Adam T. Gerstenblith

Conjunctival Flora Antibiotic Resistance Patterns After Serial Intravitreal Injections Without Postinjection Topical Antibiotics

PURPOSE To report conjunctival bacterial flora antibiotic resistance patterns after serial intravitreal injections performed using a povidone-iodine preparation without the use of preinjection or postinjection topical antibiotics. DESIGN Prospective, interventional case series. METHODS SETTING Single-center clinical practice in Pennsylvania. STUDY POPULATION Thirteen eyes of 13 treatment-naïve patients undergoing serial intravitreal anti-vascular endothelial growth factor (VEGF) injections for exudative age-related macular degeneration or macular edema attributable to retinal vein occlusion. INTERVENTION Conjunctival cultures from the treatment eye were performed prior to each injection preparation. A minimum of 3 monthly conjunctival cultures were obtained per eye over the course of the study. Ocular surface preparation consisted of topical anesthetic and povidone-iodine 5% without the use of preinjection or postinjection topical antibiotics. MAIN OUTCOME MEASURES Conjunctival flora growth patterns and antibiotic resistance patterns to several common antibiotics tested over the course of the study. RESULTS A total of 48 cultures were performed with a 77% culture positivity rate. Over the course of the serial conjunctival cultures in each patient, there was no evidence for emergence of resistant bacteria to any of the tested antibiotics (including fluoroquinolones and azithromycin) or significant alteration from baseline conjunctival flora. Of the 47 bacterial isolates, the most commonly isolated organism was coagulase-negative Staphylococcus both at baseline (73%) and following serial intravitreal injections (78%, P = .73). CONCLUSIONS Ocular surface preparation for intravitreal injection using povidone-iodine 5% alone in the absence of postinjection topical antibiotics does not appear to promote bacterial resistance or a discernible change in conjunctival flora.

Scleral fixation of posterior chamber intraocular lenses using gore-tex suture with concurrent 23-gauge pars plana vitrectomy.

In the absence of capsular support, options for intraocular lens (IOL) placement include anterior chamber intraocular lenses, iris-fixated posterior chamber intraocular lenses (PCIOLs), and scleral-fixated PCIOLs. In a 2003 Ophthalmic Technology Assessment report for the American Academy of Ophthalmology, Wagoner et al supported the effective use of these varying fixation techniques in the appropriate clinical setting, without clear superiority of one method. The choice of surgical technique depends on many factors, including comorbid ocular conditions and anatomical considerations. For surgeons treating patients with history of trauma or complicated cataract surgery, vitrectomy is often required along with IOL placement. Herein, we describe an effective technique for ab externo scleral fixation of PCIOLs using GoreTex (W.L. Gore & Associates, Newark, DE) suture, initially described by Slade et al, modified to include concurrent 23-gauge pars plana vitrectomy.

Microbial spectrum and outcomes of endophthalmitis after intravitreal injection versus pars plana vitrectomy

Purpose: To compare infectious organisms and visual outcomes of endophthalmitis after intravitreal injection (IVI) with endophthalmitis after pars plana vitrectomy (PPV). Methods: Retrospective, comparative, consecutive case series of patients diagnosed with presumed infectious endophthalmitis after IVI of an anti-vascular endothelial growth factor medication or PPV between January 1, 2009, and October 1, 2012, from one center. Main outcome measures were infectious organism and final visual acuity. Results: Forty-four cases of presumed infectious endophthalmitis (17 culture positive) occurred after IVI and 19 cases (9 culture positive) occurred after PPV. Of note, 56.3% of culture-positive IVI cases were due to bacteria associated with oral flora, primarily Streptococcus species, compared with none in the PPV group (P = 0.01). There was a trend approaching significance for IVI patients to have lost ≥3 lines of visual acuity compared with PPV patients at final follow-up (P = 0.07). Within the IVI group, patients were more likely to have lost ≥6 lines of visual acuity at final follow-up when endophthalmitis was due to an organism associated with oral flora (P = 0.007). Conclusion: Endophthalmitis after IVI has a higher likelihood of being due to oral flora compared with endophthalmitis after PPV. Among IVI patients, worse visual outcomes occurred when endophthalmitis was due to oral flora.

Unilateral keratitis following death of a twin as the presenting sign of herpetic infection in a neonate

Neonatal herpes simplex virus (HSV) manifests as a disease limited to skin, eyes, and/or mucous membranes, central nervous system disease with/without skin involvement, or disseminated infection. Given the high morbidity and mortality of untreated neonatal HSV, early recognition and prompt treatment are important. We report two cases of unilateral HSV keratitis, after Cesarean section, in neonates whose twin had died. Both mothers denied history of HSV. Ophthalmic diagnosis led to full systemic workup and appropriate treatment.

