Arghavan Almony

Ischemic Diabetic Retinopathy May Protect against Nuclear Sclerotic Cataract

PURPOSEnTo determine whether diabetes mellitus is protective for nuclear sclerotic cataract at baseline and 6 and 12 months after vitrectomy surgery.nnnDESIGNnProspective, interventional cohort study.nnnMETHODSnPhakic diabetic and nondiabetic patients undergoing vitrectomy surgery for a variety of retinal conditions underwent Scheimpflug lens photography in the operated and fellow eye at baseline and at 6 and 12 months after vitrectomy surgery.nnnRESULTSnOf 52 eyes included in the analysis, 23 eyes were from diabetic patients, 14 of which had surgery for ischemic retinopathy. At baseline, eyes with ischemic diabetic retinopathy had less nuclear sclerotic cataract than nonischemic diabetic and nondiabetic eyes. This was true for eyes undergoing vitrectomy surgery (P = .0001) and for fellow eyes (P = .003). Nuclear sclerotic cataract developed after vitrectomy surgery in nonischemic diabetic eyes and nondiabetic eyes at the same rate. Diabetic eyes with ischemic retinopathy showed no significant progression of nuclear opacification, and therefore had significantly less postvitrectomy nuclear cataract at 6 months (P < 1 × 10(-6)) and at 12 months (P < .001) than nondiabetic or nonischemic diabetic eyes. Normalizing to baseline opacity and adjusting for age and other comorbidities did not alter this result.nnnCONCLUSIONSnIschemic diabetic retinopathy, not just systemic diabetes mellitus, protected against nuclear sclerotic cataract at baseline and after vitrectomy surgery. These findings are consistent with the hypothesis that increased exposure to oxygen is responsible for nuclear cataract formation.

Tilting of radioactive plaques after initial accurate placement for treatment of uveal melanoma.

OBJECTIVEnTo evaluate plaque movement as a potential factor in local failure using intraoperative ultrasonography at plaque insertion and removal.nnnMETHODSnProspective study of 162 patients with uveal melanoma undergoing intraoperative B-scan ultrasonography at insertion and removal of iodine 125 plaques.nnnRESULTSnTilting of the posterior plaque edge more than 1.0 mm away from the sclera was detected in 15 patients (9%) at plaque insertion and in 85 patients (53%) at plaque removal (P < .001). Factors associated with tilt at plaque removal included male sex (P = .009), decreased tumor distance to the fovea and optic disc (P < .001 for both), notched plaque (P = .001), and episcleral hematoma (P = .009). Plaque tilt caused a reduction greater than 10% in actual radiation dose to the tumor apex in 37 patients (23%). Local failure occurred in only 3 patients (2%), all of whom had tilt of 1.95 mm or greater at plaque removal.nnnCONCLUSIONSnPlaque tilt after initial accurate placement occurs frequently during brachytherapy for uveal melanomas and may represent an important cause of local treatment failure. Recognizing and counteracting the effects of plaque tilt may reduce the risk of local failure.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00459849.

Clinical utilization of anti-vascular endothelial growth-factor agents and patient monitoring in retinal vein occlusion and diabetic macular edema

Purpose To examine the utilization of bevacizumab and ranibizumab and disease monitoring in patients with branch or central retinal vein occlusion (BRVO/CRVO) or diabetic macular edema (DME) in clinical practice. Patients and methods This retrospective claims analysis included newly diagnosed patients with one or more bevacizumab or ranibizumab injections. Bevacizumab or ranibizumab utilization was assessed by year of first injection: 2008–2010 cohorts (12-month follow-up), January to June 2011 cohort (6-month follow-up). The main outcome measures were mean annual numbers of injections, ophthalmologist visits and optical coherence tomography examinations, and proportion of patients with additional laser or intravitreal triamcinolone (IVTA) use. Results A total of 885 BRVO, 611 CRVO, and 2,733 DME patients treated with bevacizumab were included, with too few ranibizumab-treated patients for meaningful analysis. Across the 2008, 2009, and 2010 cohorts, mean annual numbers of bevacizumab injections increased, but remained low (BRVO 2.5, 3.1, 3.3; CRVO 3.1, 3.1, 3.5; and DME 2.2, 2.5, 3.6, respectively); mean ophthalmologist visits ranged between 4.4 and 6.5, and mean optical coherence tomography examinations ranged between 3.1 and 3.9 across all conditions. A total of 42.0% of BRVO, 16.5% of CRVO, and 57.7% of DME patients received additional laser or IVTA therapy. The number of bevacizumab injections was positively associated with laser use in BRVO (3.3 versus 2.9, P<0.03), and with laser or IVTA use in DME (laser, 3.3 versus 2.7, P<0.03; IVTA, 3.3 versus 3.0, P<0.05). Conclusion During the study period (2008–2011), bevacizumab was the main anti-VEGF therapy used in clinical practice for BRVO, CRVO, and DME. Patients treated with bevacizumab were monitored less frequently and received fewer injections than patients in major clinical trials of ranibizumab.

