Allen B. Thach

Two-year outcomes of the ranibizumab for edema of the mAcula in diabetes (READ-2) study.

OBJECTIVES To determine the long-term effects of ranibizumab (RBZ) in patients with diabetic macular edema (DME). DESIGN Prospective, randomized, interventional, multicenter clinical trial. PARTICIPANTS One hundred twenty-six patients with DME. METHODS Subjects were randomized 1:1:1 to receive 0.5 mg RBZ at baseline and months 1, 3, and 5 (group 1), focal or grid laser photocoagulation at baseline and month 3 if needed (group 2), or a combination of 0.5 mg RBZ and focal or grid laser at baseline and month 3 (group 3). Starting at month 6, if retreatment criteria were met, all subjects could be treated with RBZ. MAIN OUTCOME MEASURES The mean change from baseline in best-corrected visual acuity (BCVA) at month 24. RESULTS After the primary end point at month 6, most patients in all groups were treated only with RBZ, and the mean number of injections was 5.3, 4.4, and 2.9 during the 18-month follow-up period in groups 1, 2, and 3, respectively. For the 33 patients in group 1, 34 patients in group 2, and 34 patients in group 3 who remained in the study through 24 months, the mean improvement in BCVA was 7.4, 0.5, and 3.8 letters at the 6-month primary end point, compared with 7.7, 5.1, and 6.8 letters at month 24, and the percentage of patients who gained 3 lines or more of BCVA was 21, 0, and 6 at month 6, compared with 24, 18, and 26 at month 24. The percentage of patients with 20/40 or better Snellen equivalent at month 24 was 45% in group 1, 44% in group 2, and 35% in group 3. Mean foveal thickness (FTH), defined as center subfield thickness, at month 24 was 340 μm, 286 μm, and 258 μm for groups 1, 2, and 3, respectively, and the percentage of patients with center subfield thickness of 250 μm or less was 36%, 47%, and 68%, respectively. CONCLUSIONS Intraocular injections of RBZ provided benefit for patients with DME for at least 2 years, and when combined with focal or grid laser treatments, the amount of residual edema was reduced, as were the frequency of injections needed to control edema. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Macular pucker removal with and without internal limiting membrane peeling: pilot study

OBJECTIVE To investigate results of macular pucker surgery with and without internal limiting membrane (ILM) peeling. DESIGN Retrospective noncomparative interventional case series. PARTICIPANTS Forty-four consecutive patients underwent pars plana vitrectomy to remove an idiopathic macular pucker by two surgeons from June 1999 to July 2000. INTERVENTION During the vitrectomy, one surgeon removed only the macular epiretinal membrane (24 patients), whereas the other surgeon removed the macular epiretinal membrane and then performed an additional ILM peeling (20 patients). MAIN OUTCOME MEASURES Visual acuity and recurrence of macular pucker. RESULTS Twenty-four (55%) patients underwent pars plana vitrectomy without ILM peeling, and 20 patients (45%) underwent pars plana vitrectomy with ILM peeling. Visual acuity improved or was unchanged in 79% of operated eyes without ILM peeling and 100% of operated eyes with ILM peeling (P = 0.01). Visual acuity improved 5 or more lines in 25% of operated eyes without ILM peeling and 30% of operated eyes with ILM peeling. At the final visit, 21% of eyes without ILM peeling at the initial surgery showed postoperative recurrent macular pucker or persistent contraction to the ILM, whereas none of the eyes with ILM peeling had evidence of this. CONCLUSIONS This pilot study provides evidence that peeling of the ILM during macular pucker surgery may not have deleterious effects.

Accidental Nd:YAG laser injuries to the macula

PURPOSE To study the clinical course of accidental, single-focus Nd:YAG laser injuries to the macula. METHODS We reviewed the clinical course of five eyes (four patients) that sustained macular injuries from a Nd:YAG laser. All patients were examined within 24 hours of injury and were observed without surgical intervention for a mean of 20 months (range, 12 to 32 months). RESULTS A single full-thickness foveal or parafoveal retinal hole was apparent in all eyes either on initial examination or within two weeks of injury. All macular holes were within 650 microns of the foveal center. The mean final visual acuity was 20/60 (range, 20/25 to 20/400) and was related to the distance between the macular hole and the foveal center. None of the eyes developed either subretinal neovascularization or clinically significant epiretinal membrane formation during the study period. CONCLUSIONS Despite initial poor visual acuity in patients who had a full-thickness foveal or parafoveal retinal hole, visual acuity improved without treatment when the site of the laser injury was located outside the foveal center.

