A Comparative Study of Responses to Retina Questions from Either Experts, Expert-Edited Large Language Models, or Expert-Edited Large Language Models Alone.

Objective: To assess the quality, empathy, and safety of expert edited large language model (LLM), human expert created, and LLM responses to common retina patient questions. Design: Randomized, masked multicenter study. Participants: Twenty-one common retina patient questions were randomly assigned among 13 retina specialists. Methods: Each expert created a response (Expert) and then edited a LLM (ChatGPT-4)-generated response to that question (Expert + artificial intelligence [AI]), timing themselves for both tasks. Five LLMs (ChatGPT-3.5, ChatGPT-4, Claude 2, Bing, and Bard) also generated responses to each question. The original question along with anonymized and randomized Expert + AI, Expert, and LLM responses were evaluated by the other experts who did not write an expert response to the question. Evaluators judged quality and empathy (very poor, poor, acceptable, good, or very good) along with safety metrics (incorrect information, likelihood to cause harm, extent of harm, and missing content). Main Outcome: Mean quality and empathy score, proportion of responses with incorrect information, likelihood to cause harm, extent of harm, and missing content for each response type. Results: There were 4008 total grades collected (2608 for quality and empathy; 1400 for safety metrics), with significant differences in both quality and empathy (P < 0.001, P < 0.001) between LLM, Expert and Expert + AI groups. For quality, Expert + AI (3.86 ± 0.85) performed the best overall while GPT-3.5 (3.75 ± 0.79) was the top performing LLM. For empathy, GPT-3.5 (3.75 ± 0.69) had the highest mean score followed by Expert + AI (3.73 ± 0.63). By mean score, Expert placed 4 out of 7 for quality and 6 out of 7 for empathy. For both quality (P < 0.001) and empathy (P < 0.001), expert-edited LLM responses performed better than expert-created responses. There were time savings for an expert-edited LLM response versus expert-created response (P = 0.02). ChatGPT-4 performed similar to Expert for inappropriate content (P = 0.35), missing content (P = 0.001), extent of possible harm (P = 0.356), and likelihood of possible harm (P = 0.129). Conclusions: In this randomized, masked, multicenter study, LLM responses were comparable with experts in terms of quality, empathy, and safety metrics, warranting further exploration of their potential benefits in clinical settings. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of the article.

IMPACT OF FOVEAL STATUS AND TIMING OF SURGERY ON VISUAL OUTCOME IN RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To investigate the impact of surgical timing on visual acuity outcomes in retinal detachments based on the preoperative foveal status. METHODS: A retrospective multicenter cohort study was conducted. Cases were stratified into fovea-on, fovea-split, and fovea-off groups. Days to surgery was defined as the time between the preoperative examination and surgery. The main outcome measure was the final postoperative visual acuity. RESULTS: 1,675 cases were studied. More than 80% of fovea-on/fovea-split and fovea-off cases had surgery within 1 and 3 days, respectively. The mean final postoperative visual acuity did not differ significantly between the fovea-on and fovea-split groups (Snellen equivalent [SE] 20/33 ± 20/49 and 20/32 ± 20/39, P = 1.000) and did not change significantly based on days to surgery in either group. The mean final postoperative visual acuity was lowest in the fovea-off group (Snellen equivalent = 20/56 ± 20/76, P < 0.001) and was significantly lower in cases where surgery was performed after two or more days when compared with cases performed within 1 day (Snellen equivalent 20/74 ± 20/89 vs. 20/46 ± 20/63, P < 0.001). CONCLUSION: Fovea-on and fovea-split retinal detachments demonstrated comparable visual outcomes. Fovea-off RDs demonstrated worse visual outcomes, which declined further when surgery was delayed by two or more days.

Clinical Factors and Outcomes of Acute-Onset Endophthalmitis Following Small-Gauge Pars Plana Vitrectomy Surgery.

