Aleksandra V. Rachitskaya

An update on the cause and treatment of scleritis.

Purpose of review To review new clinically relevant data regarding the cause and treatment of scleritis that has been identified over the past 36 months. Recent findings A recently described T-helper cell population, known as Th-17, has been implicated in scleritis. Large-scale, retrospective reviews of standard corticosteroid-sparing systemic therapies, published in the last few years, have demonstrated only moderate efficacy for any particular immunomodulatory agent, whereas new data have confirmed excellent efficacy and tolerability to subconjunctival corticosteroids. Summary Improved understanding of the immunopathophysiology of scleritis offers hope for future molecule-specific drug design. Data continue to support the use of local steroids as a reasonable therapeutic option for nonnecrotizing, noninfectious anterior scleritis.

Is the Use of Topical Antibiotics for Intravitreal Injections the Standard of Care or Are We Better Off Without Antibiotics

Intravitreal injection of medication is one of the most commonly performed medical procedures in the United States with well over 1 million injections performed annually.1 This number is likely to increase even further because of the aging population as well as the expanding number of indications for intravitreal injections. The most serious complication of intravitreal injection is infectious endophthalmitis, with a reported incidence of 0.02% to 0.1%.2,3 Many patients treated with intravitreal injections receive injections on a monthly basis. Thus, although the risk of endophthalmitis associated with a single injection may be 0.02% to 0.1%, an individual patient’s risk during an entire treatment series may be as high as 1%.4 Although outcomes of infectious endophthalmitis have improved significantly over the past few decades, visual loss can still be severe.5 It is, therefore, imperative that the optimal infection prophylaxis regimen is used with each treatment. Despite the increasingly widespread use of intravitreal injection, the ideal method of preinjection and postinjection prophylaxis remains controversial. Most physicians routinely use povidone-iodine for antisepsis, because its bactericidal effects have been well documented.6,7 The use of preinjection and postinjection antibiotics is less universal and appears to be declining. A recent survey of retinal specialists by Green-Simms et al8 found that 99.6% of respondents used povidone-iodine; 34% used preinjection antibiotics, either for a multiday course preinjection or immediately prior to injection; and 81% used postinjection antibiotics. Green-Simms et al did not specify whether the postinjection antibiotics were used immediately after injection and/or for a multiday course. The Diabetic Retinopathy Clinical Research Network no longer requires the application of topical antibiotics with the intravitreal injection procedure, and practitioners in the Diabetic Retinopathy Clinical Research Network have decreased antibiotic usage from 89% in 2006 to 37% in 2012 without observing a corresponding increase in the rates of postinjection endophthalmitis.9-11 In the United States, topical antibiotics are routinely used perioperatively for the prevention of endophthalmitis following cataract and other intraocular surgery. Several studies have demonstrated a significantly decreased conjunctival bacterial load following the use of preoperative topical antibiotics, given anywhere between several days to 1 hour prior to the procedure.12-14 It follows that topical antibiotics, by reducing the bacterial load in the conjunctiva, should theoretically decrease the risk of postinjection endophthalmitis. Despite the evidence that topical antibiotics reduce the conjunctival bacterial load, several studies have demonstrated that the addition of preinjection or postinjection topical antibiotics to povidone-iodine antisepsis does not decrease the rates of endophthalmitis compared with the use of povidoneiodine alone.15-17 A recent prospective study reached a similar conclusion when analyzing bacterial growth from conjunctival swabs; preoperative application of moxifloxacin, 0.5%, offered no reduction in bacterial cultures beyond that of povidone-iodine alone.18 One study from the United Kingdom reported that the failure to administer topical antibiotics before injection and the failure to administer topical antibiotics immediately after intravitreal injection were significant risk factors for endophthalmitis following intravitreal injection of anti– vascular endothelial growth factor (anti-VEGF) therapy.19 However, this study was questionnaire based, relied on treating physicians to complete the questionnaire retrospectively, and did not account for such factors as use of povidone-iodine. Fourth-generation fluoroquinolones are commonly used peri-injection antibiotics because of their favorable safety profile and broad spectrum of antimicrobial activity.20 Of increasing concern, however, is the fact that, over the past decade, ocular surface flora and endophthalmitis isolates have shown a significant increase in resistance to these and other commonly used antibiotics. From 2001 to 2002, Morrissey et al21 documented a 2% resistance rate of coagulase-negative staphylococcus (CNS) to gatifloxacin in cultures isolated from various ocular infections. In 2004 and 2005, Ta et al22 examined preoperative conjunctival cultures in patients undergoing intraocular surgery and reported a 12% resistance rate of CNS to gatifloxacin and moxifloxacin. In 2010, Kim et al23 reported the rates of fluoroquinolone resistance of ocular CNS isolated from the conjunctiva of treatment-naive patients undergoing intravitreal injections. They found that CNS resistance was 33% and 37% to gatifloxacin and moxifloxacin, respectively. Most recently, Schimel et al24 reported a similar rise in CNS resistance from endophthalmitis isolates over a 22-year period. From 1990 to 1994, 3.4% of CNS isolates demonstrated some degree of resistance to gatifloxacin and moxifloxacin. From 2000 to 2004, this number increased to approximately 34% for both antibiotics, and in the latest period, from 2005 to 2011 (the era of intravitreal injections), the rate of CNS resistance to gatifloxacin and moxifloxacin increased further to 61% and 58%, respectively. Several recent studies have explored the relationship between exposure to topical antibiotics and bacterial resistance rates of ocular surface flora in eyes undergoing intravitreal injections.25-27 One prospective study found that over a 1-year period, CNS resistance to gatifloxacin and moxifloxacin roughly doubled, from rates of 39% and 34%, respectively, prior to treatment with intravitreal injections, to 67% and 70%, respectively, following treatment with intravitreal injections.25,26 These eyes were initially treatment naive, and all received 4 monthly intravitreal injections, followed by intravitreal injection as needed on an individual basis. After each injection, patients were administered 1 drop of their assigned fluoroquinolone into the injected eye and were instructed to instill 1 drop of their assigned fluoroquinolone into the injected eye 4 times per day for 4 days. Over the same 1-year study period, untreated fellow eyes of the same patients did not develop an increase in fluoroquinolone-resistant CNS strains. Opinion Editorial

