Vision Loss Reduction with Avacincaptad Pegol for Geographic Atrophy: A 12-Month Post Hoc Analysis of the GATHER1 and GATHER2 Trials.

PURPOSE: To evaluate the impact of reduction in geographic atrophy (GA) lesion growth on visual acuity in the GATHER trials using categorical outcome measures. DESIGN: Randomized, double-masked, sham-controlled phase 3 trials. PARTICIPANTS: Aged ≥50 years with noncenter point-involving GA and best-corrected visual acuity (BCVA) of 25 to 80 ETDRS letters in the study eye. METHODS: GATHER1 consisted of 2 parts. In part 1, 77 patients were randomized 1:1:1 to avacincaptad pegol (ACP) 1 mg, ACP 2 mg, and sham. In part 2, 209 patients were randomized 1:2:2 to ACP 2 mg, ACP 4 mg, and sham. In GATHER2, patients were randomized 1:1 to ACP 2 mg (n = 225) and sham (n = 223). A post hoc analysis of 12-month data for pooled ACP 2 mg and sham groups is reported. MAIN OUTCOME MEASURES: Proportion of study eyes that experienced ≥10-, ≥15-, or ≥20-BCVA ETDRS letter loss from baseline to month 12; time-to-event analysis of persistent vision loss of ≥10, ≥15, or≥ 20 BCVA letters from baseline at ≥2 consecutive visits over 12 months; proportion of study eyes with BCVA loss to a level below driving eligibility threshold at month 12 among those eligible to drive at baseline. RESULTS: Lower proportions of study eyes experienced ≥10-, ≥15-, or ≥20-BCVA letter loss from baseline over 12 months with ACP 2 mg (11.6%, 4.0%, and 1.6%, respectively) versus sham (14.1%, 7.6%, and 4.5%, respectively). There was a reduction in the risk of persistent loss of ≥15 BCVA ETDRS letters with ACP 2 mg (3.4%) versus sham (7.8%) through 12 months. A lower proportion of study eyes treated with ACP 2 mg reached the threshold for driving ineligibility versus sham by 12 months. CONCLUSIONS: Treatment with ACP 2 mg delayed the risk of progression to persistent vision loss (i.e., ≥10-, ≥15-, and ≥20-BCVA letter loss or BCVA loss to a level below driving eligibility threshold) versus sham over 12 months. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Repeatability and reproducibility of quantitative OCT angiography measurements from table-top and portable Flex Spectralis devices.

PURPOSE: The recent development of a portable investigational handheld OCT-angiography (OCTA) device has allowed for expansion of imaging into the operating room (OR) in addition to standard in-clinic imaging. The aim of this study was to assess intravisit repeatability and intervisit reproducibility of retinal microvasculature measures and central retinal thickness for in-clinic table-top and portable OR compatible OCTA devices. METHODS: Repeated 10 × 10 OCTA images were acquired in 20 healthy adult participants on two separate visit days using Spectralis spectral-domain OCTA table-top and investigational armature suspended Flex systems. Intravisit and intervisit intraclass correlation coefficients and average absolute percent difference were calculated for quantitative microvasculature measures and CRT. RESULTS: 120 OCTA images were acquired from 20 subjects (n = 20, mean age 26.7 ± 1.61 years, range 24-30 years) with both devices across two separate imaging days. FAZ and CRT measurements had near complete intravisit and intervisit agreement with ICCs between .97 and 1 for both table-top (FAZ ICC .97, .97; CRT ICC .98-1, .98-.99) and Flex (FAZ ICC .97, .95; CRT ICC .99-1, .98-.99) devices. Vessel density measures demonstrated greater variance with only fair to strong agreement (ICC .32-.75) and average absolute percent differences ranging from 2.96 to 6.63%. CONCLUSION: FAZ and CRT measures for both devices demonstrated high repeatability and reproducibility; retinal vessel density measures demonstrated less. Differences of less than 7% for retinal microvasculature measurements across time and devices are most likely attributable to expectable variance between repeat scans.

Transabdominal Fetal Ultrasound Before Early-Term Planned Delivery for Norrie Disease.