BACKGROUND AND OBJECTIVES: Describe risk factors, findings, and outcomes of acute endophthalmitis (AE) following small-gauge pars plana vitrectomy (PPV). PATIENTS AND METHODS: This was a retrospective single-center, nonrandomized study of post-PPV AE patients from 2013 to 2021. All received vitreous biopsy before treatment. Patients were divided into cohorts: 1) PPV within 3 days of diagnosis (Urgent-PPV), and 2) no urgent PPV (Other-treatment [Tx]). Main outcome was best-corrected visual acuity (BCVA) at 6 months. RESULTS: Twenty-one patients were analyzed. Epiretinal membrane was the most common indication for PPV (48%). Incidence was 0.074%. Culture-positive rate was 57%. For final BCVA, there was no significant (P = 0.85) difference between Urgent-PPV (median = 0.40 logMAR) and Other Tx cohorts (median = 0.35 logMAR). Sclerotomy wounds were not sutured in 71% of patients. Approximately 24% and 38% of patients analyzed had either no tamponade or partial tamponade, respectively. CONCLUSION: Tamponade agents and sclerotomy suturing may be important factors when evaluating post-small-gauge PPV-associated AE. Further studies are necessary for clarification. [Ophthalmic Surg Lasers Imaging Retina 2023;54:395-400.].

Evaluation of Outcomes of Acute Cataract Surgery-Related Endophthalmitis Using a Novel Management Algorithm Based on Presenting Risk Factors.

PURPOSE: Develop treatment algorithm for acute endophthalmitis (AE) following cataract surgery. METHODS: Retrospective single-center, non-randomized interventional study involving patients with AE divided into cohorts according to our novel scoring system, the Acute Cataract surgery-related Endophthalmitis Severity (ACES) score. Total score ≥3 points indicated need for urgent pars plana vitrectomy (PPV; within 24 hours), whereas <3 points indicated urgent PPV was unnecessary. Patients were retrospectively evaluated for visual outcomes based on whether their clinical course followed with or deviated from ACES score recommendations. Main outcome was best-corrected visual acuity (BCVA) at 6-month or longer after treatment. RESULTS: Total of 150 patients were analyzed. Patients whose clinical course followed the ACES score recommendation for immediate surgery had significantly (P < 0.01) better final BCVA (median = 0.18 logMAR, 20/30 Snellen) compared to those that deviated (median = 0.70 logMAR, 20/100 Snellen). For those where the ACES score deemed urgent PPV was unnecessary, no significant (P = 0.19) difference was observed between patients that followed with (median = 0.18 logMAR, 20/30 Snellen) and those that deviated from (median = 0.10 logMAR, 20/25 Snellen) recommendation. CONCLUSIONS: The ACES score may potentially provide critical and updated management guidance at presentation for when to recommend urgent PPV for patients suffering from post-cataract surgery AE.

Evolving Trends for the Clinical Presentation of Primary Rhegmatogenous Retinal Detachments From Early to Late Phases of the COVID-19 Pandemic.

OBJECTIVE: To evaluate the impact on trends in clinical presentation of acute, primary rhegmatogenous retinal detachments (RRD) from early to late phases of the COVID-19 pandemic. METHODS: This study was a single-center, consecutive case series of 1,727 patients treated after vaccine availability ("late"; 3/29/21 to 9/26/21), corresponding time frame in previous year of pandemic ("early"; 3/30/20 to 9/27/20), and prior to pandemic ("pre"; 4/1/19 to 9/29/19). Primary outcome was proportion of patients presenting with macula-off RRD. Secondary outcomes included best-corrected visual acuity (BCVA) and primary proliferative vitreoretinopathy (PVR). RESULTS: While macula-off RRD rates were significantly (P < 0.0001) elevated in early and late cohorts compared to the pre cohort, only the early cohort showed a significant (P < 0.0001) increase in both primary PVR presentation and complex RRD repair. Patients lost to follow-up in early cohort were significantly (P < 0.0001) higher than others. Early cohort showed significantly (P < 0.0001) worse final BCVA compared to others. CONCLUSION: Patients in late pandemic were less likely to exhibit clinical features of worse RRD disease and have improved visual outcomes compared to those in early pandemic. [Ophthalmic Surg Lasers Imaging Retina 2023;54:78-83.].

COVID-19 Vaccination Hesitancy and Its Association With Altered Presentation of Primary Rhegmatogenous Retinal Detachment.