Electroretinographic Effects of Omega-3 Fatty Acid Supplementation on Dry Age-Related Macular Degeneration

OBJECTIVES To evaluate the effects of high-dose oral omega-3 fatty acid supplementation on electroretinography and omega-3 index in patients with dry age-related macular degeneration. DESIGN Single institution, prospective, nonrandomized, noncomparative interventional case series comprising 34 eyes of 17 patients older than 50 years of age with early to intermediate age-related macular degeneration. Patients received oral supplementation with 4 g of omega-3 fatty acids daily (840 mg eicosapentaenoic acid/2520 mg docosahexaenoic acid) for 6 months. The main outcome measures included Early Treatment Diabetic Retinopathy Study best-corrected visual acuity, change in N1 and P1 peak amplitudes on multifocal electroretinographic testing, and change in serum omega-3 index. RESULTS Mean baseline Early Treatment Diabetic Retinopathy Study best-corrected visual acuity letter score was 77 letters (Snellen equivalent of 20/32). There were no statistically significant changes in visual acuity (P = .12) or retinal function by multifocal electroretinographic testing. Serum omega-3 index increased by an average of 7.6% during the course of the study (P < .001). Study limitations included the relatively short duration of the study and small number of participants. CONCLUSIONS Short-term supplementation with high doses of omega-3 fatty acids does not result in any measurable changes in visual acuity or retinal function by multifocal electroretinographic testing. Dietary supplementation with 4 g of omega-3 fatty acids results in a significant increase in serum omega-3 index in patients with dry age-related macular degeneration and may provide a useful clinical measure for future studies. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01258335.

Effect of topical aqueous suppression on intraocular gas duration after pure perfluoropropane injection in nonvitrectomized eyes with retinal detachment.

Purpose: To determine whether topical aqueous suppressants affect the duration of pure expansile intraocular gas in nonvitrectomized eyes. Methods: A prospective randomized controlled trial was performed on nonvitrectomized patients undergoing retinal detachment repair with scleral buckle or pneumatic retinopexy using 0.3 mL of 100% perfluoropropane (C3F8) gas tamponade. Eyes were randomly assigned to receive topical dorzolamide 2% and timolol 0.5% twice daily postoperatively until gas dissolution or to observation. Results: Twenty-one patients met all inclusion and exclusion criteria. Twelve were randomized to the control group and nine to the dorzolamide–timolol group. In the dorzolamide–timolol group, mean intraocular pressure was 17.4 on postoperative Day 1 and 12.5 on postoperative Week 1 (P = 0.03). In the control group, mean intraocular pressure was 14.5 on postoperative Day 1 and 15.1 on postoperative Week 1 (P = 0.73). The mean duration of C3F8 was 37.8 days in the dorzolamide–timolol group and 40.4 days in the control group (P = 0.70). Conclusion: Topical aqueous suppression does not seem to have a significant effect on the duration of pure expansile intraocular C3F8 in nonvitrectomized eyes after pneumatic retinopexy or scleral buckling.

COMBINED PARS PLANA VITRECTOMY AND SCLERAL FIXATION OF AN INTRAOCULAR LENS USING GORE-TEX SUTURE: One-Year Outcomes.

Purpose: To report the 1-year clinical outcomes of combined pars plana vitrectomy and ab externo scleral fixation of an intraocular lens using Gore-Tex suture. Methods: Retrospective, interventional case series. Outcome measures were change in visual acuity and occurrence of intraoperative and postoperative complications with minimum follow-up of 1 year. Results: Eighty-four eyes of 83 patients were identified. The mean best available visual acuity improved from 20/782 preoperatively to 20/65 postoperatively (P < 0.001). The mean follow-up was 598 ± 183 days (median 533 days, range 365–1,323 days). There were no intraoperative complications noted. A Bausch & Lomb Akreos AO60 intraocular lens was implanted in 77 eyes and an Alcon CZ70BD in 7 eyes. Postoperative complications included transient vitreous hemorrhage in six eyes (7.1%), cystoid macular edema in four eyes (4.8%), ocular hypertension in three eyes (3.6%), hyphema in two eyes (2.4%), and transient corneal edema in two eyes (2.4%). There were no cases of postoperative endophthalmitis, suture erosion/breakage, hypotony, retinal detachment, suprachoroidal hemorrhage, choroidal detachment, uveitis–glaucoma–hyphema syndrome, or persistent postoperative inflammation during the follow-up period. Conclusion: Combined pars plana vitrectomy and ab externo scleral fixation of an intraocular lens with Gore-Tex suture was well tolerated at a minimum of 1-year follow-up. No suture-related complications were encountered.

Candida chorioretinitis and endophthalmitis

Ocular candidiasis is a common cause of endogenous fungal endophthalmitis and can also occur in the postoperative setting. The diagnosis of ocular candidiasis is usually made on clinical grounds but microbiological cultures are helpful to establish the identity of the infecting organism and determine the antimicrobial sensitivities. It is likely that PCR technology will become more important in the near future for rapid identification of infecting organisms, as it is applicable to both anterior chamber fluid and vitreous sampling. Furthermore, PCR has the potential to assist in directing antifungal therapy. There are many different antifungal agents in clinical use. Recent studies of newer antifungals, such as voriconazole, show significant potential for their use in the treatment of intraocular infections. Vitrectomy may provide benefit in cases presenting with severe vitritis at presentation or in cases with mild vitritis unresponsive to medical therapy.