Macular holes (MHs) in highly myopic patients often develop at a younger age and may be associated with foveoschisis and a posterior retinal detachment (RD), which portend a poorer prognosis. Although recent anatomical success following primary pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peel with gas tamponade have improved to 60% to 100%, closure rates are significantly lower if associated with foveoschisis or RD, the MH may attain a flat-open configuration even following retinal reattachment, and reopening rates are higher. 1,2 Early treatment reports described perifoveolar laser photocoagulation to form chorioretinal adhesions resulting in permanent photoreceptor loss. 3 Several procedures are now available for primary repair of myopic MH and MH RD including PPV with ILM peel and gas or silicone oil tamponade, inverted ILM flaps, 4,5 episcleral posterior buckling, adjuvant blood components, 6 suprachoroidal buckling, and scleral shortening techniques. 7 However, options for patients whose MHs fail to close despite initial PPV and ILM peel are limited. Techniques described recently include temporal scleral imbrication, 8 autologous ILM flap, 5 addition of autologous blood to the autologous ILM flap, 9 and autologous anterior or posterior lens capsule flap as a scaffold to plug the MH. 10 We describe a new technique involving the use of an autologous neurosensory retinal free flap for closure of refractory myopic MHs with associated foveoschisis and/or RD. This technique involves harvesting an autologous neurosensory retinal free flap and positioning it over the refractory MH to provide a scaffold and plug for hole closure.

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Background Activation of innate immunity plays a key role in determining the outcome of an infection. Here, we investigated whether Toll-like receptors (TLRs) are involved in retinal innate response and explored the prophylactic use of TLR2 ligand in preventing bacterial endophthalmitis. Methods C57BL/6 (B6) mice were given intravitreal injections of Pam3Cys, a synthetic ligand of TLR2, or vehicle (PBS) 24 h prior to S. aureus (SA) inoculation. The severity of endophthalmitis was graded by slit lamp, electroretinography (ERG), histological examinations and determination of bacterial load in the retina. The expression of cytokines/chemokines and cathelicidin-related antimicrobial peptide (CRAMP) was assessed by ELISA and Western blot respectively. Results Intravitreal injections of Pam3Cys up-regulated TLR2 expression in the B6 retina and Pam3Cys pretreatment significantly improved the outcome of SA endophthalmitis, preserved retinal structural integrity and maintained visual function assessed with ERG in B6 mice. Furthermore, Pam3Cys pretreatment activated retinal microglia cells, induced the expression of CRAMP, and remarkably reduced the bacterial load. Conclusions This is the first report that highlights the existence and role of TLR2 in retinal innate immune response to SA infection and suggests that modulation of TLR activation provides a novel prophylactic approach to prevent bacterial endophthalmitis.

Purpose To determine the effect of anti-vascular endothelial growth factor (VEGF) therapy on choroidal thickness in eyes with diabetic macular edema (DME) Design A retrospective, cohort analysis of 59 eyes from 59 patients with DME without prior anti-VEGF therapy Methods Choroidal thickness was measured using semi-automated segmentation of enhanced-depth imaging optical coherence tomography (EDI-OCT) images at 0.5mm intervals from 2.5mm nasal to 2.5mm temporal to the fovea. Changes in choroidal thickness with and without anti-VEGF treatment over 6 months were compared. Best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were analyzed to evaluate the association of choroidal thickness with functional and anatomical outcomes. Results Of the 59 eyes with DME, 26 eyes were observed without treatment, while 33 underwent intravitreal anti-VEGF therapy (mean number of injections = 2.73) over 6 months. In untreated eyes, there was no significant change in BCVA (p=0.098), CFT (p=0.472), or choroidal thickness at all measurements along the macula (p=0.057 at the fovea). In eyes treated with anti-VEGF injections, choroidal thickness significantly decreased at the fovea (246.6μm to 224.8μm; p<0.001) and at 0.5 mm nasal (240.9μm to 221.9μm; p = 0.002) and 0.5 mm temporal (249.3μm to 224.8μm; p=0.011) to the fovea. The decrease in subfoveal choroidal thickness after anti-VEGF treatment was not associated with the cumulative number of anti-VEGF injections (R2=0.031, p=0.327), or to changes in BCVA (R2=0.017; p=0.470) or CFT (R2=0.040; p=0.263). Conclusions Central choroidal thickness decreases after anti-VEGF therapy for DME after 6 months, but may not be associated with functional or anatomical outcomes in eyes with DME.

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Background/Aims To assess peripheral retinal lesions and the posterior pole in single, widefield optical coherence tomography (OCT) volumes. Methods A wide field of view swept source OCT (WFOV SSOCT) system was developed using a commercial swept source laser and a custom sample arm consisting of two indirect ophthalmic lenses. Twenty-seven subjects with peripheral lesions (choroidal melanomas, choroidal nevii, sclerochoroidal calcification, retinitis pigmentosa, diabetic retinopathy, retinoschisis, and uveitis) were imaged with the WFOV SSOCT. Volumes were taken in primary gaze. Using the optic nerve to fovea distance as a reference measurement, comparisons were made between the lateral field of view (FOV) of the WFOV SSOCT, current generation spectral domain OCT (SDOCT), and widefield scanning laser ophthalmoscopy (SLO) of the same eyes. Results Peripheral pathologies were captured with WFOV SSOCT in 26 of the 27 subjects. The one not captured was in the far nasal periphery and was not seen in the primary gaze volume. Posterior pole associated pathologies were captured in all subjects. Current generation SDOCT had a mean lateral FOV of 2.08 ± 0.21 optic nerve-to-fovea distance units, WFOV SSOCT had a FOV of 4.62 ± 0.62 units, and SLO had a FOV of 9.35 ± 1.02 units. Conclusion WFOV OCT can be used to examine both peripheral retinal pathology and the posterior pole within a single volume acquisition. SLO had the greatest FOV, but does not provide depth information. Future studies using widefield OCT systems will help further delineate the role of WFOV OCT to quantitatively assess and monitor peripheral retinal disease in three dimensions.

Scleral buckling is a highly successful technique for the repair of rhegmatogenous retinal detachment that requires intra-operative examination of the retina and treatment of retinal breaks via indirect ophthalmoscopy. Data suggest that scleral buckling likely results in improved outcomes for many patients but is declining in popularity, perhaps because of significant advances in vitrectomy instrumentation and visualization systems. Emerging data suggest that chandelier-assisted scleral buckling is safe and has many potential advantages over traditional buckling techniques. By combining traditional scleral buckling with contemporary vitreoretinal visualization techniques, chandelier-assistance may increase the popularity of scleral buckling to treat primary rhegmatogenous retinal detachment for surgeons of the next generation, maintaining buckling as an option for appropriate patients in the future.