PURPOSE: Evaluate factors associated with coronavirus 2019 (COVID-19) vaccine hesitancy and clinical trends in primary rhegmatogenous retinal detachments (RRDs) during the first year of vaccine availability. DESIGN: Single-center, clinical cohort study. METHODS: Consecutive patients from December 14, 2020, to December 12, 2021, presenting vaccinated (Prior-), subsequently vaccinated (Later-), or remaining unvaccinated (Never-Vax). Primary outcome was proportion with macula-off (mac-off) RRD. Secondary outcomes included logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA), primary proliferative vitreoretinopathy (PVR), proportion lost to follow-up, and distance traveled. RESULTS: 1047 patients were divided into 391 Prior-, 252 Later-, and 404 Never-Vax cohorts. Significantly greater proportions of Later- and Never-Vax cohorts presented with mac-off RRDs (Prior-Vax = 44.5%; Later-Vax = 54%, P < .0001; Never-Vax = 57.9%, P < .0001) and primary PVR (Prior-Vax = 4.3%; Later-Vax = 13.6%, P < .0001; Never-Vax = 17.1%, P < .0001) compared to Prior-Vax cohort. Significantly greater proportion of Never-Vax cohort (7.7%, P < .0001) were lost to follow-up compared to Prior- (2.3%) and Later-Vax (2.2%) cohorts. Never-Vax cohort (median = 35 miles) traveled farther compared to Prior- (median = 22.3 miles; P < .0001) and Later-Vax cohorts (25.45 miles; P = .0038). Prior-Vax cohort had significantly better (P < .05) initial (median = 0.30 logMAR) and final (0.18 logMAR) BCVA compared to Later- (Initial: 0.54 logMAR; Final: 0.30 logMAR) and Never-Vax (Initial: 0.70 logMAR; Final: 0.40 logMAR) cohorts. CONCLUSIONS: COVID-19 vaccine hesitancy is associated with worse clinical presentation and outcomes for primary RRD.

Clinical Outcomes of Rhegmatogenous Retinal Detachment Treated With Pneumatic Retinopexy.

IMPORTANCE: Pneumatic retinopexy (PR) is the only clinic-based method of rhegmatogenous retinal detachment (RRD) repair. Registry-acquired clinical practice setting outcomes data with this procedure have not yet been reported. OBJECTIVE: To describe the clinical outcomes associated with RRD treated primarily with PR. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, data from patients 19 years and older with noncomplex RRD treated at academic and private ophthalmology practices participating in the American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight) were analyzed. Data were collected from January 1, 2013, to December 31, 2019, and data were analyzed from January to December 2020. EXPOSURES: Data from the IRIS Registry were queried for eyes that underwent PR for noncomplex RRD and had at least 3 months of follow-up. Cases were identified by a combination of diagnosis code for RRD and a Current Procedural Terminology code for PR. MAIN OUTCOMES AND MEASURES: The number of eyes that achieved single-operation success (SOS), defined as retinal reattachment without a subsequent retinal detachment surgery or repeated PR. RESULTS: Of 9553 included patients, 5827 (61.0%) were male, and the mean (SD) age was 62 (10) years. A total of 9659 eyes were identified. SOS was achieved in 6613 eyes (68.5%). Best-corrected visual acuity significantly differed 9 to 12 months after treatment between the SOS group, with a mean of 0.24 logMAR (95% CI, 0.23-0.25; approximate Snellen equivalent, 20/35), and the single-operation failure group, with a mean of 0.43 logMAR (95% CI, 0.40-0.46; approximate Snellen equivalent, 20/54). Among all patients, the mean time to maximal visual recovery was 268 days (95% CI, 260-276). Endophthalmitis was observed in 3 eyes (0.03%). SOS was associated with female sex (odds ratio, 1.51; 95% CI, 1.38-1.65), while current smoking status was associated single-operation failure (odds ratio, 0.78; 95% CI, 0.68-0.91). CONCLUSIONS AND RELEVANCE: In this registry-based study, which encompasses a large number of eyes drawn from multiple, heterogenous electronic health record systems, SOS was achieved in 68.5% of eyes with noncomplex RRD treated by primary PR. It is unknown how these outcomes would have compared with other methods of RRD repair in this cohort.

Return to the Operating Room after Vitrectomy for Vitreous Opacities: Intelligent Research in Sight Registry Analysis.

