To test the hypothesis that tolerating some subretinal fluid (SRF) in patients with neovascular agerelated macular degeneration (nAMD) treated with ranibizumab using a treat-and-extend (T&E) regimen can achieve similar visual acuity (VA) outcomes as treatment aimed at resolving all SRF.Design: Multicenter, randomized, 24-month, phase 4, single-masked, noninferiority clinical trial.Participants: Participants with treatment-naïve active subfoveal choroidal neovascularization (CNV). Methods: Participants were randomized to receive ranibizumab 0.5 mg monthly until either complete resolution of SRF and intraretinal fluid (IRF; intensive arm: SRF intolerant) or resolution of all IRF only (relaxed arm: SRF tolerant except for SRF >200 mm at the foveal center) before extending treatment intervals. A 5-letter noninferiority margin was applied to the primary outcome.Main Outcome Measures: Mean change in best-corrected VA (BCVA), and central subfield thickness and number of injections from baseline to month 24.Results: Of the 349 participants randomized (intensive arm, n ¼ 174; relaxed arm, n ¼ 175), 279 (79.9%) completed the month 24. The mean change in BCVA from baseline to month 24 was 3.0 letters (standard deviation, 16.3 letters) in the intensive group and 2.6 letters (standard deviation, 16.3 letters) in the relaxed group, demonstrating noninferiority of the relaxed compared with the intensive treatment (P ¼ 0.99). Similar proportions of both groups achieved 20/40 or better VA (53.5% and 56.6%, respectively; P ¼ 0.92) and 20/200 or worse VA (8.7% and 8.1%, respectively; P ¼ 0.52). Participants in the relaxed group received fewer ranibizumab injections over 24 months (mean, 15.8 [standard deviation, 5.9]) than those in the intensive group (mean, 17 [standard deviation, 6.5]; P ¼ 0.001). Significantly more participants in the intensive group never extended beyond 4-week treatment intervals (13.5%) than in the relaxed group (2.8%; P ¼ 0.003), and significantly more participants in the relaxed group extended to and maintained 12-week treatment intervals (29.6%) than the intensive group (15.0%; P ¼ 0.005).Conclusions: Patients treated with a ranibizumab T&E protocol who tolerated some SRF achieved VA that is comparable, with fewer injections, with that achieved when treatment aimed to resolve all SRF completely.

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Volcanic dykes are common discrete heterogeneities in aquifers; however, there is a lack of field examples of, and methodologies for, comprehensive in situ characterization of their properties with respect to groundwater flow and solute transport. We have applied an integrated multiphysics approach to quantify the effect of dolerite dykes on saltwater intrusion in a coastal sandstone aquifer. The approach involved ground geophysical imaging (passive magnetics and electrical resistivity tomography), well hydraulic testing, and tidal propagation analysis, which provided constraints on the geometry of the dyke network, the subsurface saltwater distribution, and the sandstone hydrodynamic properties and connectivity. A three‐dimensional variable‐density groundwater model coupled with a resistivity model was further calibrated using groundwater and geophysical observations. A good agreement of model simulations with tide‐induced head fluctuations, geophysically derived pore water salinities, and measured apparent resistivities was obtained when dykes' hydraulic conductivity, storativity, and effective porosity are respectively about 3, 1, and 1 orders of magnitude lower than the host aquifer. The presence of the dykes results in barrier‐like alterations of groundwater flow and saltwater intrusion. Preferential flow paths occur parallel to observed dyke orientations. Freshwater inflows from upland recharge areas concentrate on the land‐facing side of the dykes and saltwater penetration is higher on their sea‐facing side. This has major implications for managing groundwater resources in dyke‐intruded aquifers, including in coastal and island regions and provides wider insights on preferential pathways of groundwater flow and transport in highly heterogeneous aquifer systems.

OBJECTIVE: Combined endoscopic third ventriculostomy (ETV) and tumour biopsy is a common approach to the management of patients presenting with hydrocephalus secondary to a pineal region lesion. We report our experience in performing an ETV and limited debulking of a pineal tumour using a rigid scope through a single burr hole. This was made possible by splitting the choroid fissure (CF) and massa intermedia (MI). We also report our review of the literature of current endoscopic approaches to the biopsy of pineal region lesions combined with ETV. SUBJECT: A 13-yearold boy presented with a two-day history of rapidly progressive headache with blurred vision, diplopia and vomiting. Brain MRI revealed a pineal region lesion associated with obstructive hydrocephalus. RESULTS: An endoscopic transchoroidal approach with splitting of the MI combined with an ETV was performed. This allowed successful management of the obstructive hydrocephalus and a limited debulking of the pineal tumour. The histopathologic examination revealed an immature teratoma. Post-operatively the patient made an uneventful recovery and started chemotherapy. CON-CLUSION: The endoscopic transchoroidal approach with splitting of the massa intermedia, when possible, allows management of the hydrocephalus and biopsy/debulking of pineal tumours through a single burr hole even when a solid scope is used. With experience and improved instrumentation, complete endoscopic resection of pineal tumours may become commonplace in the future.

We report the first case of Sjögren's syndrome causing gross lacrimal gland swelling and secondary hypoglobus and uncharacteristically absent sicca syndrome. Histopathological diagnosis of the excision biopsy of the orbital lobe of the gland confirmed a mixed T and B cell infiltrate of the gland with no lymphomatous transformation. The condition remains quiescent following complete excision.