Purpose: To describe a case of early-term planned delivery of a fetus with Norrie disease. Methods: A retrospective chart review was performed. Results: A fetus with an older sibling with bilateral blindness from Norrie disease had positive NPD genetic testing on chorionic villus sampling. Transabdominal fetal ophthalmic ultrasound found bilateral total retinal detachments (RDs) at 32 weeks gestational age. The fetus was delivered at 37 weeks and had an examination under anesthesia, which showed bilateral inoperable RDs. Conclusions: Transabdominal fetal ophthalmic ultrasound was able to identity bilateral total RDs in utero. Further study is warranted on preterm or early-term delivery if a fetus has evidence of RD in utero.

Chronic Effects of e-Cigarette Aerosol Inhalation on Macular Perfusion Assessed Using OCT Angiography.

Purpose: To determine whether there are significant differences in the microvasculature and central retinal thickness (CRT) between e-cigarette users (user group) and age-matched nonusers (control group) using optical coherence tomography angiography (OCTA). Methods: In this prospective cross-sectional observational study, OCTA images were acquired of 52 eyes of 26 users and 25 eyes of 25 age-matched nonusers. Daily e-cigarette users with no ocular history were identified from provider information in the electronic medical record. A custom algorithm was used to calculate the foveal avascular zone (FAZ), vessel area density (VAD), and vessel length density (VLD). OCT software was used to calculate the foveal, superior, inferior, nasal, and temporal CRT. Generalized estimating equations using the Z-statistic were used to determine how the FAZ, VAD, VLD, and CRT parameters varied between groups and to assess the differential contribution of descriptive data in the user group. Results: No statistically significant difference was found between the user group and control group in the FAZ, superficial vascular complex (SVC) VAD, SVC VLD, or deep vascular complex (DVC) VAD. A statistically significant difference was found for DVC VLD (P = .002), with the user group having a slightly higher VLD on average. Superior, temporal, and inferior inner macular thicknesses were significantly thinner in the user group (P = .038, P = .012, and P = .035, respectively). Conclusions: Significant negative differences were found in CRT measures but not in retinal microvasculature parameters between e-cigarette users and nonusers. Decreased inferior, temporal, and superior inner macular thickness in e-cigarette users may show an early chronic structural effect that warrants further assessment of retinal effects as this population ages and continues to use e-cigarettes.

Longitudinal Choroidal Development in Preterm Infants.

Purpose: To characterize changes in subfoveal choroidal thickness in preterm infants from 30 to 60 weeks' postmenstrual age (PMA). Design: The prospective, observational Study of Eye Imaging in Preterm infantS (BabySTEPS) enrolled infants eligible for retinopathy of prematurity screening per the American Association of Pediatrics guidelines. Subjects: Infants imaged with an investigational, handheld OCT at ≥ 4 distinct imaging sessions between 30 to 60 weeks' PMA as part of BabySTEPS. Methods: Average choroidal thickness across the central subfoveal 1 mm in each eye at each time point was measured using custom segmentation software, and errors were manually corrected by a trained grader. We prospectively collected birth history data. A segmented mixed model was used to analyze the change in choroidal thickness as a function of PMA, birth weight, and gestational age (GA). Main Outcome Measures: Characterization of normative subfoveal choroidal thickness values and choroidal growth rate between 30 to 60 weeks' PMA. Results: We included 592 imaging sessions of 79 preterm infants (152 eyes). Mean (± standard deviation) GA was 27.5 ± 2.5 weeks. Mean choroidal thickness was 141.4 ± 34.5 µm at 30 weeks, 272.2 ± 83.9 µm at 38 weeks, and 306.2 ± 77.4 µm between 56 and 60 weeks. Between 30 and 60 weeks' PMA, choroidal growth followed a biphasic model, with a linear growth rate of 14.8 µm per week (95% confidence interval [CI], 13.6-16.0) from 30 until 38.4 weeks, then cessation of growth, with a growth rate of 0.3 µm per week (95% CI, -1.1 to 1.6) from 38.4 to 60 weeks. Infants with extremely low birth weight (ELBW; < 1000 g) and extremely preterm (GA < 28 weeks) infants had significantly slower initial growth rates compared with very low and low birth weight and very preterm and preterm infants (ELBW 13.0 vs. 21.0 µm per week; P < 0.0001 and extremely preterm 13.2 vs. 18.0 µm per week; P = 0.003). Conclusions: Preterm infant choroidal thickness experiences rapid linear growth from 30 to 38 weeks' PMA, at which time growth nearly stops. These foundational measurements and identification of the impact of extremes of low birth weight and prematurity on choroidal development will be essential as researchers begin to understand the role of choroidal development in ocular and retinal health in human infants. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Applicant Perceptions of In-Person versus Virtual Interview Format for Surgical Retina Fellowship.