PURPOSE: To investigate the rate of return to the operating room after vitrectomy surgery for vitreous opacities. DESIGN: Retrospective registry cohort. PARTICIPANTS: Individuals receiving care in ophthalmology practices participating in the Intelligent Research in Sight (IRIS®) Registry. METHODS: Data from the IRIS Registry were analyzed for patients who underwent vitrectomy for vitreous opacities. Cases were identified by the combination of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), codes (379.21, 379.22, 379.24, and 379.25), and a Current Procedural Terminology (CPT) code for vitrectomy surgery. MAIN OUTCOME MEASURES: The number and percentage of eyes that underwent additional eye surgery within 1 year after vitrectomy for vitreous opacities were identified, as was the nature of the additional procedures per CPT code. RESULTS: Fifty thousand eight hundred thirty-six eyes that underwent vitrectomy surgery linked to one of the ICD-9-CM or ICD-10-CM codes for vitreous opacities were identified. In 17 615 eyes, the surgery was linked to the vitreous opacities code exclusively, and not to epiretinal membrane or macular hole codes. Of these, 2187 eyes (12.4%) returned to the operating room for cataract surgery, and 643 eyes (3.7%) returned to the operating room for a noncataract procedure. Four hundred fifty-seven eyes (2.6%) returned to the operating room for retinal detachment repair. CONCLUSIONS: In the IRIS Registry, eyes undergoing vitrectomy for vitreous opacities returned to the operating room for an ophthalmic surgery other than cataract extraction 3.7% of the time, and retinal detachment repair was performed 2.6% of the time.

Frequency of Rhegmatogenous Retinal Detachment after Intravitreal Therapy in Neovascular Age-Related Macular Degeneration.

PURPOSE: To identify characteristics of neovascular age-related macular degeneration (nAMD) patients undergoing pars plana vitrectomy (PPV) after rhegmatogenous retinal detachment (RRD), including changes to injection intervals. DESIGN: Single-center retrospective, consecutive review. PARTICIPANTS: All patients with RRD receiving anti-vascular endothelial growth factor treatment for nAMD from January 1, 2014, through October 30, 2018. METHODS: Billing codes were used to identify RRD that occurred within 90 days of a previous intravitreal injection for nAMD. MAIN OUTCOME MEASURES: Outcome measures included the quadrant of the retinal break(s), visual acuity at the time of RRD and final follow-up, and postoperative injection frequency. RESULTS: An exact total of 203 000 intravitreal injections for nAMD were administered. Seventeen eyes from 17 patients demonstrated RRDs, giving a rate of 1 RRD per 11 941 intravitreal injections (0.0084%) within 90 days of intravitreal injection. Patients received a mean of 27.56 injections in the superotemporal quadrant before RRD. Of known retinal breaks, the superotemporal quadrant was involved most frequently (10 of 16 eyes [62.5%]). Six patients (35.3%) required a second surgery. Of patients requiring postoperative injections, the average interval increased from 7.18 weeks to 9.17 weeks after surgery. Eleven of 17 patients (64.7%) either increased their injection intervals or required no further injections, 3 maintained similar intervals, and 3 decreased intervals. The average number of injections in the 6 months before RRD (n = 84) and the 6 months after the first injection after PPV (n = 47) was 4.94 ± 1.89 and 2.76 ± 2.44, respectively (P = 0.009). CONCLUSIONS: Based on these results, the 90-day rate of RRD in nAMD patients receiving intravitreal injections is low. Rhegmatogenous retinal detachments in these patients may be more difficult to repair. Although many physicians worry about injection frequency in vitrectomized eyes because of a presumed increased medication clearance, this study found that most patients received fewer injections after surgery.

Primary Retinal Detachment Outcomes Study: Methodology and Overall Outcomes-Primary Retinal Detachment Outcomes Study Report Number 1.