Open Globe Injuries in Children

PURPOSE A retrospective review of open globe injuries in children was performed to identify the common types of injury and to correlate features of the injuries and surgical management with visual prognosis. METHODS The hospital records of 70 patients were reviewed to determine demographic data, the nature and location of the injuries, the anatomic and functional status of the injured eye before the initial repair, the details of all primary and subsequent surgical procedures, and the final visual outcome. RESULTS Fifty of the patients studied (71%) were male and 20 (29%) were female. The average age of the patients was 5 years. Sharp objects caused the majority of injuries (67%). Most of the injuries happened at home (72%). The cornea was involved in a majority of the injuries (92%). Thirty-two eyes (46%) required only primary repair; 15 eyes (21%) required primary repair with anterior vitrectomy and primary lensectomy; 17 eyes (24%) underwent secondary lensectomy or vitreoretinal surgeries, and 5 eyes (7%) were enucleated. Visual acuity of 20/40 or better was achieved by 45% of those patients who required only primary repair. Of those patients requiring a second procedure, 19% had a visual acuity of 20/40 or better. Initial clinical findings associated with an unfavorable visual outcome were retinal detachment, relative afferent pupillary defect, vitreous hemorrhage, and hyphema. CONCLUSION The prognosis after an open globe injury in children is strongly influenced by the nature of the injury and the extent of the initial damage. Visual outcome is better in eyes that require only primary repair.

Eye injuries in a terrorist bombing: Dhahran, Saudi Arabia, June 25, 1996.

OBJECTIVE We report the experience of our institution in the evaluation and care of multiple simultaneous ocular trauma patients after a terrorist bomb attack on a United States military base in Saudi Arabia. DESIGN Retrospective, noncomparative small case series. PARTICIPANTS Three patients who received severe ocular injuries after a terrorist bombing. INTERVENTION All patients underwent surgical repair of the injuries that were inflicted as a result of the terrorist bombing. MAIN OUTCOME MEASURES Baseline ocular characteristics, intraoperative findings, surgical procedures, and final (3 years after injury) anatomic and visual outcomes were noted. RESULTS Glass fragments caused by the blast were the mechanism of all the ocular injuries in these patients. All patients had primary repair of the injuries done in Saudi Arabia and were sent to our institution for tertiary care. Three of the four eyes injured had stable or improved visual acuity and one eye was enucleated. Two patients had no serious injury other than the globe trauma. One patient had extensive eyelid trauma and required serial procedures to allow fitting of a prosthesis. CONCLUSIONS Blast-injury patients are at risk for open globe injury as a result of glass fragments. The types of injury that can occur from terrorist blasts can be extensive and involve all the tissues of the eye, the ocular adnexa, and the orbit.

Annular Peripheral Choroidal Detachment Simulating Aqueous Misdirection after Glaucoma Surgery

PURPOSE The purpose of the study was to define a newly recognized complication after glaucoma surgery and to recommend a therapeutic regimen. METHODS Eighteen patients diagnosed initially as having aqueous misdirection after glaucoma surgery, but who subsequently were found by ultrasonography to have an annular peripheral choroidal detachment that resulted in secondary angle closure glaucoma, were studied. Ten of these patients were treated with topical cycloplegics and corticosteroids, and 8 were treated with drainage of suprachoroidal fluid. Outcomes of these two treatment methods were compared. RESULTS Annular peripheral choroidal detachment reliably was diagnosed with ultrasonography. Of the variables studied, time elapsed before resolution of the annular peripheral choroidal detachment was noted to be statistically significant (P < 0.00005). Immediate resolution followed drainage of suprachoroidal fluid, whereas a mean of 19.6 days was required for resolution after medical therapy. CONCLUSIONS Annular peripheral choroidal detachment should be considered in the differential diagnosis of a flat or shallow anterior chamber with normal or high intraocular pressure after glaucoma surgery. The diagnosis of annular peripheral choroidal detachment can be confirmed most reliably by ultrasonography. Medical therapy is as effective as is surgery, although a significantly longer time to resolution is required.

Cytomegalovirus papillitis in patients with acquired immune deficiency syndrome. Visual prognosis of patients treated with ganciclovir and/or foscarnet.