Purpose This article compares applicants' perceptions of and experiences with virtual and in-person interviews for surgical retina fellowship. Methods A survey was distributed via email to all applicants of three vitreoretinal surgery fellowship programs for the 2021 to 2022 and 2022 to 2023 application cycles. Main Outcome Measures Participants were surveyed regarding cost; burden of scheduling; number of applications and interviews completed; ability to gain a true feel of the program, location, and preceptor; and number of work and surgical days missed. Results Of 151 applicants contacted, 36 completed the survey (23.8% response rate). Of the respondents, 25.0% attended only virtual interviews, 19.4% attended mostly virtual interviews, 30.6% attended mostly in-person interviews, and 25.0% attended half virtual and half in-person interviews. Average expenditure was significantly lower for applicants with mostly and completely virtual interviews compared with applicants with mostly in-person and half virtual, half in-person ( p < 0.001). Applicants with mostly virtual interviews reported a lower ability to gain a true perception of the program and the program location ( p = 0.003 and p < 0.001, respectively). There was no difference in burden of scheduling, number of interviews completed, or number of work and surgical days missed. When applicants were asked what type of interview format they would prefer if they could repeat the cycle, those who interviewed mostly in-person largely chose in-person as their preference (72.7%), while participants who interviewed mostly or completely virtually were evenly split between in-person, virtual, and hybrid ( p = 0.136). Conclusion As fellowship programs and institutions decide whether they will return to in-person interviews or maintain a virtual interview format in the long term, they must weigh the lower cost of virtual interviews with the improved ability to gain a more accurate perception of the program and location allowed by in-person interviews, as well as potentially greater satisfaction with the in-person format.

Fluocinolone Acetonide Implant Removal From the Vitreous Cavity.

Purpose: To describe a technique for fluocinolone acetonide implant removal from the vitreous cavity. Methods: A case report and review of surgical methods were performed. Results: The technique to remove a fluocinolone acetonide implant from the vitreous cavity was safe and effective. The vitreous cutter was used to align the implant coaxially with a 25-gauge cannula. The valve of the cannula was opened, creating pressure that drew the implant into the cannula. Conclusions: Fluocinolone acetonide implants can be efficiently removed from the vitreous cavity by creating a pressure differential using the valved cannula. Advantages of this technique include avoiding invasive maneuvers such as enlarging the sclerotomy or creating a corneal wound.

Erratum: Methods for real-time feature-guided image fusion of intrasurgical volumetric optical coherence tomography with digital microscopy: publisher's note.

[This corrects the article on p. 3308 in vol. 14, PMID: 37497493.].

Methods for real-time feature-guided image fusion of intrasurgical volumetric optical coherence tomography with digital microscopy.

4D-microscope-integrated optical coherence tomography (4D-MIOCT) is an emergent multimodal imaging technology in which live volumetric OCT (4D-OCT) is implemented in tandem with standard stereo color microscopy. 4D-OCT provides ophthalmic surgeons with many useful visual cues not available in standard microscopy; however it is challenging for the surgeon to effectively integrate cues from simultaneous-but-separate imaging in real-time. In this work, we demonstrate progress towards solving this challenge via the fusion of data from each modality guided by segmented 3D features. In this way, a more readily interpretable visualization that combines and registers important cues from both modalities is presented to the surgeon.

Visualization of surgical maneuvers using intraoperative real-time volumetric optical coherence tomography.

Ophthalmic microsurgery is traditionally performed using stereomicroscopes and requires visualization and manipulation of sub-millimeter tissue structures with limited contrast. Optical coherence tomography (OCT) is a non-invasive imaging modality that can provide high-resolution, depth-resolved cross sections, and has become a valuable tool in clinical practice in ophthalmology. While there has been substantial progress in both research and commercialization efforts to bring OCT imaging into live surgery, its use is still somewhat limited due to factors such as low imaging speed, limited scan configurations, and suboptimal data visualization. In this paper we describe, to the best of our knowledge, the translation of the fastest swept-source intraoperative OCT system with real-time volumetric imaging with stereoscopic data visualization provided via a heads-up display into the operating room. Results from a sampling of human anterior segment and retinal surgeries chosen from 93 human surgeries using the system are shown and the benefits that this mode of intrasurgical OCT imaging provides are discussed.