PURPOSE: To detail the methodology for a large multicenter retrospective cohort study (RCS) of primary rhegmatogenous retinal detachment (RRD) with detailed data collection and to present overall anatomic outcomes. DESIGN: This study used an RCS method. PARTICIPANTS: All patients undergoing pars plana vitrectomy (PPV), scleral buckling (SB), and combined PPV/SB for primary RRD in 2015 from 5 large retina groups were included in the database. METHODS: To ensure validity of the cohort method, a large and detailed database was generated. Double data entry validation was conducted, and data audits were conducted. Anatomic and visual outcomes for all the cases in the dataset will be described but not compared, because the cases were not matched. In future studies, comparable cases of moderate-complexity RRD will be chosen naive to surgeon, surgery, and outcome for subgroup analysis. MAIN OUTCOME MEASURES: Precision of data entry was confirmed by inter-rater reliability (IRR). Main surgical outcome for each procedure type was single-surgery anatomic success (SSAS). RESULTS: Inter-rater reliability showed significant agreement among raters (P < 0.001). Of 2620 patients, 2335 had >90 days of follow-up. Of these, 320 eyes (13.7%) underwent SB, 1200 eyes (51.4%) underwent PPV, and 815 eyes (34.9%) underwent PPV/SB. The SSAS was 84.2% for PPV, 91.2% for SB, and 90.2% for PPV/SB. CONCLUSIONS: We compiled a large, accurately documented database of primary RRD cases repaired by PPV, SB, and PPV/SB from which cohort studies of moderately complex RRDs can be carried out. All 3 approaches had a high SSAS rate. Procedures chosen and their outcomes are described, but the broad case mix makes comparisons not possible until future cohort studies are completed.

Analysis of Emergent Nonhospital-Based Retina Consultation Requests in an Academic Nonhospital-Associated Retina Practice.

PURPOSE: To evaluate the outcomes of after-hour encounters concerning patients referred by eye physicians to on-call retina services for emergent evaluation not seen in or referred by an emergency department. DESIGN: Retrospective study. PARTICIPANTS: Patients seeking treatment at 3 private practice institutions over a 2-year period between 2017 and 2018. METHODS: A retrospective chart review was conducted comprising all patients who sought treatment emergently and after clinic hours from 3 academic nonhospital-associated retina-only private practice institutions over a 2-year period. MAIN OUTCOME MEASURES: Patient presenting symptoms, diagnosis given at time of after-hours appointment, duration of symptoms, source of after-hours consultation (patient or provider), procedure performed at appointment, and appointments that led to surgery. RESULTS: Nine hundred eighty-seven charts were reviewed. Provider referrals accounted for 49.13% (n = 485) and patient-derived referrals accounted for 50% (n = 493) of appointments. New patients accounted for 27.6% (n = 146) of patient-derived and 85.2% (n = 413) of provider-derived referrals. The most common presenting symptoms were flashes and floaters (42.5%; n = 420), decrease in visual acuity (32.1%; n = 317), generalized eye pain (7.4%; n = 73), visual field disturbance (4.3%; n = 42), and postoperative ocular pain (3.4%; n = 34). An in-office procedure was performed at the time of examination in 18% of encounters (n = 178), with most of these being laser retinopexy. Surgery was performed within 24 hours in 18% (n = 180), within 48 hours in 20.6% (n = 203), within 72 hours in 21.7% (n = 214), and within 96 hours in 22.6% (n = 223) of the appointment. When combined with procedures, 36.2% (n = 358) of encounters led to urgent intervention within 24 hours. If a provider called about an existing patient, 37.5% of these appointments (n = 27) led to surgery versus 12.8% (n = 49) if an existing patient self-referred. If a provider called about a new patient, 31.7% of these appointments (n = 131) led to surgery versus 10% (n = 14) if a new patient self-referred. CONCLUSIONS: At these 3 private practice retinal specialty clinics, 41% of after-hours appointment requests resulted in an intervention within 96 hours, and 36% of these patients underwent an intervention within 24 hours.

Primary Retinal Detachment Outcomes Study: Pseudophakic Retinal Detachment Outcomes: Primary Retinal Detachment Outcomes Study Report Number 3.