Combined central retinal vein and central retinal artery occlusions and neovascular glaucoma associated with interferon treatment.

Purpose Interferon (IFN) is a mainstay medication used for treatment of chronic hepatitis C, as well as for treatment of certain neoplastic and autoimmune conditions. We present a case of a 50-year-old man who, while on IFN treatment, developed central retinal vein and artery occlusions complicated by the development of neovascular glaucoma secondary to severe retinal ischemia. Interferon retinopathy is associated with ischemic retinal cotton-wool spots. This case illustrates how IFN can lead to severe and sight-threatening retinal ischemia. Methods Case report. Results A 50-year-old man with previously good vision presented with decreased vision in the right eye while being treated with IFN therapy for chronic hepatitis C. He was diagnosed with central retinal vein occlusion and 2 weeks later also developed a central retinal artery occlusion. His course was complicated by the development of neovascular glaucoma. The final visual acuity was ultimately light perception. Conclusions Interferon therapy is commonly utilized for chronic hepatitis C, neoplastic conditions, and multiple sclerosis. Clinicians should be aware of the sight-threatening complications of IFN therapy, especially with regard to ocular vaso-occlusive disease and severe retinal ischemia.

Endogenous Endophthalmitis Caused by Salmonella Serotype B in an Immunocompetent 12-Year-Old Child

its deficiencies, but we are concerned that the dramatic early effects of bevacizumab may lead to an underappreciation of its own limitations. We believe treatment success can be considered final not after the early response but only after there is complete retinal vascularization. This case and others that will likely follow should allow a more complete and balanced perspective. In our experience, laser after bevacizumab treatment seems to reduce severe complications, but further study is required to evaluate combined treatment. This case serves as a warning to clinicians that extensive, long-term, careful follow-up and prompt subsequent intervention are needed in infants treated with intravitreous bevacizumab.

Progression to macula-off tractional retinal detachment after a contralateral intraoperative intravitreal bevacizumab injection for proliferative diabetic retinopathy

We report a patient with progression to a macula-off tractional retinal detachment in a fellow eye after a contralateral intraoperative intravitreal bevacizumab injection. A 32-year-old diabetic man noted decreased vision in his left eye 1 week following 25 gauge pars plana vitrectomy, gas tamponade, and intraoperative injection of bevacizumab in his right eye. Left eye visual acuity decreased from 20/80 to 20/200, and macula-off tractional retinal detachment was seen on clinical exam and imaging. Progression of tractional retinal detachment associated with proliferative diabetic retinopathy in a fellow eye after a contralateral intraoperative intravitreal bevacizumab injection may occur.

Correlation between baseline echographic features of endophthalmitis, microbiological isolates, and visual outcomes

Background The purpose of this study was to examine the baseline echographic features in culture-positive and culture-negative endophthalmitis and to correlate these echographic features with final visual outcomes. Methods We identified a retrospective noncomparative case series of patients with a clinical diagnosis of endophthalmitis and a baseline echographic examination between 1996 and 2010 at a single institution. Graded echographic features studied included: dense, moderate, and mild vitreous opacities; marked, moderate, and mild vitreous membranes; retinal detachment; and choroidal detachment. These were compared between culture-negative, coagulase-negative staphylococci, and other culture-positive cases of endophthalmitis, and were correlated with final visual outcomes. Results Of 149 patients reviewed, 60 were culture-negative, 26 grew coagulase-negative staphylococci, and 60 grew other culture-positive species. Three had multiple culture isolates. The presence of dense, moderate, and mild vitreous opacities, marked, moderate, and mild vitreous membranes, retinal detachment, and choroidal detachment was not significantly different between the three groups (P = 0.86, P = 0.56, P = 0.34, P = 0.45, respectively). The presence of advanced echographic features of dense vitreous opacities, marked vitreous membranes, retinal detachment, and choroidal detachment was correlated with poorer visual acuity outcomes (P = 0.005, P = 0.0001, P < 0.0001, and P < 0.0001, respectively). Conclusion No correlation could be made between echographic features and the organism. The presence of advanced echographic features, such as dense vitreous opacities, marked vitreous membranes, retinal detachment, and choroidal detachment, was correlated with worse visual outcomes.