NOVEL METHOD FOR VISUALIZING PERIPHERAL RETINAL STRUCTURES WITH MICROSCOPE-INTEGRATED OPTICAL COHERENCE TOMOGRAPHY.

BACKGROUND/PURPOSE: Visualization of peripheral retinal structures with optical coherence tomography (OCT) can be challenging but can offer valuable clinical information. We describe a method for intraoperative OCT of the peripheral retina. METHODS: An investigational microscope-integrated OCT system with real-time 4D volumetric imaging was used in conjunction with a Goldmann style mirrored contact lens intraoperatively to capture peripheral images in three patients. RESULTS: We identified retinoschisis, a retinal break, and areas of focal retinal detachment using our peripheral OCT method. CONCLUSION: Use of a Goldmann lens in conjunction with intraoperative OCT offers surgeons the ability to resolve peripheral pathology that cannot be easily evaluated with OCT otherwise.

Quantitative measurements of intraocular structures and microinjection bleb volumes using intraoperative optical coherence tomography.

Intraoperative optical coherence tomography (OCT) systems provide high-resolution, real-time visualization and/or guidance of microsurgical procedures. While the use of intraoperative OCT in ophthalmology has significantly improved qualitative visualization of surgical procedures inside the eye, new surgical techniques to deliver therapeutics have highlighted the lack of quantitative information available with current-generation intraoperative systems. Indirect viewing systems used for retinal surgeries introduce distortions into the resulting OCT images, making it particularly challenging to make calibrated quantitative measurements. Using an intraoperative OCT system based in part on the Leica Enfocus surgical microscope interface, we have devised novel measurement procedures, which allowed us to build optical and mathematical models to perform validation of quantitative measurements of intraocular structures for intraoperative OCT. These procedures optimize a complete optical model of the sample arm including the OCT scanner, viewing attachments, and the patient's eye, thus obtaining the voxel pitch throughout an OCT volume and performing quantitative measurements of the dimensions of imaged objects within the operative field. We performed initial validation by measuring objects of known size in a controlled eye phantom as well as ex vivo porcine eyes. The technique was then extended to measure other objects and structures in ex vivo porcine eyes and in vivo human eyes.

Associations between systemic health and retinal nerve fibre layer thickness in preterm infants at 36 weeks postmenstrual age.

BACKGROUND/AIMS: Neonatal insults from systemic diseases have been implicated in the pathway of impaired neurodevelopment in preterm infants. We aimed to investigate the associations between systemic health factors and retinal nerve fibre layer (RNFL) thickness in preterm infants. METHODS: We prospectively enrolled infants and imaged both eyes at 36±1 weeks postmenstrual age (PMA) using a hand-held optical coherence tomography system at the bedside in the Duke intensive care nurseries. We evaluated associations between RNFL thickness and 29 systemic health factors using univariable and multivariable regression models. RESULTS: 83 infants with RNFL thickness measures were included in this study. Based on the multivariable model, RNFL thickness was positively associated with infant weight at imaging and was negatively associated with sepsis/necrotising enterocolitis (NEC). RNFL thickness was 10.4 µm (95% CI -15.9 to -4.9) lower in infants with than without sepsis/NEC in the univariable analysis (p<0.001). This difference remained statistically significant after adjustment for confounding variables in various combinations (birth weight, birthweight percentile, gestational age, infant weight at imaging and growth velocity). A 250 g increase in infant weight at imaging was associated with a 3.1 µm (95% CI 2.1 to 4.2) increase in RNFL thickness in the univariable analysis (p<0.001). CONCLUSIONS: Low infant weight and sepsis/NEC were independently associated with thinner RNFL in preterm infants at 36 weeks PMA. To our knowledge, this study is the first to suggest that sepsis/NEC may affect retinal neurodevelopment. Future longitudinal studies are needed to investigate this relationship further.

Resident Vitreoretinal Procedure Volume: Effect of Intravitreal Injections, Region, Program Size, and Vitreoretinal Fellowship and Veterans Affairs Affiliation.