PURPOSE: This study evaluates outcomes of comparable pseudophakic rhegmatogenous retinal detachment (RRD) treated with pars plana vitrectomy (PPV) or PPV with scleral buckle (PPV-SB). DESIGN: Multicenter, retrospective, interventional cohort study. PARTICIPANTS: Data were gathered from patients from multiple retina practices in the United States with RRD in 2015. METHODS: A large detailed database was generated. Pseudophakic patients with RRD managed with PPV or PPV-SB were analyzed for anatomic and visual outcomes. Eyes with proliferative vitreoretinopathy, giant retinal tears, previous invasive glaucoma surgery, and ≤90 days of follow-up were excluded from outcomes analysis. Single surgery anatomic success (SSAS) was defined as retinal attachment without ongoing tamponade and with no other RRD surgery within 90 days. MAIN OUTCOME MEASURES: Single surgery anatomic success and final Snellen visual acuity (VA). RESULTS: A total of 1158 of 2620 eyes (44%) with primary RRD were pseudophakic. A total of 1018 eyes had greater than 90 days of follow-up. Eyes with proliferative vitreoretinopathy, previous glaucoma surgery, and giant retinal tears were excluded, leaving 893 pseudophakic eyes eligible for outcome analysis. A total of 461 (52%) were right eyes. A total of 606 patients (67%) were male, with a mean age of 65±11 years. Pars plana vitrectomy and PPV-SB as the first procedure were performed on 684 eyes (77%) and 209 eyes (23%), respectively. The mean follow-up was 388±161 days, and overall SSAS was achieved in 770 eyes (86%). Single surgery anatomic success was 84% (577/684) for PPV and 92% (193/209) for PPV-SB. The difference in SSAS between types of treatment was significant (P = 0.009). In eyes with macula-on RRD, SSAS was 88% in eyes treated with PPV and 100% in eyes treated with PPV-SB (P = 0.0088). In eyes with macula-off RRD, SSAS was 81% in eyes treated with PPV and 89% in eyes treated with PPV-SB (P = 0.029). Single surgery anatomic success was greater for PPV-SB than PPV for inferior (96% vs. 82%) and superior (90% vs. 82%) detachments. Mean final VA was similar for PPV (20/47) and PPV-SB (20/46; P = 0.805). CONCLUSIONS: In pseudophakic RRDs, SSAS was better in patients treated with PPV-SB compared with PPV alone, whereas visual outcomes were similar for both groups.

Primary Retinal Detachment Outcomes Study Report Number 2: Phakic Retinal Detachment Outcomes.

PURPOSE: Anatomically similar rhegmatogenous retinal detachments (RRDs) can be treated with scleral buckle (SB), pars plana vitrectomy (PPV), or SB combined with PPV (PPV/SB). This study compares moderately complex phakic primary RRD treated with SB, PPV, or PPV/SB to review anatomic and visual outcomes. DESIGN: Multicenter, retrospective, interventional cohort study. PARTICIPANTS: Data were gathered on all patients from multiple retina practices in the United States with RRD in 2015 and >90 days of follow-up. The cohort of phakic patients with moderately complex RRD was analyzed. METHODS: A large and detailed database was generated. Eyes with findings that would bias toward PPV (vitreous hemorrhage, dense cataract, proliferative vitreoretinopathy, giant retinal tear, among others) were excluded. Age <40 years (bias toward SB) was excluded. Comparable cases of moderately complex RRD were then chosen naive to surgeon, surgery, and outcome for subgroup analysis. MAIN OUTCOME MEASURES: Single surgery anatomic success (SSAS), defined as retinal attachment with no other RRD surgery within 90 days, is the main outcome measure. Final visual acuity is the secondary outcome measure. Pearson's chi-square and analysis of variance were used to test treatment effect of surgery type on SSAS and vision. RESULTS: Single surgery anatomic success was noted in 155 of 169 SB cases (91.7%), 207 of 249 PPV cases (83.1%), and 271 of 297 PPV/SB cases (91.2%). Scleral buckle and PPV/SB were superior to PPV for SSAS (P = 0.0041). For macula-on or split cases, SB had significantly better visual outcomes than PPV or PPV/SB even after controlling for cataract (cases with minimal cataract at final follow-up or after cataract surgery) (P < 0.001). CONCLUSIONS: For phakic moderately complex primary RRDs in this study of PPV versus SB versus PPV/SB, SB had the best visual outcomes, and PPV had the worst SSAS outcomes.

Complications of vitreoretinal surgery.