Clinical Utilization of Anti-VEGF Agents and Disease Monitoring in Neovascular Age-Related Macular Degeneration

PURPOSEnTo examine bevacizumab and ranibizumab utilization and disease monitoring patterns in patients with neovascular age-related macular degeneration (neovascular AMD) in clinical practice.nnnDESIGNnRetrospective medical claims analysis.nnnMETHODSnPatients receiving ≥1 ranibizumab or bevacizumab injection during the 12 months after initial neovascular AMD diagnosis were included. Annual bevacizumab and/or ranibizumab injection utilization was assessed by year of first injection cohorts: 2006 and 2007 (received either agent because of billing code overlap), 2008, 2009, and January-June 2010 (received each agent). Outcome measures were time to first injection relative to neovascular AMD diagnosis and mean numbers of intravitreal injections, ophthalmologist visits, and optical coherence tomography (OCT) and fluorescein angiography (FA) examinations in 12 months.nnnRESULTSnIn the 2006 and 2007 cohorts (n = 8767), mean annual numbers of bevacizumab or ranibizumab injections were 4.7 and 5.0, respectively. Over 92% of patients in all cohorts received first treatment within 3 months of neovascular AMD diagnosis. In the 2008-2010 cohorts (n = 10 259), mean annual number of injections remained low (bevacizumab: 4.6, 5.1, and 5.5; ranibizumab: 6.1, 6.6, and 6.9), as did mean numbers of ophthalmologist visits (bevacizumab only) and OCT examinations (both agents), but there was no such trend in FA examinations.nnnCONCLUSIONSnCompared with treatment paradigms validated by clinical trials published at the time, in clinical practice, patients with neovascular AMD received fewer bevacizumab or ranibizumab injections and less-frequent monitoring from 2006 to mid-2011. Factors contributing to this lower injection frequency and visual outcomes associated with reduced utilization need to be researched.

Small-gauge vitrectomy does not protect against nuclear sclerotic cataract.

Purpose: To determine whether the gauge of vitrectomy instrumentation is associated with the progression of nuclear sclerotic cataract. Methods: A prospective interventional and observational study of patients undergoing vitrectomy surgery for various retinal conditions. Patients had Scheimpflug lens photography in the operated and fellow eye at baseline and at 6 months and 12 months after vitrectomy surgery. Results: Of 42 eyes included in the analysis, 11 had 20-gauge surgery, 22 had 23-gauge surgery, and 9 had 25-gauge surgery. In all operated eyes, vitrectomy surgery led to the significant progression of nuclear sclerotic cataract, compared with the fellow, unoperated eye. This small study was unable to detect a difference in nuclear sclerotic progression when comparing small-gauge surgery (23 and 25 gauge) with standard 20-gauge surgery. Conclusion: Removal of the vitreous gel using any-gauge vitrectomy surgery leads to significant progression of nuclear sclerotic cataract at 6 months and 12 months. The findings are consistent with the hypothesis that the vitreous gel is important in protecting the lens from increased exposure to oxygen that leads to the formation of nuclear sclerotic cataract. This increased exposure to oxygen occurs as a result of removing the vitreous gel and is independent of the gauge of vitrectomy instrumentation.

Recurrent retinal detachment: does initial treatment matter?

Background/Aims To evaluate the treatment course of patients with primary rhegmatogenous retinal detachment (RRD) that re-detach after initial retinal detachment surgery. Methods Patients were divided into three groups based on initial surgical treatment: scleral buckle procedure (SBP) (63 eyes), pars plana vitrectomy (PPV) (88 eyes) and combined SBP/PPV (135 eyes). Charts were reviewed for a mean follow-up of 12u2005months. Results Average number of secondary procedures to achieve anatomical success was lowest in the SBP group (1.1), compared with the PPV group (1.47) and the SBP/PPV group (1.5) (p<0.05). Patients that re-detached after initial PPV/SBP, PPV or SBP required silicone oil injection in 83%, 60% and 22% of the cases and had final best-corrected visual acuity better than or equal to 20/50 in 21%, 33% and 45% of the cases, respectively. Phakic patients that re-detached after initial treatment with PPV/SBP, PPV and SBP required pars plana lensectomy (PPL) in 42%, 25% and 12.5% of the cases, respectively. Conclusion Patients with primary RRD that re-detach after initial treatment with SBP require fewer number of secondary operations and silicone oil injections, show a trend for better visual outcomes and are less likely to develop dense cataract or to require PPL compared to patients that re-detach after initial PPV or PPV/SBP.

Macular hole closure with triamcinolone-assisted internal limiting membrane peeling.