Zone 3 ruptured globe from a dog bite.

Periocular injuries from dog bites are relatively common in school-age children, but intraocular trauma is exceedingly rare. We present a 7-year-old boy who sustained a zone 3 ruptured globe injury after attack by a Perro de Presa Canario. At presentation, visual acuity in the injured eye was counting fingers. Surgical exploration revealed an inferotemporal corneoscleral laceration extending 15 mm posterior to the limbus, with protrusion of uveal tissue, which was repaired. Visual acuity improved to 20/40 by the first postoperative month.

Benign Yellow Dot Maculopathy: A New Macular Phenotype

PURPOSE To describe a novel macular phenotype that is associated with normal visual function. DESIGN Retrospective, observational case series. PARTICIPANTS Thirty-six affected individuals from 23 unrelated families. METHODS This was a retrospective study of patients who had a characteristic macular phenotype. Subjects underwent a full ocular examination, electrophysiologic studies, spectral-domain optical coherence tomography (OCT), and fundus autofluorescence imaging. Genomic analyses were performed using haplotype sharing analysis and whole-exome sequencing. MAIN OUTCOME MEASURES Visual acuity, retinal features, electroretinography, and whole-exome sequencing. RESULTS Twenty-six of 36 subjects were female. The median age of subjects at presentation was 15 years (range, 5-59 years). The majority of subjects were asymptomatic and presented after a routine eye examination (22/36 subjects) or after screening because of a positive family history (13/36 subjects) or by another ophthalmologist (1/36 subjects). Of the 3 symptomatic subjects, 2 had reduced visual acuity secondary to nonorganic visual loss and bilateral ametropic amblyopia with strabismus. Visual acuity was 0.18 logarithm of the minimum angle of resolution (logMAR) or better in 30 of 33 subjects. Color vision was normal in all subjects tested, except for the subject with nonorganic visual loss. All subjects had bilateral symmetric multiple yellow dots at the macula. In the majority of subjects, these were evenly distributed throughout the fovea, but in 9 subjects they were concentrated in the nasal parafoveal area. The dots were hyperautofluorescent on fundus autofluorescence imaging. The OCT imaging was generally normal, but in 6 subjects subtle irregularities at the inner segment ellipsoid band were seen. Electrophysiologic studies identified normal macular function in 17 of 19 subjects and normal full-field retinal function in all subjects. Whole-exome analysis across 3 unrelated families found no pathogenic variants in known macular dystrophy genes. Haplotype sharing analysis in 1 family excluded linkage with the North Carolina macular dystrophy (MCDR1) locus. CONCLUSIONS A new retinal phenotype is described, which is characterized by bilateral multiple early-onset yellow dots at the macula. Visual function is normal, and the condition is nonprogressive. In familial cases, the phenotype seems to be inherited in an autosomal dominant manner, but a causative gene is yet to be ascertained.

The Spectrum of Pediatric Orbital BB Gun Injuries: A Case Series.

Three cases of pediatric BB orbital injury are reported demonstrating varying outcomes. Pediatric orbital BB injuries have a wide spectrum of clinical outcomes depending on the ocular structures involved. Improved safety education of patients and parents is necessary to reduce the burden of these vision-threatening injuries.

Prolonged Curvularia endophthalmitis due to organism sequestration.

IMPORTANCE Endophthalmitis caused by Curvularia is a rare condition seen after cataract surgery and trauma. The clinical course has not been described previously. OBJECTIVE To examine the clinical course of 6 postoperative and trauma-related cases of Curvularia endophthalmitis. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series. We reviewed the archives of the microbiology laboratory of Bascom Palmer Eye Institute, a tertiary referral hospital, from January 1, 1980, through September 30, 2013, to identify cases of Curvularia endophthalmitis. Data collected included demographic information, the cause of endophthalmitis, presenting features, treatment course, the number of recurrences, the area of organism sequestration, and final visual outcome. EXPOSURES Trauma and cataract surgery. MAIN OUTCOMES AND MEASURES Times from the inciting event to presentation of symptoms, diagnosis, and eradication; visual acuity; and identification of the area of sequestration. RESULTS We identified 6 patients with Curvularia endophthalmitis, including 5 who underwent cataract surgery and 1 after trauma. The diagnosis was established rapidly in the trauma case. In the postoperative cases, the time from the surgery to first symptoms ranged from 2 to 5 months; from the surgery to correct diagnosis, 7 to 24 months; and from the surgery to eradication, 8 to 27 months. Despite aggressive antifungal therapy, eradication of the infection could be achieved only by identification and removal of the nidus of sequestration. The median follow-up was 29.5 months. CONCLUSIONS AND RELEVANCE In cases of endophthalmitis caused by Curvularia, the diagnosis and treatment are often delayed, especially in postoperative cases. The eradication of the organism requires identification and removal of the nidi of sequestration.