PURPOSE OF REVIEW: The present article reviews the most common and most serious vision-threatening and life-threatening complications of vitreoretinal surgery. RECENT FINDINGS: Serious complications after vitreroretinal surgery are rare. Endophthalmitis for example has recently been estimated to occur in 0.08% of small gague vitrectomy. Other complications such as cataract are almost unavoidable, becoming visually significant in up to 80% of patients. The introduction of smaller gauge vitrectomy systems has reduced surgical times, conjunctival scarring and inflammation, and the rate of some complications such as retinal tears. Ocular venous air embolism is an exceedingly rare complication that is potentially life threating and therefore important for all vitreoretinal surgeons to be aware of. SUMMARY: Though vitreoretinal surgery is well tolerated and effective, it is inevitable that all surgeons will experience complications and are therefore best served by understanding the potential complications, strategies to reduce the likelihood of them occurring, and ways to address them when they do happen.

Return to the Operating Room after Macular Surgery: IRIS Registry Analysis.

PURPOSE: To investigate the rate of return to the operating room after vitrectomy surgery to treat macular hole or epiretinal membrane. DESIGN: A retrospective registry cohort. PARTICIPANTS: Individuals receiving care in ophthalmology practices participating in the Academy IRIS (Intelligent Research in Sight) Registry. METHODS: Data from the IRIS Registry were analyzed for patients who underwent vitrectomy for macular holes or epiretinal membranes. Cases were identified by the combination of International Classification of Diseases, 9th revision code (362.54, 362.56) and a current procedural terminology (CPT) code for vitrectomy surgery between January 1, 2013 and June 30, 2017. MAIN OUTCOME MEASURES: The eyes that underwent additional eye surgery within 1 year after initial vitrectomy for macular hole or epiretinal membrane were identified, as was the nature of the additional procedures per CPT code. RESULTS: A total of 41 475 eyes underwent vitrectomy for macular hole and 73 219 eyes underwent vitrectomy for epiretinal membrane during the study period. In the macular hole group, 7573 had a second surgery within 1 year, and 2827 (6.8%) had a second surgery that was not cataract related. In the epiretinal membrane group, 12 433 had a second surgery within 1 year, 4022 (5.5%) of which were not cataract related. In the macular hole group, 4.6% of eyes returned to the operating room for another macular hole repair surgery, and 2.0% returned for retinal detachment repair. In the epiretinal membrane group, 1.4% returned for a second vitrectomy with membrane stripping, and 2.5% returned for retinal detachment repair. CONCLUSIONS: This registry-based study encompassed a large number of patients but was limited by the inaccessibility of some information and the potential for inaccurate medical records or coding, as it obtained data from multiple electronic health records entities. Excluding cataract surgery, approximately 6% of eyes that underwent vitrectomy to address macular hole or epiretinal membrane returned for a second ophthalmic procedure within a year. In the macular hole group, most secondary non-cataract surgeries were for another macular hole repair procedure. For both macular holes and epiretinal membranes, approximately 2% of eyes required retinal detachment repair surgery within 1 year.

Endophthalmitis after Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitors: Management and Visual Outcomes.

