parafoveal gray lesion in the macula and optical coherence tomography showed a corresponding placoid hyperreflective band at the level of the inner nuclear layer consistent with PAMM. The patient was asymptomatic. At 10 weeks follow up the PAMM lesion was resolved. Conclusions: PAMM occurred following internal carotid artery stenting despite the use of a filter embolic protection device, likely due to embolic debris passing through the filter device or debris released while the filter was in a collapsed state. The PAMM lesion was small and resolved without visual sequelae.

Developmental Dysplasia of the Hip: An Audit of the Ultrasound Screening Programme.

Aims Developmental dysplasia of the hip (DDH) is an important cause of disability in children and young adults. Early diagnosis and treatment can help avoid more invasive interventions and long-term morbidity. This study examines the ultrasound screening programme conducted in University Hospital Waterford (UHW), and the outcomes for infants with DDH in the Southeast of Ireland. Methods We conducted an audit of all the DDH screening ultrasounds performed in UHW in the year 2020, a total of 992 infants. Data included referral and ultrasound times, screening results, interventions, and outcomes. Results Of those screened, 255 (26%) were referred to the Orthopaedic clinic, with a significant female majority of nearly 3:1. At the time of writing, only two infants were ultimately referred for further management of persistent DDH, the rest being successfully treated by less invasive interventions such as harnessing and bracing. There were no babies scanned within the recommended 6 weeks who later presented with a dislocated hip or required tertiary referral for DDH management. Conclusion The ultrasound screening programme in UHW is shown to be successful in the prompt diagnosis and early treatment of DDH. This plays a significant role in avoiding the lifelong disabling outcomes of untreated DDH, and the invasive surgical procedures required in the management of late-stage disease.

Multimodal imaging of soccer ball-related ocular posterior segment injuries.

PURPOSE: To investigate the clinical and anatomic characteristics of soccer ball-induced posterior segment injuries in the era of modern multi-modal imaging. METHODS: Retrospective case series of patients with soccer ball injury and diagnostic imaging from 2007 to 2020 at a single vitreoretinal practice. RESULTS: Eight patients met inclusion criteria. Fundus photographs (FP) and optical coherence tomography (OCT) were obtained in eight patients, fundus autofluorescence (FAF) in five patients, fluorescein angiography (FA) in three patients, and en-face OCT and OCT-Angiography (OCT-A) were obtained in two patients each. FA and FAF identified traumatic pigment epitheliopathy secondary to commotio. Increased hypo-autofluorescence was associated with shallow, peripheral retinal detachment on FAF. OCT of the macula displayed outer retinal changes associated with commotio, and offered insight into the acute and subacute changes of traumatic macular hole formation. A patient displayed foveal hyper-reflectivity in the shape of an hourglass with retinal cyst at the level of the external limiting membrane (ELM) as seen on OCT and En-face OCT. A patient with commotio involving the macula lacked microvascular changes on OCT-A. CONCLUSION: OCT, FA, and FAF imaging may aid in the work-up and management of the soccer ball-related posterior segment injuries.

Bartonella henselae-associated recurrent, bilateral segmental periphlebitis.

Purpose: To describe a patient with atypical Bartonella henselae (B. henselae)-associated ocular inflammation that manifested with recurrent, bilateral segmental periphlebitis. Observations: A 32-year-old White man presented with multiple paracentral scotomata in each eye. Examination revealed mild vitreous cell, segmental sheathing of the retinal veins, and inflammation of the paravenous retina in each eye. Multimodal imaging, including optical coherence tomography as well as widefield fundus autofluorescence, fluorescein angiography, and indocyanine green angiography, was consistent with bilateral, segmental retinal periphlebitis with paravenous inflammation and retinochoroidal scarring. Serology showed elevated B. henselae antibody titers, but was otherwise unrevealing, and the patient was diagnosed with presumed B. henselae-associated ocular inflammation. Treatment with systemic doxycycline (100 mg PO BID) for four weeks improved the patient's symptoms and posterior uveitis. However, after an asymptomatic period of nearly one year, his bilateral pericentral scotomata recurred and posterior segment examination confirmed new foci of retinal periphlebitis in each eye. Re-treatment with doxycycline (100 mg PO BID) for four weeks again yielded improvement, but one month after completing his antibiotic course, his visual symptoms recurred, and we observed additional areas of periphlebitis and paravenous retinitis with associated branch retinal vein occlusions in each eye. This time a dual antibiotic regimen of doxycycline (100 mg PO BID) and rifampin (300 mg PO BID) was administered for three months, with improvement. Over the next eight years, the patient experienced no further disease relapse, and the previous sites of retinal periphlebitis eventually developed perivenous fibrosis with paravenous retinochoroidal scarring. Conclusion: Rarely, patients with B. henselae-associated ocular inflammation develop segmental retinal periphlebitis with or without retinal vein occlusion. This form of ocular bartonellosis can recur, requiring multiple courses of antimicrobial therapy.