Purpose To analyze resident vitreoretinal procedure volume across Accreditation Council of Graduate Medical Education (ACGME) accredited ophthalmology residency programs. We assessed the effect of the increase in intravitreal injections (IVI), geographic region, program size, and Veterans Affairs (VA) and vitreoretinal fellowship affiliation on vitreoretinal procedures. Methods A request was sent to all residency programs in 2018 for their graduating residents' ACGME case logs. Vitreoretinal procedures were defined by ACGME case log categories and included vitreoretinal surgery, peripheral retinal lasers, and IVI. Procedures were categorized by Current Procedural Terminology (CPT) code. Programs were studied by geographic region, program size, and by VA and vitreoretinal fellowship affiliation. Results A total of 38 of 115 (33.0%) programs responded, and 167 residents logged 32,860 vitreoretinal procedures. The median number of retina procedures per resident was 146 (range 36-729). Programs with a vitreoretinal fellowship had a higher average number of vitreoretinal procedures per resident (208.3 vs. 125.0; p = 0.002), but there was no difference between the average number of non-IVI vitreoretinal procedures (60.0 vs. 64.2; p = 0.32). For IVI, VA affiliation (146.6 vs. 71.1; p = 0.02) and vitreoretinal fellowship (149.4 vs. 60.8; p < 0.001) were associated with a greater number. More IVI strongly correlated with a larger total volume of retinal procedures ( r = 0.98), and there was no difference across programs for total retinal procedures when IVI was removed. Conclusions The presence of a vitreoretinal fellowship at a residency program had a positive effect on resident total vitreoretinal case volume, but their residents performed more IVI. Programs without vitreoretinal fellowships completed on average more non-IVI procedures.

Association Between Retinal Microanatomy in Preterm Infants and 9-Month Visual Acuity.

Importance: Preterm infants are at risk for poor visual acuity (VA) outcomes, even without retinal problems on ophthalmoscopy. Infant retinal microanatomy may provide insight as to potential causes. Objective: To evaluate the association between preterm infant retinal microanatomy and VA at 9 months' corrected age. Design, Setting, and Participants: This prospective observational study took place from November 2016 and December 2019 at a single academic medical center and included preterm infants enrolled in Study of Eye Imaging in Preterm Infants (BabySTEPS). Infants were eligible for enrollment in BabySTEPS if they met criteria for retinopathy of prematurity (ROP) screening, were 35 weeks' postmenstrual age or older at the time of first OCT imaging, and a parent or guardian provided written informed consent. Of 118 infants enrolled in BabySTEPS, 61 were included in this analysis. Data were analyzed from March to April 2021. Exposures: Bedside optical coherence tomography (OCT) imaging at a mean (SD) 39.85 (0.79) weeks' postmenstrual age and monocular grating VA measurement at 9 months' corrected age. Main Outcomes and Measures: Presence and severity of macular edema and presence of ellipsoid zone at the fovea measured by extracting semiautomated thicknesses of inner nuclear layer, inner retina, and total retina at the foveal center; choroid across foveal 1 mm; and retinal nerve fiber layer (RNFL) across the papillomacular bundle (PMB). Pearson correlation coefficients were calculated and 95% CIs were bootstrapped for the association between retinal layer thicknesses and continuous logMAR VA. Associations were analyzed between retinal microanatomy and normal (3.70 cycles/degree or greater) vs subnormal grating VA at 9 months' corrected age using logistic regression and with logMAR VA using linear regression, adjusting for birth weight, gestational age, and ROP severity at the time of OCT imaging and accounting for intereye correlation using generalized estimating equations. Results: The mean (SD; range) gestational age of included infants was 27.6 (2.8; 23.0-34.6) weeks, and mean (SD; range) birth weight was 958.2 (293.7; 480-1580) g. In 122 eyes of 61 infants, the correlations between retinal layer thicknesses and logMAR VA were as follows: r, 0.01 (95% CI, -0.07 to -0.27) for inner nuclear layer; r, 0.19 (95% CI, 0.01 to 0.35) for inner retina; r, 0.15 (95% CI, -0.02 to 0.31) for total retina; r, -0.22 (95% CI, -0.38 to -0.03) for choroid; and r, -0.27 (95% CI, -0.45 to 0.10) for RNFL across the PMB. In multivariable analysis, thinner RNFL across the PMB (regression coefficient, -0.05 per 10-µm increase in RNFL thickness; 95% CI, -0.10 to -0.01; P = .046) and prior ROP treatment (regression coefficient, 0.33 for ROP treatment; 95% CI, 0.11 to 0.56; P = .003) were independently associated with poorer 9-month logMAR VA. Conclusions and Relevance: In preterm infants, RNFL thinning across the PMB was associated with poorer 9-month VA, independent of birth weight, gestational age, need for ROP treatment, and macular microanatomy. Evaluation of RNFL thickness using OCT may help identify preterm infants at risk for poor vision outcomes.