PURPOSE: We describe the presentation of patients developing endophthalmitis after intravitreal injection with vascular endothelial growth factor (VEGF) inhibitors. Moreover, we evaluate the management by comparing the outcomes of immediate tap and injection of intravitreal antibiotics (TAI) versus initial surgical pars plana vitrectomy (PPV). Finally, we analyze the predictive factors of visual outcomes at 6-month follow-up. DESIGN: Retrospective, single-center, nonrandomized interventional study. PARTICIPANTS: Patients developing endophthalmitis after receiving an intravitreal injection of anti-VEGF agent between 2006 and 2016. METHODS: All patients received a vitreous biopsy sent for cultures before the initiation of treatment: TAI group versus PPV with intravitreal antibiotics (PPV group). MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA) at 6-month follow-up after treatment for endophthalmitis. RESULTS: A total of 258 357 intravitreal injections occurred over the course of the 10-year period, of which 40 patients (0.016%) had endophthalmitis within 3 weeks after injection. In total, 34 patients (85.0%) had pain and 25 patients (62.5%) had hypopyon on initial examination. Among 24 culture-positive cases, 66.7% of the causative organisms were coagulase-negative Staphylococcus, followed by Streptococcus species (10.0%). The best-corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution [logMAR]) at 6-month follow-up was significantly worse for patients who had a positive culture for Streptococcus species (4.0; standard deviation [SD], 0.8) (approximately light perception) compared with those who had a positive culture for coagulase-negative Staphylococcus (0.4; SD, 0.3) (∼20/50) (P < 0.0001). Compared with the TAI group, a higher proportion of samples were culture-positive in the PPV group (90.9% vs. 48.3%, P = 0.03). There was no statistically significant difference in BCVA at 6-month follow-up between the TAI and PPV groups. Younger age (<85 years) and lower intraocular pressure (IOP) (≤25 mmHg) at presentation were predictive of achieving a BCVA of 20/400 or better at 6-month follow-up after treatment. Initial management (TAI vs. PPV), duration of symptoms, presence of pain, presence of hypopyon, presenting BCVA, and culture status (positive vs. negative) were not found to be predictive of visual outcomes at 6-month follow-up. CONCLUSIONS: No significant difference in BCVA at 6-month follow-up was detected between the TAI and PPV groups. Younger age and lower IOP at presentation were associated with better visual outcomes at 6-month follow-up.

Epiretinal membrane and cystoid macular edema as predictive factors of recurrent proliferative vitreoretinopathy.

PURPOSE: Proliferative vitreoretinopathy (PVR) is the most common cause of recurrent retinal detachment (RD). We sought to determine the predictive factors of recurrent PVR formation and the need for additional vitreoretinal surgical intervention after uncomplicated primary RD repair. METHODS: This is a retrospective single-center case-control study of consecutive patients with PVR formation after uncomplicated RD repair. Logistic regression was used to assess factors associated with recurrent PVR formation. RESULTS: Thirty-seven eyes (37 patients) who had recurrent RD secondary to PVR formation were included. Among those, 27 eyes needed one additional surgery, whereas the remainder 10 eyes required two or more additional surgeries. In the univariate analysis, patients who had cystoid macular edema (CME) after the second surgery were 8.33 times (crude odds ratio [COR], 95% confidence interval [CI]: 1.23-56.67, p=0.0302) more likely to have recurrent PVR formation compared to those who did not have CME after the second surgery. Similarly, those who had epiretinal membrane (ERM) after the second surgery were 8.00 times (COR, 95% CI: 1.43-44.92, p=0.0182) more likely to have recurrent PVR formation compared to those who did not have ERM after the second surgery. In the multivariate analysis, patients who had ERM after the second surgery were 8.20 times (adjusted odds ratio [AOR], 95% CI: 1.08-62.40, p=0.0422) more likely to develop recurrent PVR compared to those who did not have ERM after the second surgery, when adjusted for age, sex, and CME after the second surgery. CONCLUSION: ERM and CME are potential predictive factors for recurrent PVR formation after uncomplicated primary RD repair. Early recognition and treatment of ERM and CME may be critical to prevent subsequent PVR formation and improve visual outcomes.

Retinal Injury Secondary to Laser Pointers in Pediatric Patients.

This case report describes 4 male children (age, 9-16) who had laser-related retinal injury to the macula of 1 eye or both eyes due to the mishandling of the laser pointer devices at a single vitreoretinal clinical practice. The presenting symptoms associated with laser pointer injury include central vision loss, central scotoma, and metamorphopsia. Clinical findings of laser-related retinal injury include reduced visual acuity, disruption of the photoreceptor ellipsoid zone, retinal pigment epithelium atrophy, and choroidal neovascular membrane formation. Disruption of the foveal ellipsoid zone (photoreceptor inner segment/outer segment layer) is the most common finding on optical coherence tomography imaging. Three patients had potential irreversible vision loss. Laser pointers are readily available and appropriate use of laser pointers in the pediatric population must be emphasized due to the potential irreversible retinal injury. Health professionals, school teachers, and parents should raise public awareness of this emerging public health issue by educating children about the dangers of laser pointers. Laser pointer devices among children should be discouraged and limited due to the possibility of permanent harm to themselves and others. Legislation and laws may be required to better control the sale and use of these devices.