Optic disc edema with peripapillary serous retinal detachment as the presenting sign of necrotizing herpetic retinitis.

PURPOSE: To describe an atypical case of necrotizing herpetic retinitis (NHR) that presented initially with mild anterior uveitis, optic disc swelling, and peripapillary serous retinal detachment (SRD). OBSERVATIONS: A 48-year-old Asian Indian man presented with blurred central vision and pain in his left eye. Examination revealed mild anterior chamber inflammation, optic disc swelling, and a peripapillary SRD in the affected eye. Multimodal imaging, including widefield fluorescein angiography, showed optic disc leakage and confirmed the presence of a peripapillary SRD, but was otherwise unremarkable with no evidence of retinitis. The patient was diagnosed with presumed Vogt-Koyanagi-Harada disease and was treated with systemic corticosteroids. While there was objective visual improvement initially, the patient subsequently noted peripheral vision loss and was found to have peripheral necrotizing retinitis and occlusive retinal vasculitis in affected eye. Polymerase chain reaction-based testing of aqueous humor detected varicella zoster virus DNA, confirming the diagnosis of NHR. CONCLUSION AND IMPORTANCE: Optic disc edema and peripapillary SRD may precede the development of overt retinitis in some patients with NHR.

Paracentral Acute Middle Maculopathy and the Ischemic Cascade: Toward Interventional Management.

PURPOSE: To present select cases of paracentral acute middle maculopathy (PAMM) demonstrating progressive vascular occlusion and the ischemic cascade and illustrate scenarios in which therapeutic intervention may be considered. DESIGN: Perspective. METHODS: Review and interpretation of selected literature, with perspective on the evaluation and management of patients with PAMM lesions. Multimodal imaging of 3 illustrative cases of PAMM are presented, including cross-sectional and en face optical coherence tomography (OCT), with progressive vascular occlusion and evidence of the ischemic cascade noted in 2 of the cases. RESULTS: All 3 cases showed evidence of PAMM at baseline, including perivenular PAMM in 2 cases. Progression from a mild central retinal vein occlusion (CRVO) to a more severe CRVO was noted in the first case, while the second case progressed from an incomplete to complete central retinal artery occlusion (CRAO). In the third case, there was resolution of PAMM lesions associated with partial CRAO after the patient began taking aspirin. CONCLUSIONS: Perivenular PAMM can be the only presenting sign of retinal vascular occlusion. In such cases, it is important to differentiate between partial CRVO and incomplete CRAO as the underlying cause. We provide guidance on making this important distinction, which plays a critical role in directing the nature and urgency of the systemic work-up. In patients with PAMM caused by partial retinal arterial occlusion, a benign empirical approach, such as low-dose aspirin (81 mg), may be reasonable to reduce the likelihood of subsequent vision loss from progression to complete arterial occlusion. A clinical trial, however, is necessary to support such a strategy.

RETINAL PIGMENT EPITHELIAL LESIONS ASSOCIATED WITH A SPORADIC CASE OF FAMILIAL ADENOMATOUS POLYPOSIS.