BACKGROUND Of those patients with acquired immune deficiency syndrome in whom cytomegaloviral retinitis develops, cytomegaloviral papillitis reportedly develops in up to 4% as well. Although occasionally patients have a good visual outcome, the majority have a poor visual prognosis, with a visual acuity of 20/200 or worse, even with treatment. METHODS To evaluate the effects of prolonged induction with foscarnet or ganciclovir on the visual prognosis of cytomegalovirus (CMV) papillitis, the records of 22 patients seen between 1990 and 1995 at the Los Angeles County-University of Southern California Eye Clinic were reviewed. Papillitis was defined as greater than 270 degrees of disc edema/blurring of the disc margins as seen on direct examination and on color fundus photographs. RESULTS Eighteen patients with a mean initial visual acuity of 20/69 (range, 20/ 15-20/400) were treated with induction doses of intravenous ganciclovir (range, 5-7.5 mg/kg twice daily) or foscarnet (range, 60-90 mg/kg twice or 3 times daily) for a mean of 3.3 weeks. The mean follow-up period was 4.8 months (range, 1-13 months). These patients maintained a mean final visual acuity of 20/68 (range, 20/ 25-20/400) with greater than 90% resolution of the papillitis. The remaining four patients had poor outcomes (visual acuity < 20/400) because of progressive CMV papillitis or retinitis. The median survival time was 4.5 months from the diagnosis of papillitis, but 7 months from the onset of CMV ocular infection. CONCLUSION Patients with CMV papillitis have good visual prognosis when managed with high and prolonged doses of intravenous foscarnet and/or ganciclovir.

Retinal manifestations of acute murine typhus

Purpose: To report the ocular manifestations of acute serologically confirmed murine typhus. Methods: A retrospective analysis of the clinical history, photography and fluorescein angiography of two patients with acute murine typhus with ocular involvement was conducted. Results: A 38 year old male and a 49 year old female were included in the study. Both complained of fever, headache, rash, night sweats and pulmonary symptoms. They had noted the recent onset of diminished visual acuity and floaters. Examination of the posterior pole revealed mild optic nerve head edema (in one patient), intraretinal hemorrhages and small localized areas of retinal whitening. The history confirmed that both patients had been exposed to fleas and the serologic testing was positive for Rickettsia typhi. The systemic and ocular findings resolved after the use of systemic antibiotics. Conclusion: Rickettsial diseases such as murine typhus should be included in the differential diagnosis of otherwise healthy individuals who present with an acute systemic febrile illness and retinitis or neuroretinitis. Summary Statement: The clinical features of two patients with serologically proven acute murine typhus with ocular involvement are presented. Both patients presented with a retinal whitening that resolved after treatment.

The Effects of California Proposition 187 on Ophthalmology Clinic Utilization at an Inner-city Urban Hospital

PURPOSE To determine the effect on ophthalmology clinic utilization at a major public inner-city hospital of California Proposition 187 and the debate surrounding its passage. Proposition 187 was a statewide referendum passed by 63% of the electorate in the November 1994 election that would restrict social services to undocumented immigrants and require providers to report them to immigration authorities. METHODS The ophthalmology clinic volume at the Los Angeles County/ University of Southern California Medical Center was analyzed from October 1 to December 31, 1993 and 1994. RESULTS New walk-in patients significantly decreased (P < 0.001) for a 2-month period around the election, but returned to baseline levels in December 1994. The new patient cancellation and no show rate was not affected. No change in return patient behavior was noted for general and specialty clinics. CONCLUSIONS Proposition 187 may have caused a statistically significant decrease in new walk-ins to the ophthalmology clinics during a 2-month period surround the November 1994 election, but it had no measurable effect on other indicators of utilization. In addition, utilization rates returned to baseline after the implementation of Proposition 187 was stayed by the judicial system, and concern that providers would be required to report undocumented immigrants to authorities was alleviated.

Feasibility of telerobotic microsurgical repair of corneal lacerations in an animal eye model.

We evaluated the feasibility of telerobotic microsurgical repair of corneal lacerations. The telerobotic microsurgical device consisted of a Robotic Slave Micromanipulator Unit (RSMU) coupled to a Telepresence Surgical System (TeSS). Five mm central full-thickness corneal wounds were fashioned in five enucleated rabbit eyes and repaired remotely using the telerobotic system. Five additional eyes were also repaired by hand using a standard technique. The primary outcome measure was creation of a watertight seal. All eyes in both groups maintained an intraocular pressure (IOP) of 25 mm Hg without leak. The mean repair time was 80 min (range 50–130) with telerobotic surgery compared to 8 min (range 7–9) by hand. Histological evaluation showed that suture placement was similar in robotically assisted repair and manual repair. Subjectively, the telerobotic system provided adequate three-dimensional visualization of the surgical field. The study showed that a surgeon could close standardized corneal wounds using the telerobotic system. The potential benefits of remote eye surgery include improved access, surgical teleconsultation and telementoring.