Arsham Sheybani

Intravitreal Bevacizumab for Choroidal Neovascularization in Ocular Histoplasmosis

PURPOSE To define the role of intravitreal bevacizumab in individuals with choroidal neovascularization (CNV) resulting from Ocular Histoplasmosis syndrome (OHS). DESIGN Retrospective chart review of a surgical therapy. METHODS We reviewed the course of 28 eyes of 28 patients who underwent intravitreal injection of bevacizumab for treatment of CNV secondary to OHS. Outcome was measured by pretreatment and posttreatment visual acuity (VA). RESULTS The average pretreatment logarithm of the minimum angle of resolution (logMAR) VA was 0.65 (Snellen equivalent of 20/88). Mean follow-up was 22.43 weeks with an average of 1.8 intravitreal injections. Average final logMAR VA was 0.43 (Snellen equivalent of 20/54). Twenty eyes (71%) experienced an increase in central VA, whereas four eyes (14%) were unchanged and four eyes (14%) experienced a decrease in vision. CONCLUSIONS Intravitreal bevacizumab may improve or stabilize VA in a significant majority of patients with neovascular complications of OHS (24 eyes [85.7%] in our study population).

Fluid Dynamics of a Novel Micro-Fistula Implant for the Surgical Treatment of Glaucoma.

PURPOSE The purpose of this study was to describe the fluidics of a novel non-valved glaucoma implant designed to prevent hypotony and compare the fluidics of this device with two commonly used non-valved glaucoma devices. METHODS The XEN 45 micro-fistula implant was designed to limit hypotony by virtue of its length and width according to the Hagen-Poiseuille equation. Flow testing was performed using a syringe pump and pressure transducer at multiple flow rates. The pressure differentials across the XEN implant, the Ex-Press implant, and 10 mm of silicone tubing from a Baerveldt implant at a physiologic flow rate (2.5 μL/min) were extrapolated. RESULTS The XEN 45 achieved a steady-state pressure calculated at 7.56 mm Hg at 2.5 μL/min. At the same flow rate, the Ex-Press device and Baerveldt tubing reached steady-state pressures of 0.09 and 0.01 mm Hg, respectively. CONCLUSIONS Under flow testing, the XEN micro-fistula implant was able to maintain backpressure above numerical hypotony levels without the use of complex valve systems. This is due to the XEN implants design, derived from the principles that dictate Newtonian fluids.

Phacoemulsification combined with a new ab interno gel stent to treat open-angle glaucoma: Pilot study

Purpose To study the effect on intraocular pressure (IOP) of implanting a new gelatin stent at the time of cataract surgery in the treatment of open‐angle glaucoma (OAG). Setting Multicenter university and private‐practice settings. Design Nonrandomized prospective clinical trial. Methods The implantation of 2 models of a gelatin stent (Xen140 and Xen63) was performed at the time of cataract surgery without mitomycin‐C. Complete success was defined as a postoperative IOP of less than 18 mm Hg and more than a 20% reduction in IOP at 12 months without glaucoma medication. Failure was defined as loss of light perception vision or worse, a need for additional glaucoma surgery, or less than a 20% reduction in the IOP from baseline. Results The study included 37 eyes of 37 patients. The mean preoperative IOP was 22.4 mm Hg ± 4.2 (SD) on 2.5 ± 1.4 medication classes. Twelve months postoperatively, the mean IOP was reduced to 15.4 ± 3.0 mm Hg on 0.9 ± 1.0 medication classes (P < .0001). This resulted in a qualified success of 85.3% and a complete success rate off medications of 47.1%. There were no failures. Conclusion Cataract surgery combined with implantation of the gelatin stent resulted in a significant reduction in IOP in eyes with OAG. Financial Disclosure Dr. Sheybani has received travel reimbursement from Aquesys, Inc. Dr. Ahmed is a paid consultant to Aquesys, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Early Clinical Results of a Novel Ab Interno Gel Stent for the Surgical Treatment of Open-angle Glaucoma.

Purpose:To evaluate the intraocular pressure (IOP) lowering effect of the XEN140 microfistula gel stent implant for the surgical treatment of open-angle glaucoma. Patients and Methods:Forty-nine eyes of 49 patients with an IOP>18 mm Hg and ⩽35 mm Hg were studied in a prospective nonrandomized multicenter cohort trial of the surgical implantation of the XEN140 implant in patients with open-angle glaucoma. Complete success was defined as a postoperative IOP⩽18 mm Hg with ≥20% reduction in IOP at 12 months without any glaucoma medications. Failure was defined as vision loss of light perceptions vision or worse, need for additional glaucoma surgery, or <20% reduction of IOP from baseline. Results:The average age was 64.3 (28.1 to 86.9) years old. Twenty-one eyes had prior failed trabeculectomy with mitomycin C surgery. IOP at 12 months decreased from a mean of 23.1 (±4.1) mm Hg to 14.7 (±3.7) mm Hg for a 36.4% reduction in IOP from baseline. The number of patients at 12 months who achieved an IOP⩽18 mm Hg and ≥20% reduction in IOP was 40 (89%). The number of patients who achieved an IOP⩽18 mm Hg and ≥20% reduction in IOP without antiglaucoma medications was 18 (40%). Conclusions:The XEN140 gel stent lowers IOP with few complications when implanted for the surgical treatment of open-angle glaucoma.

Vascular events in patients with age-related macular degeneration treated with intraocular bevacizumab.