Insights into the developing fovea revealed by imaging.

Early development of the fovea has been documented by histological studies over the past few decades. However, structural distortion due to sample processing and the paucity of high-quality post-mortem tissue has limited the effectiveness of this approach. With the continuous progress in high-resolution non-invasive imaging technology, most notably optical coherence tomography (OCT) and OCT angiography (OCT-A), in vivo visualization of the developing retina has become possible. Combining the information from histologic studies with this novel imaging information has provided a more complete and accurate picture of retinal development, and in particular the developing fovea. Advances in neonatal care have increased the survival rate of extremely premature infants. However, with enhanced survival there has been an attendant increase in retinal developmental complications. Several key abnormalities, including a thickening of the inner retina at the foveal center, a shallower foveal pit, a smaller foveal avascular zone, and delayed development of the photoreceptors have been described in preterm infants when compared to full-term infants. Notably these abnormalities, which are consistent with a partial arrest of foveal development, appear to persist into later childhood and adulthood in these eyes of individuals born prematurely. Understanding normal foveal development is vital to interpreting these pathologic findings associated with prematurity. In this review, we first discuss the various advanced imaging technologies that have been adapted for imaging the infant eye. We then review the key events and steps in the development of the normal structure of the fovea and contrast structural features in normal and preterm retina from infancy to childhood. Finally, we discuss the development of the perifoveal retinal microvasculature and highlight future opportunities to expand our understanding of the developing fovea.

Referable Macular Hemorrhage-A Clinically Meaningful Screening Target in Newborn Infants. Position Statement of the Association of Pediatric Retina Surgeons.

Universal newborn eye screening facilitates early diagnosis of ocular abnormalities and mitigates vision loss. "Referral warranted" eye disease is present at birth in about 5.5% of term infants, with "macular hemorrhage impinging on the fovea" representing about 50% of referral warranted disease. The Association of Pediatric Retina Surgeons held a symposium on February 9, 2021 that culminated in a position statement on "referable macular hemorrhage" (RMH) in newborn infants. RMH is meaningful in that in can cause amblyopia through deprivation, can be readily captured with wide-angle photography in a safe and efficient manner, and may lead to early intervention with mitigation of vision loss. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:3-6.].

INTRAOPERATIVE OPTICAL COHERENCE TOMOGRAPHY AND ENDOSCOPY-GUIDED EXPLANTATION OF ARGUS II DEVICE.

PURPOSE: To describe a surgical approach using intraoperative optical coherence tomography and endoscopy for successful Argus II retinal prosthesis system removal. METHODS: Retrospective review of a patient undergoing Argus II explantation 8 months after initial implantation. RESULTS: Successful explantation of the Argus II device was performed in this patient. CONCLUSION: Explantation of the Argus II device can be a difficult surgery, and intraoperative optical coherence tomography and endoscopy can be used to help avoid potential complications.

A Unique Case of Syphilitic Hypopyon Panophthalmitis.

Purpose: This work reports a unique case of syphilitic hypopyon panophthalmitis. Methods: A case report is presented. Results: A 25-year-old man with a history of HIV and intravenous (IV) drug use presented to an outside hospital with blurred vision and swelling of the right eye. Computed tomography was concerning for orbital cellulitis. On examination, he had limited extraocular motility, relative exophthalmos, periocular edema, 4+ anterior chamber cell, an irregular layering hypopyon, and no view of the fundus. Magnetic resonance imaging showed enhancement of the sclera, lateral rectus muscle, and lacrimal gland concerning for infectious or inflammatory panophthalmitis. The patient's history and presentation were concerning for bacterial or fungal etiologies from an endogenous source. He began antimicrobial therapy. Diagnostic vitrectomy was unrevealing. Syphilis testing was positive. The patient showed improvement with IV antiluetic therapy. Conclusions: We present a case of syphilitic hypopyon panophthalmitis, a new constellation of findings in syphilitic ocular disease.