PURPOSE: To report a sporadic case of a familial adenomatous polyposis (FAP) discovered in a patient with bilateral retinal pigment epithelial lesions. METHODS: Case report. RESULTS: A 30-year-old Asian woman presented for evaluation of bilateral pigmented lesions at the level of the retinal pigment epithelium. She had no personal or family history of colonic polyps or colon cancer. Colonoscopy revealed innumerable adenomatous polyps and genetic testing revealed a mutation in the adenomatous polyposis coli gene consistent with FAP. She subsequently underwent prophylactic total colectomy. CONCLUSION: The pigmented retinal pigment epithelium lesions of FAP have a characteristic appearance and it is vital for the retinal specialist to be familiar with them. De novo mutations in the APC gene are responsible for 20% to 30% of FAP cases. In the presence of the characteristic retinal pigment epithelium lesions, it is important to send the patient for work up of FAP even in the absence of family history of FAP.

Occlusive retinal vasculitis associated with systemic sclerosis and antiphospholipid antibodies.

PURPOSE: To report a series of patients with occlusive retinal vasculitis associated with systemic sclerosis (SSc) and elevated antiphospholipid antibody titers. METHOD: Case series. Main outcome measures included clinical and fluorescein angiographic findings at presentation and over time. OBSERVATIONS: Case 1 - A 61-year-old woman initially diagnosed with idiopathic, bilateral panuveitis and retinal vasculitis causing peripheral nonperfusion was subsequently diagnosed with limited cutaneous systemic sclerosis (lcSSc). Her ocular inflammation and retinal vasculitis were controlled with topical and periocular corticosteroids, but she eventually developed peripheral retinal vascular occlusion that progressed to macular ischemia 11 years after presentation. Repeat serologic evaluation detected interval development of antiphospholipid antibodies. Case 2 - A 58-year-old woman was found to have bilateral peripheral nonperfusion and retinal neovascularization in her right eye. Given her elevated hemoglobin A1c of 8.5%, she was diagnosed with presumed proliferative diabetic retinopathy. Three years after initial presentation, she was diagnosed with lcSSc. Subsequent serum workup detected elevated B2-glycoprotein antibody titers. Her peripheral nonperfusion progressed despite adequate glycemic control, resulting in further neovascularization in each eye. Case 3 - A 40-year-old woman with diffuse cutaneous systemic sclerosis (dcSSc) and elevated titers of anti-cardiolipin antibodies developed multiple branch retinal artery occlusions with subsequent neovascularization of the retina, optic disc, and angle in the right eye. CONCLUSION AND IMPORTANCE: Vision-threatening occlusive retinal vasculitis may develop in select patients with SSc. The presence of elevated anti-phospholipid antibody titers may confer increased risk for this vision-threatening complication.

Red Panda feces from Eastern Himalaya as a modern analogue for palaeodietary and palaeoecological analyses.

Modern feces samples of the endangered red panda (Ailurus fulgens) were examined using multiproxy analysis to characterize the dietary patterns in their natural habitat in India. An abundance of Bambusoideae phytoliths and leaves (macrobotanical remains) provide direct evidence of their primary dietary plants. In contrast, Bambusoideae pollen is sporadic or absent in the pollen assemblages. An abundance of Lepisorus spores and its leaves along with broadleaved taxa, Betula, Engelhardtia, and Quercus are indicative of other important food sources. Average δ13C values (- 29.6‰) of the red panda feces indicate typical C3 type of plants as the primary food source, while the, δ15N values vary in narrow range (3.3-5.1‰) but conspicuously reveal a seasonal difference in values most likely due to differing metabolic activities in summer and winter. The multiproxy data can provide a baseline for the reconstruction of the palaeodietary and palaeoecology of extinct herbivores at both regional and global scales.

Massive Delayed Hemorrhagic Choroidal Detachment and Giant Retinal Tear Detachment Following Scleral-Fixated Akreos IOL.

A 78-year-old woman underwent 25-gauge pars plana vitrectomy and scleral fixation for a dislocated intraocular lens in the left eye under general anesthesia. She developed massive hemorrhagic choroidal detachment 1 day later. A giant retinal tear detachment and proliferative vitreoretinopathy was noted at postoperative Week 7 and repaired with choroidal drainage, 240° peripheral retinectomy, perfluorocarbon liquid, endolaser, and silicone oil. Hypotony associated with the 25-gauge sclerotomies used for suture fixation was the suspected etiology for this complication. Use of 27-gauge instrumentation or application of fibrin glue to superior sclerotomies may help reduce the incidence of postoperative hypotony. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:288-292.].