Purpose: The purpose of this study was to determine the incidence of vascular events in patients treated with intraocular injections of bevacizumab. Methods: The subjects were 769 persons (mean age, 79.9 years; range, 47–97 years) from the Barnes Retina Institute in St. Louis. Patients received at least one intraocular injection of bevacizumab for the treatment of neovascular age-related macular degeneration. The study endpoints included myocardial infarction, cerebrovascular accident, thromboembolic disease, new hypertension, bleeding, and death. Results: There were events in 74 patients (9.6%; 95% confidence interval, 7.5–11.7%) over a mean follow-up of 13.2 months (range, 1–23 months). Among other events, 15 patients (2.0%; 95% confidence interval, 1–3%) had a nonlethal myocardial infarction, 27 patients (3.5%; 95% confidence interval, 2.2–4.8%) had an episode of new or increased blood pressure, and 19 patients (2.5%; 95% confidence interval, 1.4–3.6%) died. There was no correlation between the number of bevacizumab injections and incidence of any event. Conclusion: Intraocular bevacizumab may be safe for intraocular use from a systemic standpoint.

Intraoperative management of posterior capsular rupture.

Purpose of review Posterior capsular rupture (PCR) and vitreous loss are inevitable complications encountered in cataract surgery across all levels of surgical experience and in spite of technological advances to improve safety. Thus, cataract surgeons must always be prepared to practice safe and effective intraoperative management strategies for capsular rupture. Recent findings Novel approaches for lens fragment removal, vitrectomy, and lens implantation have expanded the available options for cataract surgery in the setting of an open posterior capsule. Intraoperative PCR management strategies should prioritize safety and strive to minimize vitreous traction, stabilize anterior chamber volume, maintain capsular and zonular integrity, and protect the corneal endothelium and other anterior segment structures. Summary With appropriate management of PCR and vitreous, surgeons may still deliver safe and satisfactory visual outcomes for modern cataract surgery.

Immunohistochemical study of epiretinal membranes in patients with uveitis

BackgroundThe purpose of this study is to report two cases of idiopathic uveitis with secondary epiretinal membrane (ERM) formation in order to describe histologic and immunohistochemical features that may help distinguish uveitic from idiopathic ERMs.MethodsThe study utilized a clinical case series and histopathological and immunohistochemical findings.ResultsThere was no identifiable etiology of inflammation in either case. Histology and immunohistochemistry demonstrated a mixture of abundant inflammatory cells, including lymphocytes, histiocytes, plasma cells, and occasional eosinophils, among a stromal matrix composed of glial elements and condensed vitreous, but no retinal pigment epithelium (RPE) was present. The relative proportions of the various inflammatory cell types were assessed with immunohistochemistry, and among the lymphocyte population, T cells predominated over B cells. In one of the cases, there was an abundance of histiocytes, consistent with granulomatous uveitis, which was later confirmed on histology of the enucleated globe.ConclusionsIdiopathic ERM formation is thought to be secondary to glial cell migration that may require some involvement of RPE cells. The absence of RPE and abundance of inflammatory cells may be used to identify ERMs as secondary to uveitis.

Effect of endoscopic cyclophotocoagulation on refractive outcomes when combined with cataract surgery

OBJECTIVE To determine the difference between predicted and actual refractive outcomes after combined endoscopic cyclophotocoagulation and cataract surgery (phaco-ECP) in patients with open-angle glaucoma (OAG). DESIGN Retrospective case-control study of patients with OAG who underwent phaco-ECP compared with cataract surgery alone. PARTICIPANTS Eighty-three patients with OAG, aged 55 to 91 years, who underwent a combined phaco-ECP procedure and 58 biometry- and age-matched control patients with OAG who underwent cataract surgery alone. METHODS Patient records were retrospectively reviewed at the Department of Ophthalmology and Visual Sciences, Washington University School of Medicine in St. Louis (St. Louis, Mo.). The primary outcome was the difference in predicted and actual refractive outcomes in patients undergoing either phaco-ECP or standard cataract surgery. RESULTS Compared with phaco alone, the difference in predicted versus actual postoperative results was more myopic in the phaco-ECP group (0.029, -0.110, and -0.095 vs -0.169, -0.325, and -0.312 [p < 0.05] for Sanders, Retzlaff, Kraff/Theoretical, Hoffer Q, and Holladay, respectively). Moreover, the F test for variability showed significantly more variability in refractive outcomes in the phaco-ECP group compared with standard cataract surgery. CONCLUSIONS Patients undergoing phaco-ECP may have postoperative refractive errors that may vary from that predicted preoperatively more so than in cataract surgery alone. Surgeons may consider analyzing their results to determine whether any adjustment should be made to lens power selection when performing phaco-ECP.

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.

In-the-bag nasal intraocular lens optic truncation for treatment of negative dysphotopsia

We describe in-the-bag nasal intraocular lens (IOL) optic truncation, a new technique for the treatment of negative dysphotopsia. After a plane is created between the nasal capsular bag and the IOL, micrograspers and intraocular scissors are used to amputate the nasal optic edge. The amputation is to reduce the optical impact of the IOL edge and nasal anterior capsule on the occurrence of negative dysphotopsia. The technique addresses many of the proposed mechanisms contributing to the development of negative dysphotopsia and can theoretically be used in all patients with chronic symptomatology. In the case we describe, the dysphotopsia resolved immediately after in-the-bag nasal IOL optic truncation. FINANCIAL DISCLOSURE None of the authors has a financial or proprietary interest in any material or method mentioned.