Purpose: To evaluate the anatomic and visual outcomes of patients treated with triamcinolone-assisted internal membrane peeling for macular hole. Methods: A retrospective chart review of 37 consecutive cases done by a single vitreoretinal surgeon for idiopathic macular hole. All surgery involved triamcinolone-assisted internal limiting membrane peeling. All patients had at least 3-month follow-up. Main outcome measures included anatomic macular hole closure, visual acuity, and operative complications. Results: Mean follow-up was 11 months (range, 3–56 months). Anatomic macular hole closure was achieved in 36 eyes (97%). Mean overall preoperative visual acuity was 20/150 and final acuity was 20/63 (P < 0.0001). Nineteen eyes (51%) had best corrected visual acuity at most recent postoperative visit of ≥20/50. There were no postoperative complications. Conclusions: Triamcinolone-assisted internal limiting membrane peel is an effective surgical technique in macular hole surgery. Use of triamcinolone acetonide did not adversely impact macular hole closure. Anatomic closure rates and visual outcomes compared favorably with published literature on macular hole surgery.

Neovascular age-related macular degeneration and anti-VEGF nonresponders

Neovascular age-related macular degeneration is responsible for the overwhelming majority of vision loss in age-related macular degeneration. Not too long ago, the disease was poorly controlled with few treatment options. Today, angiogenesis is the central focus in the pathogenesis of this disease, with VEGF identified as a major mediator of this process. These advances have opened the door for targeted anti-VEGF therapy, leading to significant improvements in visual outcomes for a majority of patients. There is, however, a portion of the population that responds poorly to initial treatment with little explanation as to why this occurs. Combination therapies are now being investigated to tackle anti-VEGF monotherapy nonresponders.

Clinical Monitoring of Patients With Age-Related Macular Degeneration Treated With Intravitreal Bevacizumab or Ranibizumab

BACKGROUND AND OBJECTIVEnPatients with neovascular age-related macular degeneration (AMD) require frequent follow-up and regular anti-VEGF injections for optimal outcomes. Although studies suggest that injection frequency is suboptimal in clinical practice, monitoring frequency in this setting is unclear. This study evaluates annual monitoring patterns between 2008 and 2011.nnnPATIENTS AND METHODSnThis retrospective claims analysis included newly diagnosed neovascular AMD patients with at least one intravitreal bevacizumab or ranibizumab injection (8,811 and 2,877 patients, respectively). Patient monitoring and treatment patterns were assessed at 12-month intervals.nnnRESULTSnFrom 2008 to 2010, the mean number of injections increased. In the 2010 cohort, among bevacizumab- and ranibizumab-treated patients, respectively, less than 23% and less than 40% had at least 10 ophthalmologist visits, and less than 4% and less than 21% had at least 10 optical coherence tomography scans.nnnCONCLUSIONnPatients with neovascular AMD in clinical settings during 2008 to 2011 were monitored less frequently and received fewer anti-VEGF injections than patients in major clinical trials, which may affect outcomes.

Successful treatment of choroidal blastomycosis with oral administration of voriconazole

Blastomycosis dermatitidis is a dimorphic fungus endemic to the midwestern and southeastern U.S. and was first described by Gilchrist in 1894. Inhalation of airborne spores arising from the soil may lead to pulmonary, cutaneous, and genitourinary symptoms. Ocular involvement is extremely rare; however, eyelid infection, conjunctivitis, keratitis, iritis, choroiditis, endophthalmitis, panophthalmitis, and orbital cellulitis have all been described. We report a patient with disseminated blastomycosis and choroidal involvement who was effectively treated with oral administration of voriconazole (Vfend, Pfizer Inc, New York, N.Y.). To our knowledge, there have been no prior reports of ocular blastomycosis treated in this way. A 57-year-old man with a history of cardiac transplant for ischemic cardiomyopathy sought treatment for lowgrade fevers, dyspnea, nonproductive cough, weight loss, and myalgias for 1 month’s duration. He also reported a 2-day history of blurry vision in the left eye. Physical examination showed pustular skin lesions on the back, abdomen, and feet; diffuse, fine crackles were appreciated in the lungs. On initial ophthalmic examination, best-corrected visual acuity (BCVA) was 20/20 in the right eye and 20/40 in the left eye. The anterior segment examination was unremarkable. Dilated fundus examination revealed multiple choroidal lesions bilaterally, including a subfoveal lesion in the left eye (Fig. 1). There was no vitritis. Computed tomographic results of the chest showed innumerable small pulmonary nodules in a miliary pattern throughout the lungs. Biopsy of the lung and skin lesions showed multiple broad-based budding yeasts, consistent with blastomycosis. Magnetic resonance imaging of the brain was normal. The patient was treated orally with 200 mg of voriconazole every 12 hours. His acute renal failure precluded him from receiving amphotericin B, which is nephrotoxic. He showed no evidence of central nervous system involvement. The patient’s symptoms subsided, the choroidal and skin lesions resolved, and the patient regained 20/25 BCVA in the left eye. The subfoveal lesion in the left eye, as well as the peripheral lesions in both eyes, involuted after treatment (Fig. 2). Pariseau et al. summarized 41 cases of ophthalmic blastomycosis previously reported in the literature. Eight of these were intraocular cases described within the last 30 years. All 8 cases were treated with amphotericin B. Voriconazole, which has a 96% bioavailability when taken